Nicholas Lowe

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Independent investigation into
the death of Mr Nicholas Lowe,
on 16 October 2025, following
his release from HMP Five Wells
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, 2026
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visit nationalarchives.gov.uk/doc/open-government-licence/version/3
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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 investigated 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 Nicholas Lowe died from the toxic effects of synthetic cannabinoids on 16
October 2025, the day after his release from HMP Five Wells. He was 44 years old.
We offer our condolences to those who knew him.
5. Mr Lowe had a history of drug use and was resident on the drug rehabilitation unit
at Five Wells up to his release. We found that he received appropriate support.
6. We did not identify any significant learning relating to the pre-release planning or
post-release supervision of Mr Lowe.
7. We make no recommendations.
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The Investigation Process
8. HMPPS notified us of Mr Lowe’s death on 12 December 2025.
9. The PPO investigator obtained copies of relevant extracts from Mr Lowe’s prison
and probation records.
10. We informed HM Coroner for West Sussex of the investigation. She gave us the
results of the post-mortem examination. We have sent the Coroner a copy of this
report.
11. The Ombudsman’s office contacted Mr Lowe’s brother to explain the investigation
and to ask if he had any matters he wanted us to consider. He asked us to clarify
why Mr Lowe was released from Five Wells, why he arrived late to his release
address, and for more information on the circumstances of his death. We have
addressed these issues in our report.
12. We shared our initial report with HMPPS and the prison’s healthcare provider,
Practice Plus Group. They found no factual inaccuracies.
13. We sent a copy of our initial report to Mr Lowe’s brother. He did not notify us of any
factual inaccuracies.
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Background Information
HMP Five Wells
14. HMP Five Wells is a category C male resettlement prison. It is managed by G4S.
Practice Plus Group provides primary healthcare, mental health services, and
substance misuse services.
Probation Service
15. The Probation Service works with all individuals subject to custodial and community
sentences. During a person’s imprisonment, they oversee their sentence plan to
assist in rehabilitation, prepare reports to advise the Parole Board and have links
with local partnerships to which they refer people for resettlement services, where
appropriates. Post-release, the Probation Service supervises people throughout
their licence period and post-sentence supervision.
Deaths following release from prison
16. Between September 2021 and the end of April 2026, the PPO started investigations
into approximately 300 deaths of people who died within 14 days of release from
prison. The PPO has published two learning lessons bulletins about post-release
deaths, most recently in July 2024. Our investigations highlight the acute
vulnerability of prison leavers, especially during the first few days post-release, and
indicate that prison leavers often have multiple risk factors such as mental health
and substance use issues and homelessness which further increase their
vulnerability and risk of death following release from prison.
Previous deaths following release from HMP Five Wells
17. Mr Lowe was the second man to die within 14 days of release from Five Wells since
October 2022. The other death was due to natural causes. Up to the end of April
2026, there have been two further deaths, one from natural causes and one that is
awaiting classification. We found that there were no issues with pre-release
planning or post-sentence supervision in our investigation into the previous death.
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Key Events
Background
18. On 17 July 2025, Mr Nicholas Lowe was arrested for breaching his community
behaviour order and burglary of a shop. He was remanded in prison and taken to
HMP Lewes.
19. On 15 August, Mr Lowe was sentenced to 14 months in prison for criminal damage.
He returned to Lewes.
20. On 27 August, Mr Lowe was moved to HMP Five Wells. While being transferred in
the escort van, he took psychoactive substances (PS, synthetic drugs designed to
mimic illegal drugs). Staff called for an ambulance and Mr Lowe was taken to
hospital. When discharged, he was returned to Five Wells.
21. On 2 September, Mr Lowe was moved to the drug rehabilitation unit (DRU) at Five
Wells after staff found him under the influence of drugs on three consecutive days.
While on the DRU, Mr Lowe attended weekly Alcoholics Anonymous and Narcotics
Anonymous groups and remained in the DRU until his release.
