Peter Osborne

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Independent investigation into
the death of Mr Peter Osborne,
on 11 June 2024 following his
release from HMP Elmley
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. 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.
3. Since 6 September 2021, the PPO has investigated post-release deaths that occur
within 14 days of the person’s release from prison.
4. Mr Peter Osborne was found unresponsive in his room on 11 June 2024, following
his release from HMP Elmley on 29 May 2024. The cause of his death could not be
ascertained. He was 38 years old. We offer our condolences to those who knew
him.
5. We did not identify any significant learning relating to the pre-release planning or
post-release supervision of Mr Osborne.
6. We make no recommendations.
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The Investigation Process
7. HMPPS notified us of Mr Osborne’s death on 12 June 2024.
8. The PPO investigator obtained copies of relevant extracts from Mr Osborne’s prison
and probation records.
9. The investigator interviewed the Prison Offender Manager and the Community
Offender Manager on 20 September 2024.
10. We informed HM Coroner for Kent and Medway 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 Osborne’s family to explain the investigation
and to ask if they had any matters they wanted us to consider. We did not receive a
response.
12. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS pointed out some factual inaccuracies, and this report has been amended
accordingly.
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Background Information
HMP Elmley
13. HMP Elmley is a category C prison which holds remanded male prisoners. It is
managed by HMPPS.
Probation Service
14. 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
15. On 27 February 2024, Mr Peter Osborne was remanded to HMP Elmley charged
with burglary offences.
16. During his reception health screen, Mr Osborne told a nurse that he felt like his
mental health was deteriorating, that he had been diagnosed with schizophrenia,
and he was prescribed medication for this. The nurse referred him to the prison’s
mental health team. The nurse also discussed Mr Osborne’s substance misuse
history with him and referred him to the substance misuse team.
17. On 5 March, a recovery worker from the substance misuse team saw Mr Osborne
for an assessment. Mr Osborne said he was managing well in prison. He said that
he used drugs sporadically in the community, and he would like to work on
abstaining from drugs. The recovery worker discussed harm reduction and triggers
with Mr Osborne and spoke to him about rehabilitation options.
18. On 28 March, the prison’s mental health team invited Mr Osborne to attend an
Emotional Coping Skills workshop. He did not attend.
19. On 3 April, a physiotherapist at the prison saw Mr Osborne about his back, hip and
neck pain. Mr Osborne said that he had been involved in a motorbike accident,
injured his head during a fall and injured his knee playing football. Mr Osborne
attended the appointment but walked out before the appointment had ended.
20. On 4 April, the prison’s mental health team invited Mr Osborne to attend a paranoia
workshop. He did not attend.
21. On 6 April, a healthcare nurse saw Mr Osborne about his back, hip and neck pain.
Mr Osborne said he wanted to be prescribed co-codamol (pain relief medication)
and threatened to harm himself if not. The nurse told him that she would refer him
for physiotherapy and advised him to take paracetamol. Following the appointment,
the nurse referred Mr Osborne for physiotherapy.
22. On 17 April, Mr Osborne was sentenced to six months imprisonment for burglary.
23. On 19 April, Mr Osborne’s Prison Offender Manager (POM) held a supervision
appointment with him. Mr Osborne said that he was suffering with his mental health
and was feeling stressed. The POM referred him to the mental health team.
24. On 22 April, following a mental health assessment, a nurse referred Mr Osborne to
the psychology team.
25. On 23 April, the physiotherapist at the prison saw Mr Osborne again. After the
appointment, the GP at the prison saw him and they discussed pain management.
The GP prescribed Mr Osborne co-codamol.
26. On 29 April, the mental health team assessed Mr Osborne. He presented with
issues relating to a lack of post-release accommodation, financial issues and
medication. The nurse noted that Mr Osborne needed to apply for support from the
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pre-release team regarding accommodation and finances, and had upcoming
appointments with the GP and physiotherapy regarding his pain and medication.
27. On 2 May, the physiotherapist at the prison saw Mr Osborne and advised exercises
to ease his pain, but Mr Osborne said that he felt lazy and did not want to. Mr
Osborne said he wanted the GP to increase his pain medication instead. The
physiotherapist discharged Mr Osborne from the service.
28. On 14 May, the recovery worker from the substance misuse team saw Mr Osborne,
where he disclosed that he had been using Spice (a synthetic cannabinoid) in
prison. Mr Osborne said that in the community, he used crack cocaine and alcohol,
and he recognised that homelessness, negative peers and finances were all risk
factors in his recovery. The recovery worker gave him harm reduction advice and
information, and confirmed that Mr Osborne would have a Naloxone kit upon
release, and had received training for using it.
29. On 22 May, the psychologist at the prison was due to see Mr Osborne for an
appointment, but he did not attend.
