Ross Parker

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Independent investigation into
the death of Mr Ross Parker
on 7 April 2024, following his
release from HMP Holme House
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 Ross Parker died in hospital on 7 April 2024, from injuries sustained when he
was hit by a Metro train the day before, four days after his release from HMP Holme
House. He was 26 years old. We offer our condolences to those who knew him.
5. The toxicology report showed that Mr Parker had consumed alcohol and ketamine
prior to his death. Mr Parker had a history of substance misuse, however he
declined support from the prison’s substance misuse team and appeared to remain
drug-free in prison. He was provided with details of community substance misuse
services if he wanted to self-refer on release.
6. We did not identify any significant learning relating to the pre-release planning or
post-release supervision of Mr Parker. We make no recommendations.
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The Investigation Process
7. HMPPS notified us of Mr Parker’s death on 11 September 2024.
8. The PPO investigator obtained copies of relevant extracts from Mr Parker’s prison
and probation records.
9. We informed HM Coroner for Newcastle of the investigation. She gave us the cause
of death. We have sent the Coroner a copy of this report.
10. The Ombudsman’s office contacted Mr Parker’s next of kin to explain the
investigation and to ask if they had any matters they wanted us to consider. They
did not respond.
11. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
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Background Information
HMP Holme House
12. HMP Holme House is a category C resettlement prison which holds convicted male
prisoners. It is managed by HMPPS.
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 1 February 2024, Mr Ross Parker was recalled to prison because he did not
attend the Approved Premises (accommodation that provides additional supervision
to those who present a high or very high risk of harm) on the day of his release as
required.
15. Mr Parker remained unlawfully at large for five weeks before being arrested on 7
March. He was sent to HMP Durham. On arrival, his urine tested positive for
benzodiazepines (prescription drugs used to treat anxiety but also widely abused).
16. On 8 March, a member of the Drug and Alcohol Recovery Team (DART) completed
an induction with Mr Parker. He declined to engage with DART because he said he
had no issues that required support. The DART worker told him how to self-refer if
he needed support.
HMP Holme House
17. On 13 March, Mr Parker was moved to HMP Holme House.
18. At his reception health screen, Mr Parker told the nurse he had ADHD and was not
taking his medication. Mr Parker also said he had a history of substance misuse
including cannabis, cocaine, crack cocaine, benzodiazepines and amphetamines.
The nurse referred Mr Parker to the mental health team and the DART team.
19. On 14 March, a DART worker saw Mr Parker for a drug harm reduction induction.
She gave him harm reduction advice, and they discussed the risks of reduced
tolerance levels.
20. On 15 March, a DART worker saw Mr Parker. He declined any treatment but said
he required support from the DART team to remain drug free in the community. The
plan was for Mr Parker to be allocated a recovery worker for harm reduction
support.
Pre-release planning
21. Mr Parker’s community offender manager (COM) had arranged a video link
appointment with Mr Parker on 18 March. However, she had arranged this with
Durham and was unaware he had been moved to Holme House in the meantime.
She was not able to rebook a video link appointment before she took her annual
leave from 25 March to 2 April.
22. On 22 March, the Offender Management Unit (OMU) at Holme House told Mr
Parker’s COM that from 2 April 2024, legislation would be changing which would
impact the recall of individuals serving a sentence of less than 12 months. This
change applied to Mr Parker, whose release date was now 2 April rather than 27
May. The OMU asked Mr Parker’s COM to review Mr Parker’s case and complete
the necessary forms. The COM told the investigator she was not able to complete
those tasks as she was in meetings all day and was then on annual leave.
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23. In the COM’s absence, the prison emailed her line manager to complete Mr
Parker’s licence conditions and provide reporting instructions for the day of his
release. This was completed by a colleague.
24. On 23 March, a nurse completed a mental health assessment with Mr Parker. He
told her that he was not using drugs in prison but in the community, he took illicit
pregabalin for nerve damage in his hand, as well as cocaine, cannabis, ecstasy,
MDMA, Spice (synthetic cannabinoids), Subutex (a heroin replacement medication),
and he also smoked crack cocaine. Mr Parker spoke about restarting his ADHD
medication, however because he was due for release it was not possible to
complete a further assessment and the nurse noted that a referral to Mental Health
Care Navigators (MHCN) was needed. The nurse told the investigator that the
referral was completed the next day. Mr Parker was discussed at their Integrated
Management Panel (IMP) on 25 March. All patients discussed in the meeting were
added to the Reconnect MHCN waiting list, and then the care navigators would
assess those people and take any appropriate actions.
25. On 27 March, a MHCN visited Mr Parker to complete an induction and discuss
individual therapies. However, Mr Parker was at work and the MHCN was unable to
visit him again before his release. Therefore, he left his details in the wing office for
Mr Parker to contact him on release if he wanted to.
26. The community lead for MHCN told the investigator the service would have tried to
contact Mr Parker in the community if his contact details were provided on the
referral, however the prison did not have these, and therefore they were not able to
contact him directly on release. She said that contact could also be attempted
through probation, however this did not take place prior to his death.
