Paul Deville

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Independent investigation into
the death of Mr Paul Deville,
a prisoner at HMP Manchester,
on 7 July 2024
A report by the Prisons and Probation Ombudsman
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Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
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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.
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.
Mr Paul Deville died from acute myocardial insufficiency (acute heart failure) on 7 July
2024, while a prisoner at HMP Manchester. This was caused by coronary artery atheroma
(blocked arteries) and synthetic cannabinoid (psychoactive substances) use. Mr Deville
was 53 years old. I offer my condolences to his family and friends.
The clinical reviewer concluded that Mr Deville’s clinical care was equivalent to that which
he could have expected to receive in the community.
Mr Deville had a history of substance misuse in the community and in prison. While at
Manchester, the drug and alcohol recovery service tried to engage with him and warned
him of the risks associated with drug use. However, he told staff he would not stop taking
them.
Substance misuse in prison is one of the biggest challenges that HMPPS faces and it is a
complex, multi-faceted problem with no simple answer. In October 2024, following an
inspection of Manchester, HM Chief Inspector of Prisons issued an urgent notification to
the Secretary of State for Justice as they had noted a significant deterioration since their
previous inspection. They were particularly concerned about the use of drones in
delivering drugs and other illicit items into the prison and the proportion of prisoners testing
positive for drugs.
We do not underestimate the significant challenges Manchester faces in tackling
organised crime and the supply of drugs into the prison which will require the support of
HMPPS, the police and other security services.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Adrian Usher
Prisons and Probation Ombudsman August 2025
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 2
Background Information ................................................................................................... 3
Key Events ....................................................................................................................... 5
Findings ........................................................................................................................... 9
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Summary
Events
1. In September 2010, Mr Paul Deville was sentenced to 11 years in prison for
aggravated burglary and malicious wounding.
2. On 3 July 2023, Mr Deville was transferred to HMP Manchester.
3. Mr Deville had a history of using illicit substances in the community and in prison,
and he also had significant problems with alcohol. When he arrived at Manchester,
Mr Deville refused any involvement from substance misuse services.
4. On 7 July 2024, staff found Mr Deville unresponsive in his cell. A medical
emergency code blue was called (used when a prisoner has difficulty or has
stopped breathing) and staff started cardiopulmonary resuscitation (CPR).
Paramedics arrived and continued resuscitation efforts but they were unable to
revive Mr Deville and pronounced life extinct at 4.55pm.
Findings
5. Mr Deville had a history of substance misuse. The prison’s drug and alcohol
recovery service tried to engage with Mr Deville but he made it clear he did not want
their support.
6. The supply of and demand for drugs is a significant issue at Manchester.
7. When staff found Mr Deville, they should have immediately radioed a medical
emergency. This is an issue that we have highlighted to Manchester in previous
investigations.
Recommendations
• The Governor should ensure that the new drug strategy precisely diagnoses the
issues to be tackled, sets out the specific and measurable actions, with timescales
to address them, and includes a robust assurance process, including metrics
against which the prison can monitor the progress of actions.
• The PGD for the LTHSE should continue to monitor the actions being taken by HMP
Manchester to address the long-standing issues around emergency responses.
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The Investigation Process
8. HMPPS notified us of Mr Paul Deville’s death on 7 July 2024.
9. The investigator issued notices to staff and prisoners at HMP Manchester informing
them of the investigation and asking anyone with relevant information to contact
him. No one responded.
10. The investigator obtained copies of relevant extracts from Mr Deville’s prison and
medical records, including intelligence reports. He watched CCTV and body-worn
video camera (BWVC) footage of the emergency response. Mr Cameron also
obtained information from the Northwest Ambulance Service.
11. NHS England commissioned a clinical reviewer to review Mr Deville’s clinical care
at the prison.
12. The investigator and clinical reviewer interviewed three members of staff on 28 and
29 August 2024. The investigator interviewed a further officer in October.
13. Another PPO investigator interviewed the Head of Safer Custody, the Acting Head
of Healthcare and the Drug Trial Lead on 11 September.