22. On 4 September, Mr Lowe told a substance misuse service (SMS) worker that he
wanted to restart quetiapine (an antipsychotic medication that helps mood stability)
and diazepam (a benzodiazepine that helps with symptoms of anxiety) for his
mental health and that he had an appointment booked with the mental health team
to discuss.
Pre-release planning
23. On 30 September, Mr Lowe and his community offender manager (COM) had a
telephone call with Change Grow Live, the community substance misuse provider.
They discussed whether Mr Lowe would consider going to rehab on release. Mr
Lowe said he was substance free and did not think he needed rehab. They agreed
that the COM would instead arrange an assessment with Filey Care and Support, a
supported living provider for adults with complex needs. During the call, Mr Lowe
told the COM he had recently stopped taking his mental health medication, and the
COM emailed healthcare staff to request an update.
24. On 13 October, Mr Lowe’s prison offender manager (POM) and COM received
confirmation that a room was available for Mr Lowe in supported accommodation.
They agreed with the Offender Management Unit (OMU) that Mr Lowe would be
released on 15 October, to allow time for them to complete the release checks. Mr
Lowe was being released under Home Detention Curfew (HDC, allows prisoners
assessed as low risk to finish part of their sentence at home, under strict rules and
electronic monitoring).
25. Later that day, Mr Lowe saw a mental health nurse in the clinic. Mr Lowe said he
was being released in two days’ time and wanted to start antipsychotic medication
again as he was struggling with hearing voices. The nurse did not see any signs of
psychosis in Mr Lowe’s presentation but agreed to restart him on quetiapine
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(100mg daily) and issued a prescription for 28 days. They agreed for a review with
his community GP in six weeks.
Release from HMP Five Wells
26. On 15 October, at around 6.13pm, Mr Lowe was released from Five Wells on HDC.
The delay in his release was due to the prison awaiting confirmation from the police
that no action would be taken in relation to an outstanding disciplinary charge. He
saw a nurse in reception before he left and declined assistance with registering for
a GP. He told the nurse that he was on medication but did not need it and he
planned to throw it down the toilet.
27. Mr Lowe was released to St Martins Place, a Filey Care and Support
accommodation that provides support to prison leavers with complex mental health
and substance misuse needs.
28. Mr Lowe arrived at the accommodation at around 10.00pm. He told staff that he had
arrived in Brighton earlier, at around 9.00pm, but had gone for a drink with a friend
first. Staff showed him to his room, and he said he was very happy with the
placement. Mr Lowe then told staff that he was going to sleep.
29. Mr Lowe was due to have an electronic curfew tag fitted. However, as he arrived at
his accommodation later than expected, he missed the appointment. This was due
to be rearranged.
Circumstances of Mr Lowe’s death
30. On 16 October, at around 10.20am, a member of staff found Mr Lowe unresponsive
in his room. He was sitting on the bed near the window, holding a lighter. The staff
member phoned for an ambulance and started CPR.
31. An ambulance arrived at 10.26am. Paramedics observed signs of rigor mortis
(stiffening of the body after death) and decided that CPR was not appropriate. They
asked staff to stop CPR. At 10.29am, paramedics pronounced life extinct.
Post-mortem report
32. The post-mortem report concluded that Mr Lowe died from MDMB-4en-PINACA
(synthetic cannabinoid) toxicity. Emphysema with bronchopneumonia (lung
diseases) were listed as contributory factors.
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Findings
Substance use
33. Mr Lowe was referred to the substance misuse service at Five Wells and agreed to
engage with psychosocial support, in the form of group therapy sessions. He was
also a resident on the drug rehabilitation unit (DRU). Mr Lowe declined a referral to
the community SMS prior to his release. We consider that he received appropriate
support with his substance use.
Housing
34. Mr Lowe’s POM worked with him to apply for release under HDC. His COM made
the appropriate housing referrals for him and secured a suitable placement, which
was designed to support people with complex needs. We consider that Mr Lowe’s
placement for HDC was appropriate.
35. We make no recommendations.
Adrian Usher
Prisons and Probation Ombudsman August 2026
Inquest
36. At the inquest, held on 8 July 2026, the Coroner concluded that Mr Lowe’s death
was drug related.
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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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