Neil Yates

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Neil Yates
on 25 April 2023, following his
release from HMP Altcourse
A report by the Prisons and Probation Ombudsman
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
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© Crown copyright, 2024
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Summary
1. The Prisons and Probation Ombudsman aims to make a significant contribution to
safer, fairer custody and community supervision. One of the most important ways in
which we work towards that aim is by carrying out independent investigations into
deaths, due to any cause, of prisoners, young people in detention, residents of
approved premises and detainees in immigration centres.
2. Since 6 September 2021, the PPO has been investigating post-release deaths that
occur within 14 days of the person’s release from prison.
3. If my office is to best assist His Majesty’s Prison and Probation Service (HMPPS) in
ensuring the standard of care received by those within service remit is appropriate,
our recommendations should be focused, evidenced and viable. This is especially
the case if there is evidence of systemic failure.
4. Mr Neil Yates died of mixed drug (including opioids) toxicity and bronchopneumonia
(infection of the lungs) on 25 April 2023, following his release from HMP Altcourse
on 21 April. He was 53 years old. We offer our condolences to those who knew him.
5. Mr Yates had a history of opioid misuse. We found that although the substance
misuse services at Altcourse trained Mr Yates in the use of naloxone (a medication
that rapidly reverses the effects of opioid overdose), they did not offer Mr Yates a
take home naloxone kit when he was released. We are satisfied that Altcourse has
a local operating policy for take home naloxone and that the failure to offer Mr Yates
a naloxone kit appears to have been an error. We bring this to the attention of the
Head of Healthcare.
6. We make no recommendations.
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The Investigation Process
7. HMPPS notified us of Mr Yates’ death on 4 May 2023.
8. The PPO investigator obtained copies of relevant extracts from Mr Yates’ prison
and probation records.
9. We informed HM Coroner for Sefton of the investigation. They gave us the results
of the post-mortem examination. We have sent the Coroner a copy of this report.
10. The Ombudsman’s family liaison officer contacted Mr Yates’ sister to explain the
investigation and to ask if she had any matters she wanted us to consider. She had
questions about Mr Yates’ prescription medication and whether this had any impact
on his death. These questions have been addressed in the report.
11. Mr Yates’ sister received a copy of the initial report. She did not make any
comments.
12. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS pointed out one factual inaccuracy, and this report has been amended
accordingly.
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Background Information
HMP Altcourse
13. HMP Altcourse is a category B local prison which holds up to 1,164 male prisoners
who have either been convicted or are on remand. Up to June 2023, it was
managed by G4S, and G4S was the substance misuse treatment provider. It is
currently run by Sodexo, who took over management of the prison in June 2023.
HM Inspectorate of Prisons
14. The most recent inspection of HMP Altcourse was in November 2021. Inspectors
reported that all new arrivals were screened for alcohol and drug issues and if
necessary, referred to the GP. Clinical assessments took place promptly and opiate
substitution treatment was prescribed. Prisoners with drug or alcohol issues were
placed on a detoxification wing. Inspectors reported that there were staff shortages
within the substance misuse team, which meant there was limited access for
prisoners who needed psychosocial support. The substance misuse team were
unable to provide a holistic recovery service and the restricted regime limited the
opportunities for group work. Prisoners received naloxone and training in how to
use it, and information was shared with community services to support them on
release.
Probation Service
15. The Probation Service work with all individuals subject to custodial and community
sentences. During a person’s imprisonment, they oversee their sentence plan to
assist in rehabilitation, as well as prepare reports to advise the Parole Board and
have links with local partnerships to whom, where appropriate, they refer people for
resettlement services. Post-release, the Probation Service supervise people
throughout their licence period and post-sentence supervision.
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Key Events
16. On 20 February 2023, Mr Neil Yates was remanded to HMP Altcourse, charged
with driving offences. He was convicted and sentenced to 20 weeks in prison on 6
March.
Substance misuse services
17. When Mr Yates arrived at Altcourse on 20 February, a GP saw him to discuss his
medication. Mr Yates told the GP that in the community, he was taking 600mg of
MST (an opiate medication used to treat pain) each day. (He had initially been
prescribed opiate medication for pain relief but then began to use it illicitly too, and
also had a long history of heroin use.) The GP was unable to continue prescribing
MST as it is a controlled drug that must be administered a few times a day, which is
difficult to do within a prison setting. Instead, the GP prescribed him methadone
(medication used to treat the symptoms of opiate withdrawal), as this has a long
half-life and only needs to be administered once a day.
18. On 21 February, a substance misuse service (SMS) worker at Altcourse saw Mr
Yates for an assessment. She gave Mr Yates training on naloxone (a medication
that can rapidly reverse the effects of an overdose of heroin or other opioids).
19. On 25 February, a SMS worker saw Mr Yates for a review. Mr Yates told the SMS
worker that he felt stable on his methadone. Mr Yates said that as he was on
remand, he did not have a release date but that he was under the care of the local
community drug team, and that he had an allocated keyworker.