14. Another investigator took over the investigation in February 2025.
15. We informed HM Coroner for Manchester City of the investigation. The Coroner
gave us the results of the post-mortem examination. We have sent the Coroner a
copy of this report.
16. The Ombudsman’s office contacted Mr Deville’s parents to explain the investigation
and to ask if they had any matters, they wanted him to consider. Mr Deville’s
parents gave the investigator some information, but they did not have any specific
questions.
17. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS who pointed a factual inaccuracy, and this report has been amended
accordingly.
18. Mr Deville’s family received a copy of the draft report. They did not make any
comments.
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Background Information
HMP Manchester
19. HMP Manchester is a high security category B training prison, which accepts long-
term prisoners. There is a category A unit for prisoners who pose a greater security
risk. Greater Manchester Mental Health NHS Foundation Trust provides 24-hour
primary care and mental health care at the prison. Drug and alcohol recovery
services are delivered by Delphy Medical seven days a week.
HM Inspectorate of Prisons
20. The most recent inspection of HMP Manchester took place in September 2024.
Following this, HMIP issued an urgent notification to alert the Lord Chancellor and
Secretary of State directly of their significant concerns about Manchester’s
performance.
21. Inspectors reported that they found a very unstable environment due to organised
criminal activity, serious violence and widespread drug use and an officer group that
lacked confidence and capability. They recorded that the proportion of prisoners
testing positive for drug use was very high at 39%. They identified examples of poor
physical security and a failure to replace damaged netting which hampered the
prison’s efforts to fight the supply of illicit items, including drugs. They noted that in
the last year, there had been over 220 drone sightings which was by far the highest
across all prisons in England and Wales.
22. In respect of the support and treatment for prisoners with addictions, inspectors
reported that the substance misuse support was a seven day a week service which
was well embedded within the prison and the staff worked closely with healthcare
and prison staff.
23. Since the inspection HMPPS and the Ministry of Justice have submitted an action
plan which seeks to address HMIP’s priorities and key concerns.
Independent Monitoring Board
24. Each prison has an Independent Monitoring Board (IMB) of unpaid volunteers from
the local community who help to ensure that prisoners are treated fairly and
decently. The latest annual report covered the year to February 2022, and reported
on the ongoing impact of the pandemic. The main concerns were about a lack of
staff and a lack of progress in relation to the installation of secure windows.
Previous deaths at HMP Manchester
25. Mr Deville was the sixteenth prisoner to die at Manchester since July 2021. Of the
previous deaths, seven were self-inflicted, six were from natural causes, one was
drug-related and the cause of one has yet to be determined. Up to the end of May
2025, there have been three self-inflicted deaths and one the cause of which has
yet to be ascertained.
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26. Our reports into three deaths at Manchester found delays in calling medical
emergency response codes.
Psychoactive substances (PS)
27. PS refer to drugs or other substances that affect mental process. Synthetic
cannabinoids and synthetic opioids (including nitazenes) are substances that mimic
the effects of traditional controlled drugs such as cannabis, cocaine, heroin and
amphetamines. Synthetic cannabinoids and synthetic opioids can be difficult to
detect as the compounds used in their manufacture can vary and use of these
substances presents a serious problem across the prison estate.
28. PS can affect people in a number of ways, including increasing heart rate, raising
blood pressure, reducing blood supply to the heart and vomiting. Prisoners under
the influence of these substances can present with marked levels of disinhibition,
heightened energy levels, a high tolerance of pain and a potential for violence.
Besides emerging evidence of such dangers to physical health, the use of PS is
associated with the deterioration of mental health, suicide and self-harm. Testing for
PS is in place in prisons as part of existing mandatory drug testing arrangements.
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Key Events
29. On 10 September 2010, Mr Paul Deville was sentenced to 11 years imprisonment
for aggravated burglary. Mr Deville was released on licence in November 2015 but
recalled to prison in February 2016.
30. Mr Deville had a history of alcohol and substance misuse in the community and
prison. There are a number of entries in his prison record where Mr Deville had
been found under the influence of illicit substances.
