Paul Stephenson

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Independent investigation into
the death of Mr Paul Stephenson
on 5 October 2024,
following his release from
HMP Northumberland
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, 2025
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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 Paul Stephenson died from multiple drug toxicity on 5 October 2024, two days
after his release from HMP Northumberland. He was 52 years old. We offer our
condolences to those who knew him.
5. Mr Stephenson had a history of substance misuse, however he appeared to remain
drug-free in prison. He engaged with the prison’s substance misuse team who
provided him with details of community substance misuse services should he want
to self-refer on release.
6. Despite having a history of opioid use, Mr Stephenson was not offered naloxone (a
medicine that rapidly reverses opioid overdose) before his release as he should
have been. The substance misuse lead told us that a new process has since been
introduced so that prisoners with a history of opioid use are identified and offered
naloxone.
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The Investigation Process
7. HMPPS notified us of Mr Stephenson’s death on 7 October 2024.
8. The PPO investigator obtained copies of relevant extracts from Mr Stephenson’s
prison and probation records.
9. We informed HM Coroner for County Durham and Darlington of the investigation.
He gave us the results of the post-mortem examination. We have sent the Coroner
a copy of this report.
10. Mr Stephenson had no identified next of kin so the Ombudsman’s office did not
contact anyone about this investigation.
11. We shared our initial report with HMPPS. They pointed out one error which has
been amended in this report.
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Background Information
HMP Northumberland
12. HMP Northumberland, run by Sodexo Justice Services, is a category C prison
which holds male prisoners. Spectrum Community Health CIC provides healthcare
services and substance misuse services. Rethink provides primary mental health
services. Tees, Esk, and Wear Valley Mental Health NHS Foundation Trust
provides secondary mental health services.
Probation Service
13. 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.
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Key Events
Background
14. On 2 September 2024, Mr Paul Stephenson was convicted of motoring offences
and was sentenced to 12 weeks in prison. He was sent to HMP Durham.
15. Mr Stephenson had a history of substance misuse and when he arrived at Durham,
his urine tested positive for cocaine and benzodiazepines.
16. On 3 September, a member of the Drug and Alcohol Recovery Team (DART)
assessed Mr Stephenson and offered him support but he declined. They told him
how to self-refer if he changed his mind.
17. The same day, the DART worker sent a referral to We Are With You (WAWY - drug
and alcohol service) so that Mr Stephenson could receive support on release.
However, there was no release date on the referral, so it was used for information
only. The WAWY team told the investigator they usually received another referral
closer to release requesting a release appointment, but Mr Stephenson had moved
to another prison by then.
HMP Northumberland
18. On 6 September, Mr Stephenson was moved to HMP Northumberland. He told the
reception nurse that he had had no problems with drugs or alcohol within the last
three months. Mr Stephenson declined a referral to the substance misuse service.
19. The same day, a DART worker completed an induction with Mr Stephenson as part
of the reception induction, and Mr Stephenson changed his mind and said he
wanted to engage with DART. The DART worker told him he would be allocated a
recovery co-ordinator. He declined treatment but said his main goal was to remain
drug free in prison and in the community.
20. On 11 September, a recovery co-ordinator saw Mr Stephenson for a drug harm
reduction induction. She gave him harm reduction advice, and they discussed the
risk of reduced tolerance levels. Mr Stephenson said he was only in prison for a
short time so did not have time to complete any work. He declined a personal care
plan.
Pre-release planning
21. On 18 September, a probation services officer (PSO) in the resettlement team
completed a basic custody screening with Mr Stephenson. He told her he had been
evicted from his property and would be homeless on release. However, she spoke
to Mr Stephenson’s community offender manager (COM) and Darlington Council,
who both said he had not been evicted. Mr Stephenson was refusing to return to his
previous property because he was too scared to live there due to previous
cuckooing (when vulnerable individuals are exploited by criminals who use their
property for criminal activity, such as storage of drugs). The council told the PSO
that if Mr Stephenson refused to return to his address, then he would be making
himself intentionally homeless, and they would not offer any further support.
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Following this appointment the PSO completed a Duty To Refer (DTR) to Darlington
Council and she also referred Mr Stephenson to Commissioned Rehabilitative
Service (CRS) for accommodation support.
22. On 24 September, an accommodation worker from Thirteen Group (a housing
association) responded to the CRS referral and said they would not have time to
find alternative accommodation for Mr Stephenson so close to his release date. She
said she would speak to Mr Stephenson about returning to his property for a short
period.