20. On 1 March, a nurse at Altcourse saw Mr Yates to discuss his methadone
prescription. Mr Yates said that he was having withdrawal symptoms and would like
to have his methadone dose increased. The nurse sent this request to the GP to
review.
21. On 3 March, a GP at Altcourse increased Mr Yates’ methadone dose by 10mls.
22. On 17 April, a GP at Altcourse saw Mr Yates to discuss his medication. Mr Yates
said that he would like to be prescribed zopiclone to help him sleep. However, the
GP said that as he was already on five other sedative drugs, this would not be safe.
The GP advised Mr Yates that he should consider weaning off some of the sedative
drugs, however Mr Yates said that as he was being released soon, he would prefer
to explore this with his GP in the community.
23. On 21 April, Mr Yates was released from Altcourse with a two-week supply of his
medication.
Release from Altcourse
24. On 21 April, Mr Yates was released from Altcourse on Home Detention Curfew
(HDC, where an individual is released early from prison and is monitored through
curfew conditions) to his own rental property.
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25. The same day, Mr Yates attended St Helens Probation office as instructed. Mr
Yates’ community offender manager (COM) completed his induction and issued Mr
Yates with his next appointment.
26. The same day, the COM made a referral to Change Grow Live (CGL- the local
community substance misuse service) and an assessment appointment was
arranged for Mr Yates for 24 April.
27. On 24 April, Mr Yates attended his assessment appointment at CGL. The recovery
worker noted that Mr Yates engaged well and did not appear under the influence of
any illicit substances. The recovery worker gave him his next appointment for 5
May.
Circumstances of Mr Yates’ death
28. In the early hours of 25 April, Mr Yates returned to his home address with a friend
after going out to get some food. The friend said that he left Mr Yates sitting in a
chair at approximately 2.00am while he went to a bedroom to go to sleep. At around
6.00pm, the friend woke up and found Mr Yates unresponsive in his chair. He called
the emergency services and when paramedics arrived at approximately 7.00pm,
they declared that Mr Yates was dead.
29. On 26 April, Merseyside Police informed HMPPS that Mr Yates had died.
Post-mortem report
30. The post-mortem report concluded that Mr Yates died of mixed drug toxicity and
bronchopneumonia. Chronic obstructive pulmonary disease (COPD, chronic lung
disease) and cirrhosis (scarring of the liver caused by long term liver damage) were
contributing factors.
31. The pathologist found a medium level of methadone in Mr Yates’ blood. The
pathologist was unable to determine whether this level was consistent with
prescribed or illicit usage.
32. The pathologist found a high level of morphine in Mr Yates’ blood. The pathologist
acknowledged that Mr Yates was prescribed morphine, however he said that the
presence of a heroin metabolite suggested recent illicit heroin use and that this was
highly likely to have contributed to Mr Yates’ death.
33. Mr Yates was prescribed pregabalin. The pathologist found a high concentration of
pregabalin in Mr Yates’ blood which was consistent with excessive consumption
and was highly likely to have contributed to Mr Yates’ death. The pathologist noted
that the combined use of opiates with pregabalin would have enhanced the toxicity
of both drugs and increased the likelihood of respiratory depression and death.
34. The pathologist noted that the effects of respiratory depression would have been
more severe due to Mr Yates’ COPD. He also noted that Mr Yates cirrhosis would
have increased the likelihood of developing infections.
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Findings
Naloxone
35. Mr Yates had a history of opiate misuse and was prescribed methadone.
Altcourse’s local operating policy for take home naloxone acknowledges that for
prisoners with a history of opioid use, the risks related to overdose and death are
extremely high in the immediate period after release due to high rates of relapse
and lower opioid tolerance. It states that a take home naloxone kit should be
considered for all patients with a history of opiate misuse, and that they should be
trained in its use.
36. We found that although SMS staff at Altcourse trained Mr Yates in the use of
naloxone, they did not offer Mr Yates a naloxone kit when he was released from
prison. We asked the Deputy Head of Healthcare at Altcourse why this was, but she
was unable to provide an explanation as it was standard practice to issue naloxone
to prisoners with a history of opiate use.
37. As Altcourse has a policy in place, we do not make a recommendation but bring this
to the attention of the Head of Healthcare.
Substance misuse services
38. We found that SMS staff at Altcourse did not make a referral to the community drug
and alcohol services. However, Mr Yates told the substance misuse service at
Altcourse that he was already under the care of the local community drug and
alcohol service with an allocated keyworker.
39. We are satisfied that Mr Yates’ probation practitioner put appropriate measures in
place to address his substance misuse issues when he was released from prison.
This included arranging a release appointment with the local substance misuse
agency and adding licence conditions for Mr Yates to comply with any requirements
relating to addressing his substance misuse issues.
Adrian Usher
Prisons and Probation Ombudsman March 2024
Inquest
The inquest, held on 1 November 2024, concluded that Mr Yates’ death was drug related.
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