HMP Manchester
31. On 3 July 2023, Mr Deville was transferred from HMP Long Lartin to HMP
Manchester. Officers recorded no concerns about his risk of suicide or self-harm. It
was noted that he had last been managed under suicide and self-harm monitoring,
known as ACCT, in 2021. Mr Deville’s risk to others was considered high and he
was given a single cell on A Wing (the prison’s induction unit).
32. At Mr Deville’s initial health screen, staff noted his history of substance misuse,
anxiety and depression. Mr Deville declined to be referred to the substance misuse
team.
33. On 4 July, a recovery worker, spoke to Mr Deville to introduce the drug and alcohol
recovery service (DARS). Mr Deville did not want to engage. She told him how to
access the service if he changed his mind.
34. On 9 September, an officer noted that Mr Deville had been found under the
influence of an illicit substance and healthcare staff saw him.
35. On 10 September, a recovery worker, saw Mr Deville. She recorded that Mr Deville
had said that he had been using drugs and would continue to do so. She gave him
harm reduction advice and offered to sign him up to DARS support. She recorded
that Mr Deville declined and said, “Everyone has a time to go and if mine is here,
then so be it.”
36. On 24 October, Mr Deville told staff that he had burnt himself after falling asleep on
the pipes in his cell following an anaphylactic episode. A GP operating in
Manchester, saw Mr Deville and sent him to hospital for treatment.
37. On 14 December, during a search of Mr Deville’s cell, staff found two five litre tubs
of liquid. Staff noted that Mr Deville brewed hooch (an illicitly distilled alcoholic
drink).
38. On 17 January 2024, an entry in Mr Deville’s security file noted that he had been
seen under the influence of an unknown substance in the exercise yard.
39. On 9 March, during a routine search of Mr Deville’s cell, staff found five litres of
hooch under his bed. Mr Deville admitted that it belonged to him and he was
subsequently placed on report.
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40. On 5 April, a DARS worker saw Mr Deville as part of a wellbeing check following the
death of another prisoner from suspected illicit substance use. He was given harm
reduction advice.
41. On 5 May, an officer noted that staff had found a bottle of fermenting liquid in Mr
Deville’s cell. He was given a behaviour warning.
42. On 15 May, Mr Deville was taken to the segregation unit because he had climbed
on to the wing’s safety netting in protest at not being moved to another wing. (Mr
Deville thought he was under threat due to an incident that had happened at
another prison. We did not find any particular evidence to support this.)
43. On 2 July, Mr Deville left the segregation unit and moved to G Wing.
44. At approximately 5.00pm on 5 July, a Healthcare Assistant was called to Mr
Deville’s cell as officers were concerned that he was under the influence of drugs.
She recorded that Mr Deville was lying on the floor, appeared uncoordinated and
needed help from officers to move and sit up. It was agreed that officers would
monitor him throughout the night.
45. At around 6.00pm, a nurse reviewed Mr Deville in his cell. She noted that he was
conscious, coherent and denied illicit drug use.
46. At 12.46pm on 6 July, a recovery worker, visited Mr Deville in his cell. She recorded
that he was standing in his cell, holding his hand against the wall to support himself.
She said she believed he was under the influence and notified the officers on the
wing. She recorded that he would be seen the following day about harm reduction.
47. A short while later, a nurse went to check on Mr Deville in his cell. She noted that
he was swaying backwards and forwards and was conscious. She noted that no
further intervention was needed.
Events of 7 July 2024
48. At 9.25am on 7 July, an officer unlocked Mr Deville’s cell. CCTV footage shows that
Mr Deville then left his cell and for the rest of the morning, he was seen moving
freely around the wing, in and out of other prisoners’ cells.
49. At 11.37am, a recovery worker, arrived at Mr Deville’s cell. She recorded that they
discussed harm reduction advice thoroughly.
50. At 12.09am, an officer went to Mr Deville’s cell to lock it for lunchtime. She said that
another prisoner was in the cell with Mr Deville and neither appeared under the
influence.