23. The same day, a housing officer from Darlington Council acknowledged the DTR,
and asked if a Gateway assessment could be completed (part of the DTR process
to provide more details, i.e. needs and address history). This was completed by the
accommodation worker.
24. On 30 September, the PSO met Mr Stephenson for his final review, and she
reiterated the consequences if he did not return to his flat, but he was adamant he
would not return to that address because he did not feel safe there.
25. On 1 October, a DART worker completed a planned intervention with Mr
Stephenson prior to his release. She noted he had only been in prison for a few
weeks and therefore did not have a lot of engagement with the DART team. Mr
Stephenson was under the non-clinical DART team and had the choice to decline a
referral to the community drug and alcohol service. The DART worker discussed
this with Mr Stephenson, and he declined a referral, so she gave him the details for
WAWY Darlington, if he wanted to self-refer on release.
Post-release management
26. On 3 October, Mr Stephenson was released from Northumberland. Due to the time
he was released, his COM allowed him to attend his initial probation appointment
the next day.
27. On 4 October, Mr Stephenson attended his initial probation appointment with his
COM. He engaged well. The IOM representative (integrated offender management
– a cross agency response to manage persistent and problematic offenders in the
community) also attended this meeting. During the meeting, they called Darlington
Council to explain that Mr Stephenson was not making himself intentionally
homeless, but in fact he could not return to the property because he feared for his
life. The council agreed to rehouse Mr Stephenson and instructed him to attend
Durham Council (the neighbouring council as Mr Stephenson wanted to be away
from his old area) the following Monday.
28. Mr Stephenson also said he wanted to go to a rehabilitation facility for support with
long-term drug abstinence. His COM gave him another appointment for the
following Monday to return to the office to complete the application forms for
potential facilities. According to his COM, Mr Stephenson said it was the most
positive probation appointment he had ever had, and he was happy with the plan
when he left.
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Circumstances of Mr Stephenson’s death
29. On 4 October, Mr Stephenson went to his friend’s house and they used drugs
together including cocaine, heroin, zopiclone (medication to aid sleep) and
pregabalin (prescribed for nerve pain and epilepsy but often misused). His friend
said she went to bed and when she woke up the next morning, she assumed Mr
Stephenson was still asleep on the sofa. She went out to the shops, and when she
returned, she noticed Mr Stephenson was unresponsive and his skin was
discoloured.
30. At approximately 3.30pm she called 999 and the police were already at the scene
when the paramedics arrived at 3.40pm. On arrival, the paramedics confirmed Mr
Stephenson was deceased, and they pronounced life extinct at 3.53pm.
Post-mortem report
31. The post-mortem report concluded that Mr Stephenson died from acute
cardiorespiratory failure caused by mixed drug toxicity. Ischaemic heart disease
was listed as a contributing factor.
32. The toxicology report showed that Mr Stephenson had consumed cocaine,
morphine, pregabalin, zopiclone, codeine, benzoylecgonine and paracetamol.
33. At the inquest held on 10 April 2025, the coroner concluded Mr Stephenson’s cause
of death was drug related.
Findings
Substance misuse
34. Mr Stephenson had a history of substance misuse but appeared to remain drug-free
during his short time in prison. Prior to his release, he declined a referral to
community drug and alcohol services. Substance misuse services at
Northumberland gave Mr Stephenson the contact details of the local drug and
alcohol services if he wished to self-refer after his release.
35. Mr Stephenson had not been prescribed methadone for two years and he wanted to
continue with his progress and was hopeful he would be able to access a
rehabilitation facility for support with long term abstinence. His probation officer
supported this request and arranged for Mr Stephenson to attend the office
separately to his next probation appointment, to complete the application forms for
suitable facilities.
36. Despite Mr Stephenson having a history of opioid use, he was not offered naloxone
(a medicine that rapidly reverses opioid overdose) before his release. The service
manager for Reconnected to Health (the non-clinical substance misuse team at
Northumberland) accepted that Mr Stephenson should have been offered naloxone.
She told us that a new process had been put in place to check whether a prisoner
has a history of opiate use so that naloxone is offered to all eligible prisoners before
release.
6 Prisons and Probation Ombudsman
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Adrian Usher
Prisons and Probation Ombudsman April 2025
Prisons and Probation Ombudsman 7
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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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