Sabrina Lyttle

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Independent investigation into
the death of Ms Sabrina Lyttle,
on 30 November 2024,
following her release from
HMP Styal
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. Ms Sabrina Lyttle died from mixed drug toxicity (multiple drugs used
simultaneously) on 30 November 2024 following her release from HMP Styal on 27
November. She was 47 years old. We offer our condolences to those who knew
her.
5. Ms Lyttle had significant alcohol and substance misuse issues, including a history of
heroin and crack cocaine use. Although she was in prison for only three weeks,
prison, probation and healthcare staff provided substance misuse support prior to
her release. They arranged for several community agencies to work with Ms Lyttle
and for this to continue in the community after release. This included staff from one
agency meeting Ms Lyttle outside the prison on release and supporting her at her
first-day appointments.
6. We do not think that prison and probation staff could have done any more to
support Ms Lyttle in the short time from when she was sent to prison until her death.
We make no recommendations.
Prisons and Probation Ombudsman 1
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The Investigation Process
7. We were notified of Ms Lyttle’s death on 11 December 2024.
8. The PPO investigator obtained copies of relevant extracts from Ms Lyttle’s prison
and probation records.
9. We informed HM Coroner for Blackpool of the investigation. He gave us the results
of the post-mortem examination. We have sent the Coroner a copy of this report.
10. The Ombudsman’s office contacted Ms Lyttle’s daughter to explain the investigation
and to ask if she had any matters she wanted us to consider. She did not respond.
11. We shared the initial report with HM Prison and Probation Service
(HMPPS). HMPPS pointed out five factual inaccuracies and we have amended this
report accordingly.
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Background Information
HMP Styal
12. HMP Styal holds women in a variety of residential units, with 16 separate houses
each holding about 20 women. Spectrum Community Health provides healthcare
services at the prison. Greater Manchester West Mental Health NHS Foundation
Trust provides mental health services. The prison has 24-hour nursing cover.
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 whom, where appropriate, they refer people for
resettlement services. Post-release, the Probation Service supervises people
throughout their licence period and post-sentence supervision.
Prisons and Probation Ombudsman 3
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Key Events
14. On 5 November 2024, Ms Sabrina Lyttle was convicted of theft and sentenced to
eight weeks in prison. She was sent to HMP Styal. Ms Lyttle had been to prison
several times before (although not for over a year) and had a history of substance
misuse.
15. At the reception health screening, Ms Lyttle said that she smoked heroin and crack
cocaine daily and also misused diazepam (a benzodiazepine commonly known by
the brand name Valium that is prescribed for conditions including anxiety and
alcohol withdrawal). Healthcare staff identified that she was withdrawing from drugs
and alcohol, but she initially refused opiate substitution treatment. Ms Lyttle said
that she had previously been prescribed mirtazapine (an antidepressant) but had
not collected this for some time. (The prescription was not continued in prison.)
16. On 6 November, Ms Lyttle started a methadone maintenance programme.
(Methadone is a prescription medication used to treat opiate withdrawal.) She told
healthcare staff she last used drugs and alcohol approximately three days prior to
prison. Ms Lyttle asked to speak with mental health team (MHT). MHT staff saw Ms
Lyttle in her cell, but she said she was not feeling well and did not wish to engage
as she was detoxing. Staff agreed to review her the next day.
17. On 7 November, Ms Lyttle attended substance misuse services. Healthcare staff
did recovery checkups on Ms Lyttle and agreed regular clinical observations on her.
They contacted Blackpool Horizon (community drug and rehabilitation services) and
waited for their appointment details for Ms Lyttle. The medical records did not say if
Ms Lyttle was seen by MHT as requested by her the previous day.
18. On 11 November, healthcare staff referred Ms Lyttle to the MHT. Substance misuse
service staff also met Ms Lyttle to complete her pre-release substance misuse
assessment. They told Ms Lyttle she was required to attend Blackpool Horizon at
3.00pm on the day of her release. Blackpool Horizon staff said they would meet Ms
Lyttle at the prison gate when she was released.
19. On 12 November, substance misuse staff referred Ms Lyttle to Reconnect Cheshire
(a national programme which is designed to assist individuals leaving prison by
providing support, including to access health needs). Reconnect Cheshire staff
booked an appointment to see Ms Lyttle at 9.00am on 26 November via videolink.
20. On 13 November, pre-release prison staff completed a needs assessment for Ms
Lyttle. Staff raised accommodation issues and completed a Duty to Refer (public
authorities have a duty to refer those whom they believe to be homeless or
threatened with homelessness - for example, if it is likely they will become
homeless within 56 days) to Blackpool Housing for Ms Lyttle.
21. On the same day, the prison offender manager (POM) introduced himself to Ms
Lyttle. He was familiar with Ms Lyttle as she knew him in his former role as a prison
officer. The POM noted that Ms Lyttle had settled on the wing and was feeling much
better. She was due for release on 27 November and had now been referred to
Lancashire Women (a charity supporting women with employment, mental health
and wellbeing support). This referral was undertaken by the COM on 19 November.
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22. On 14 November, healthcare staff met Ms Lyttle to complete release planning and
gave her a release appointment letter. Blackpool Horizon staff had sent healthcare
staff details of the nearest pharmacy where Ms Lyttle could collect her methadone
prescription. Healthcare staff gave Ms Lyttle harm reduction advice and explained
tolerance and overdose awareness. They also gave Ms Lyttle training on using a
naloxone pack ahead of her release. (Naloxone is used to reverse or reduce the
effects of an opioid overdose.)
23. On 19 November, Ms Lyttle was due to attend a Reconnect assessment, but did not
attend. (The reason Ms Lyttle did not attend this or a later assessment was not
recorded.)