51. At 12.10pm, a Supervising Officer (SO) arrived at Mr Deville’s cell. He said that he
told the other prisoner to leave the cell and once he had left, he locked Mr Deville’s
cell door. The SO told the investigator that at the time, Mr Deville looked reasonable
and alert. However, he had been concerned that the other prisoner might have
taken something as he was a bit sluggish and unsteady on his feet.
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52. At 3.59pm, an officer unlocked Mr Deville’s cell door. In his statement to the police,
the officer said that he found Mr Deville slumped in the corner of his cell, with his
head between his legs. He said he tried to get a response by calling Mr Deville’s
name and shaking his shoulders, but he did not respond. He also tried to find a
pulse but could not feel one. Approximately 30 seconds later, the officer left the cell
and called for a second officer to help him.
53. At 4.01pm, a second officer arrived at Mr Deville’s cell. The first officer told her that
he could not find a pulse. The first officer told the investigator that she also tried to
find a pulse but could not. She said she then shouted for the SO to help and
radioed healthcare staff to attend.
54. At approximately 4.02pm, the SO arrived at the cell. He told the investigator that Mr
Deville was slumped in the corner of his cell so he instructed the first officer to help
move him and they laid him on his side. The SO said he then radioed a code blue
(which indicates a prisoner is not breathing or having breathing difficulties, triggers
the control room to call an emergency ambulance and healthcare staff to attend).
The SO checked for a pulse and as he was not sure he found one, they moved Mr
Deville on to his back and began cardiopulmonary resuscitation (CPR).
55. At 4.02pm, the prison called for an ambulance.
56. At approximately 4.03pm, healthcare staff arrived at the cell. The SO told the
investigator that he and the first officer continued with CPR while healthcare staff
set up their equipment. The SO said that while doing CPR, he had noticed part of
an asthma inhaler on the floor. Once he was no longer needed for CPR, he took a
closer look. He said that the asthma inhaler had been modified and looked as
though it had been used to smoke illicit substances. He said that he wrapped up the
inhaler and gave it to a colleague to place in an evidence bag.
57. According to the ambulance records, the ambulance arrived at the prison at
4.14pm. The paramedics were with Mr Deville at 4.19pm and continued treating
him. At 4.55pm, paramedics pronounced life extinct.
Contact with Mr Deville’s family
58. The prison appointed the chaplain, as the family liaison officer (FLO). Following a
check of his prison records the liaison officer identified Mr Deville’s parents as the
next of kin and she sought to verify their contact details. However, she was unsure
of their house number.
59. The prison contacted HMP Doncaster to see if they were able to deploy an officer,
as the address was closer to them, but they were unable to assist. Following a
conversation with the prison Governor, the decision was made to contact the family
by phone.
60. At 6.55pm, the FLO informed the next of kin that Mr Deville had died and after a
conversation she arranged to visit them the next day.
61. The prison contributed to the cost of Mr Deville’s funeral in line with national
instructions.
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Support for prisoners and staff
62. Later that day, a senior prison manager debriefed and offered support to staff
involved in the emergency. However, the prison could not confirm that postvention
procedures (actions to reduce the risk of suicide and to provide support to people
following a sudden death) were followed.
Post-mortem report
63. A post-mortem examination found that Mr Deville died from acute myocardial
insufficiency caused by coronary artery atheroma and synthetic cannabinoid
receptor agonists.
64. The pathologist recorded that Mr Deville’s coronary artery disease was so severe
that it could have caused his sudden cardiac death at any time, even at rest or
during sleep. He noted that the toxicological assessment of the blood revealed the
presence of three synthetic cannabinoid drugs although the toxicologist did not
formally confirm their presence.
Inquest into Mr Deville’s Death
65. The inquest into Mr Deville’s death was held on 28 January 2026. The coroner
concluded that it was a drug related death. The coroner recorded that Mr Deville’s
death was due to acute myocardial insufficiency caused by coronary artery
atheroma and synthetic cannabinoid receptor agonists.
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Findings
Mr Deville’s substance misuse
66. Mr Deville declined to be referred to DARS when he arrived at Manchester.
However, recovery workers encouraged him to engage with the service and gave
him harm reduction advice on a number of occasions. Following an incident in early
September when Mr Deville had been found under the influence, a recovery worker
recorded that Mr Deville had confirmed that he had taken drugs and would continue
to do so. Given that Mr Deville did not want to engage, the support DARS could
offer was limited.