Pre-release planning
30. On 12 March, the resettlement team saw Mr Osborne. During the appointment they
completed a Duty to Refer (a referral to the local authority if someone is homeless
or threatened with homelessness) to Ashford Council, as Mr Osborne said he would
be homeless upon release.
31. On 21 March, Mr Osborne had an accommodation appointment with Ashford
Council, but he did not attend.
32. On 1 May, the prison notified the Community Offender Manager (COM) by email
that Mr Osborne was eligible for early release under the End of Custody Supervised
Licence (ECSL) scheme. (This scheme allowed prisoners to be released up to 70
days early from 23 May 2024 to ease overcrowding in prisons, it ended in
September 2024). The email said that Mr Osborne’s new release date was 29 May.
33. On 3 May, Mr Osborne’s COM referred him to the personal wellbeing service for
additional support following his release into the community. Mr Osborne did not
engage with the service, so the referral was closed on 17 May.
34. On 7 May, the COM returned the ECSL documentation to the prison.
35. Later that day, the COM referred Mr Osborne to the Community Accommodation
Service Tier 3 (CAS3 - provides short term accommodation to prison leavers), as
Mr Osborne would be homeless upon release.
36. On 13 May, the COM referred Mr Osborne to the Community Rehabilitative
Services so that Mr Osborne’s accommodation options could be further explored.
37. On 17 May, an Integrated Offender Manager (IOM) multi-agency meeting was held
to discuss Mr Osborne. During the meeting, Mr Osborne’s accommodation, mental
health and substance misuse were discussed, and the COM had actions to ensure
all relevant referrals were complete. The COM confirmed that he had completed
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referrals to the community substance misuse team, personal wellbeing service and
completed some accommodation referrals.
38. Following the multi-agency meeting, the COM completed a Community
Accommodation Service Tier 2 (CAS2 - provides housing for people who do not
have a suitable address whilst on licence or bail) referral, as there was no CAS3
accommodation available.
39. On 13 May, the resettlement team met with Mr Osborne. They completed a new
Duty to Refer to Ashford, as Mr Osborne had failed to attend the last appointment
with Ashford Council.
40. On 24 May, the COM received an email from CAS2 confirming that Mr Osborne had
been offered accommodation in Rochester.
41. The COM prepared Mr Osborne’s licence, which instructed him to attend Ashford
probation office upon his release and included licence conditions relating to
attendance at substance misuse team appointments, and electronically monitored
GPS satellite tagging.
Post-release management
42. On 29 May, Mr Osborne was released from Elmley under the ECSL scheme.
43. Mr Osborne attended Ashford probation office for his induction appointment with his
COM and his Integrated Offender Manager (IOM) intense support worker. During
the appointment, Mr Osborne signed the induction paperwork, and the COM gave
Mr Osborne his appointment with the substance misuse team for the next day. The
COM gave Mr Osborne a next probation appointment for 7 June.
44. Following the induction appointment, Mr Osborne’s IOM intense support worker
escorted him to the CAS2 accommodation in Rochester.
45. On 30 May, the substance misuse team in the community were due to see Mr
Osborne. During interview, the COM told us that Mr Osborne did not attend this
appointment.
46. On 7 June, Mr Osborne was due to attend Ashford probation office for a supervision
appointment with his COM. He did not attend the appointment. The COM spoke to
Mr Osborne on the telephone, and he said that he was okay. He issued Mr Osborne
with a licence compliance letter, which instructed him to attend his next appointment
on 14 June.
47. On 10 June, the Electronic Monitoring Service emailed the COM to advise him that
they had been unable to fit Mr Osborne’s ankle monitor, as he was not at his
accommodation at the allocated time. As this was a breach of his licence, he issued
Mr Osborne with a second licence compliance letter.
Circumstances of Mr Osborne’s death
48. On 11 June, a support worker from the CAS2 accommodation emailed the COM
asking if he had had any contact with Mr Osborne, as he had not been seen since
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the weekend. The COM responded and said that he had not, which prompted staff
at the CAS2 accommodation to conduct a welfare check on Mr Osborne. When they
entered his room, they found Mr Osborne motionless on the floor. They called the
emergency services immediately. At 3.15pm, paramedics pronounced Mr
Osborne’s life extinct.
Post-mortem report
49. The post-mortem report concluded that there were no significant findings, and the
Coroner could not ascertain Mr Osborne’s a cause of death.
Findings
50. Our investigation found that staff completed appropriate pre-release planning,
including referrals, for Mr Osborne. We did not identify any significant learning
relating to the pre-release planning or post-release supervision of Mr Osborne.
Adrian Usher
Prisons and Probation Ombudsman March 2025
Inquest
51. At the inquest held on 9 July 2025, The Coroner confirmed that a post-mortem
examination could not establish a cause of death. The Coroner concluded Mr
Osborne’s death was open.
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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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