27. Later that day, a DART worker met with Mr Parker and gave him harm reduction
advice. She also provided Mr Parker with the details of the local drug and alcohol
service in the community if he wanted support on release.
28. Mr Parker was subject to additional licence conditions on release; to provide
samples for drug tests as required, and to attend the North Tyneside Recovery
Programme as directed to address his substance misuse:
Post-release management
29. On 2 April, Mr Parker was released from Holme House. He had an initial
appointment with probation at 2.30pm. However, he called the probation office and
told them he was not going to make his appointment as he had an appointment with
the Job Centre at 3.00pm. He was advised to attend the probation office at 6.00pm.
30. As Mr Parker’s COM was on annual leave, a colleague completed Mr Parker’s initial
appointment and gave him another appointment with the COM on 5 April at 1.30pm.
31. Mr Parker went to his parents’ address. The COM told the investigator she would
not have approved that address, because Mr Parker had previously assaulted his
sister in the family home. However, she was not able to complete the necessary
housing referrals prior to his release due to the short time frame given.
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32. The COM told the investigator that during the next probation appointment with Mr
Parker she planned to discuss his support needs which, at that time, included
housing, substance misuse, relationships and thinking and behaviour. She said
referrals would have been made following the appointment.
33. Mr Parker failed to attend the appointment with the COM on 5 April.
Circumstances of Mr Parker’s death
34. At approximately 12.10am on 6 April, Mr Parker was taken to A&E after being hit by
a Metro train at North Shields Metro station. Mr Parker was trapped under the Metro
for approximately one hour before he could be removed and was unconscious.
35. Mr Parker’s family told the doctors that Mr Parker would occasionally take a short
cut over the Metro line to get home, and it was not considered a suicide attempt.
36. The consultants at the hospital reviewed Mr Parker's CT scan and considered that
the extent of his brain injury along with his reduced consciousness level and
unreactive pupils represented an unsurvivable injury. It was agreed with his family
that his life support should be switched off.
37. Mr Parker died at 12.26pm on 7 April.
Cause of death
38. A post-mortem examination was not carried out as the coroner accepted the cause
of death provided by a doctor. The doctor gave Mr Parker’s cause of death as
traumatic brain injury.
39. The toxicology report showed that Mr Parker had consumed alcohol and ketamine.
40. At the inquest held on 24 June 2024, the coroner concluded that Mr Parker’s death
was due to an accident.
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Findings
Early release
41. Due to new legislation put in place around recall, Mr Parker was released eight
weeks earlier than expected. As a result, his COM was given only one week’s
notice of Mr Parker’s new release date. The legislative change and earlier release
date impacted the COM’s ability to put risk management plans in place and did not
allow sufficient time to complete all necessary release planning. In addition, the
COM had pre-planned annual leave during this time, and therefore was not able to
complete the necessary tasks before Mr Parker’s new release date.
42. A colleague completed Mr Parker’s licence conditions using EPF (standardised tool
to generate licence conditions) and provided the prison with reporting instructions.
Although the COM said she would not have approved Mr Parker returning to his
parents’ address, his mother was fully supportive of this. On her return from leave,
the COM concluded that it was better for Mr Parker to reside with his parents
temporarily, until alternative accommodation was found.
43. The COM booked Mr Parker’s next appointment for the earliest opportunity (three
days later), in order to explore the necessary referrals and support he required in
the community; however, he did not attend that appointment and therefore no
referrals were completed prior to his death.
Substance misuse
44. Mr Parker had a history of substance misuse. While he was in prison, he was seen
by the DART team and warned about the risks and dangers of taking drugs. He
declined any treatment or intervention in prison. Prior to his release he was
provided with the details of the community substance misuse service if he wanted
support in the community.
45. We are satisfied that probation staff put appropriate measures in place to address
Mr Parker’s substance misuse issues when he was released from prison. Although
he was abstinent in prison, probation staff took precautionary measures because of
the change in circumstance back into the community. This included adding licence
conditions to comply with any requirements relating to addressing his substance
misuse issues, should he need support if he relapsed in the community.
46. We are satisfied that both the prison and probation services did all they could to
manage the risks associated with his substance misuse.
Mental health
47. We found that Mr Parker was promptly assessed by the mental health services at
Holme House, and they appropriately referred him for continued support in the
community.
48. We are satisfied that the mental health team at Holme House liaised with MHCN
ahead of his release from prison, following an assessment completed by the mental
health team, where Mr Parker said he would like to recommence his ADHD
medication. This ensured he would have had access to mental health support in the
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community. Unfortunately, Mr Parker was not able to access the support he needed
prior to his death.
49. We make no recommendations.
Adrian Usher
Prisons and Probation Ombudsman April 2025
Inquest
The inquest, held on 26 June 2024, concluded that Mr Parker’s death was due to an
accident.
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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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