Drug misuse at Manchester
67. In their inspection report, HMIP identified that the prison had a serious problem with
drugs which was exacerbated by weaknesses in physical and procedural security.
68. In response to HMIP’s urgent notification, the Ministry of Justice and HMPPS
produced an action plan to address the priorities and key concerns identified. This
plan includes actions to address the weaknesses in physical and procedural
security which was allowing large quantities of drugs to enter the prison.
The prison also requested support from HMPPS’s National Drug Strategy Team.
The Drug and Alcohol Support (Custody) Team visited the prison in February 2025
and later produced a report in which they identified a number of key areas for
improvement and some recommendations. They concluded that while there had
been real progress in security and harm reduction strategies, there were still
challenges in demand reduction, regime stability and staff-prisoner engagement.
They identified that to reduce drug use and improve overall prison safety and
rehabilitation outcomes, the prison needed to enhance their security measures,
improve their rehabilitation policies and adopt strategic intelligence sharing.
69. The prison’s substance misuse strategy (which was updated in August 2023) is
thorough, detailed and ambitious, setting out many initiatives and actions to tackle
drugs. However, it was not always clear which actions were being taken forward
and how they would be tracked or measured. The prison did not have a set of
metrics in place to measure outcomes, but told us that they were looking at how
they could record their data more effectively.
70. The prison said that their review of their drug strategy, scheduled for August 2024,
had been delayed as their focus had been on rolling out nasal naloxone (which can
reverse the effects of an opioid overdose) among prison staff (this was completed in
April 2025). They confirmed that they would start their review in May 2025 and the
areas for improvement and associated recommendations that the Drug and Alcohol
Support (Custody) Team had identified would be included in the new strategy.
71. Given the significant issues that Manchester faces and the impact of drugs on the
safety and stability of the prison, we make the following recommendation:
The Governor should ensure that the new drug strategy precisely diagnoses
the issues to be tackled, sets out the specific and measurable actions, with
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timescales to address them, and includes a robust assurance process,
including metrics against which the prison can monitor the progress of
actions.
Emergency response
72. PSI 03/21013 on medical emergency response codes sets out the actions staff
should take in a medical emergency, including calling a medical emergency code if
they find a prisoner unconscious.
73. When an officer found Mr Deville in his cell, slumped, unresponsive and with no
pulse, he should immediately have radioed an emergency code. Instead, the officer
left the cell to call for help from a colleague.
74. A second officer who responded also failed to call an emergency code. Instead, she
checked for a pulse and when she could not find one, she called for the SO to help
and radioed for healthcare staff to attend. It was not until the SO arrived that a code
blue medical emergency was called. This led to a delay of two to three minutes
before an ambulance was called.
75. Following a previous death at Manchester, the Executive Director for the Long Term
and High Security Estate accepted our recommendation that he should take steps
to satisfy himself that all staff at Manchester understood their responsibilities during
medical emergencies. We were told that this would be done through regular
discussions with the Governor and performance and assurance meetings. We were
also told that the Executive Director had tasked his Group Safety Team to
undertake periodic dip tests to provide continued assurance, with deficiencies
reported to the Executive Director for oversight. We were also told that the prison
had completed comprehensive work to raise staff awareness. Despite these
actions, we have identified the same issue in this investigation and therefore make
the following recommendation:
The PGD for the LTHSE should continue to monitor the actions being taken
by HMP Manchester to address the long-standing issues around emergency
responses.
Clinical findings
76. The clinical reviewer found that the clinical care Mr Deville received was of a good
standard and was at least equivalent to that which he could have expected to
receive in the community.
77. She identified good practice in the healthcare team continuing to visit Mr Deville
when he was found under the influence of substances and giving him harm
reduction advice despite him not engaging with them.
Governor to note
78. There was no evidence to confirm that prison staff had checked on prisoners who
were subject to suicide and self-harm prevention procedures following Mr Deville’s
death.
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