24. On 21 November, a substance misuse nurse reviewed Ms Lyttle. She reported that
she was very excited to be involved in a police scheme (OASIS - aims to create a
safer and more secure environment in Blackpool town centre). This meant that she
would be supported and provided with accommodation. She would also be
supported by Blackpool Horizon (which is connected to the Changing Futures) and
under the care of the community drug team. The support from Horizon had been
facilitated by a referral from the COM and included Ms Lyttle being picked up at the
prison gate on the day of her release. Ms Lyttle was still prescribed methadone.
Staff assessed that she had mild withdrawal symptoms, but she said she was
otherwise okay.
25. On 22 November, healthcare staff gave Ms Lyttle a release appointment letter. As
agreed, Blackpool Horizon staff were to meet her on the morning of release. Staff
reminded Ms Lyttle that if this could not go ahead then she was to attend Blackpool
Horizon before 3.00pm on the day of release. They requested a naloxone pack, to
be given to Ms Lyttle on release. Staff also arranged for Ms Lyttle’s methadone
prescription to continue once released.
26. On 26 November, Ms Lyttle did not attend her scheduled Reconnect assessment.
As she was being released to the Blackpool area, prison staff contacted the
Lancashire Reconnect Team to advise that Ms Lyttle did not attend her
appointment. Prison staff sent all the information they had, including the referral
form for Ms Lyttle, to Lancashire Reconnect and requested they see her in the
community within 28 days.
27. Lancashire Reconnect reviewed the referral and advised prison staff that Ms Lyttle
had not been accepted. This was because she was already receiving support from
Prison Leavers (services that aim to help individuals reintegrate into society,
address health needs, and access vital resources like housing, employment, and
social support) and Lancashire Women.
28. Ms Lyttle’s community offender manager (COM) told us that she did not meet Ms
Lyttle prior to her release and did not have telephone contact with her either. As Ms
Lyttle was sentenced on 5 November and released on 27 November, she said that
there was very little time for her to make contact. (The COM said she was also
absent from work for a week during this time.) However, on 26 November she
liaised with Housing, POM and Lancashire Women to confirm release plans.
29. On 27 November, Ms Lyttle was released from prison. She was met by Changing
Futures staff. (Changing Futures is a government funded programme to help to
Prisons and Probation Ombudsman 5
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stabilise and improve the lives of adults facing multiple disadvantages, including
homelessness and substance misuse. We do not know why their staff met Ms Lyttle
rather than Blackpool Horizon staff, as had previously been suggested.) Prison staff
issued a naloxone pack to Ms Lyttle.
30. Blackpool Housing arranged temporary release accommodation for Ms Lyttle in a
hotel.
Post Release
31. On the day of release, Ms Lyttle attended Blackpool Horizon with Changing Futures
staff and was assessed as a priority need. Changing Futures staff also
accompanied Ms Lyttle to Lancashire Women, where new clothes and a phone
were issued to her.
32. Changing Futures staff brought Ms Lyttle to her initial probation induction
appointment on 27 November. The COM saw Ms Lyttle and completed the
probation induction agreement. They said that Ms Lyttle would have weekly
appointments and drug testing for the duration of her licence. Dependent on her
presentation at later appointments, Ms Lyttle could have been referred to the First
Steps to Change. This is a Probation toolkit delivered 1:1 by the COM which intends
to support engagement and compliance throughout a Community Order or period of
licence supervision by providing practical activities focused on building skills,
strengths and strategies to encourage women to desist from offending and have a
positive future.
Circumstances of Ms Lyttle’s death
33. On 30 November, Ms Lyttle was found unresponsive in a restaurant toilet in
Blackpool. Initial circumstances suggested this was because of drug use. A crack
pipe was found on the floor with a number of tablets not identified at the time. Sadly,
Ms Lyttle had been in the toilet for two days before being discovered by
maintenance staff. Paramedics attended and pronounced life extinct.
Post-mortem report
34. The post-mortem report concluded that Ms Lyttle died from mixed drug toxicity. The
toxicology report found that she had used cocaine and taken methadone and
diazepam at some time prior to her death.
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Findings
35. Ms Lyttle was a vulnerable woman with complex support needs, including a long
history of substance misuse and homelessness linked to risk of harm and offending
behaviour. After release, she was given temporary accommodation in a hotel. She
attended her initial probation induction, but we do not know her whereabouts after
this until her death.
36. Prior to her release, prison and probation staff made arrangements to support Ms
Lyttle in the community with her substance misuse issues. Her methadone
prescription was continued and she was given naloxone on release (and training on
how to use this). Arrangements were made with several community support
services, including Blackpool Horizon, Changing Futures and Lancashire Women.
Staff from these organisations engaged with Ms Lyttle on the day of her release,
and it is positive that they were able to meet her at the prison gate and accompany
and support her at her initial appointments.
37. Ms Lyttle was released from prison on 27 November, after serving just over three
weeks of her sentence. The short time period she spent in prison meant that prison
and probation staff had little opportunity to plan, including finding permanent release
accommodation for her. Nevertheless, there was some good practice in the
utilisation of staff with whom Ms Lyttle was familiar (POM), and regular discussion
between professionals on release preparation and risk management for Ms Lyttle in
the community. The COM had a good relationship with Ms Lyttle working with her
since September 2022. We found evidence that prison and probation staff, in
collaboration with community support staff, made consistent efforts to understand
her needs and how to address them. They encouraged Ms Lyttle to engage with the
support services offered her in the community. We do not think any more could
have been done to support Ms Lyttle.
Inquest
38. The inquest into Ms Lyttle’s death concluded on the 29 July 2025. The coroner
confirmed that Ms Lyttle died of mixed drug toxicity.
Adrian Usher
Prisons and Probation Ombudsman September 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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