Shyrel Grant

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Independent investigation into
the death of Shyrel Grant,
on 10 March 2024 following
their release from
HMP Drake Hall
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. Shyrel Grant (who identified as non-binary and who is referred to by their first name
in this report) died from bilateral aspiration pneumonia on 10 March 2024, following
their release from HMP Drake Hall on 7 March 2024. They were 31 years old. We
offer our condolences to those who knew them.
5. Shyrel had a history of substance misuse and mental health issues in the
community and in prison. They engaged well with the substance misuse team and
the mental health team. They completed one to one work and a methadone
detoxification programme during this time.
6. We did not identify any significant learning relating to the pre-release planning or
post-release supervision of Shyrel.
7. We make no recommendations.
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The Investigation Process
8. HMPPS notified us of Shyrel Grant’s death on 11 September 2024.
9. The PPO investigator obtained copies of relevant extracts from Shyrel’s prison and
probation records.
10. We informed HM Coroner for Black Country of the investigation. He 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 Shyrel’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.
12. 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 Drake Hall
13. HMP Drake Hall is a resettlement prison which holds convicted female 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.
HM Inspectorate of Prisons
15. The most recent inspection of HMP Drake Hall was in July-August 2024. Inspectors
reported there was a revised drug strategy and good partnership working between
the clinical substance misuse team, psychosocial support services and prison
leaders. This was a positive joint initiative and patients discussed were offered
prompt support.
16. Inspectors found, before release, prisoners were given an appointment for
community follow-up and provided a pack that included details of local support
services and harm minimisation advice. Naloxone kits were also offered on release.
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Key Events
Background
17. On 5 March 2016, Shyrel Grant was convicted of robbery and was sent to HMP
Foston Hall. On 25 August, they were sentenced to eight years in prison.
18. Between February 2017 and March 2020, they were transferred to different prisons
and moved to Foston Hall on 20 March 2020.
19. On 3 April 2020, Shyrel was released from prison on licence.
20. Shyrel was recalled to prison twice, first in April 2020 and then again in April 2021
(after another period on licence) for breaching their licence conditions. They were
returned to Foston Hall on 20 April 2021.
21. That day, a nurse completed Shyrel’s initial health screen. Their urine tested
positive for methadone, opiates, and cocaine. Shyrel had been under the care of
the community drug team, and they were recommenced on a methadone
prescription (20ml increased to 30ml).
22. On 26 September 2023, Shyrel was transferred to HMP Drake Hall.
23. On 1 January 2024, Shyrel had several seizures within a short space of time. They
were assessed by healthcare staff and paramedics who advised they needed to
attend to hospital, but they declined on each occasion and signed a disclaimer.
24. On 2 January, Shyrel was relocated to the Care and Separation Unit (CSU)
because intelligence indicated they were involved with drugs and had refused a
voluntary drug test (VDT). Shyrel self-harmed on several occasions while in the
CSU and was supported by suicide and self-harm monitoring (known as ACCT).
Following a period of stability, the ACCT was closed on 19 January.
25. During Shyrel’s time in prison, they engaged with the mental health team and the
substance misuse team. They were compliant with taking their quetiapine
(antipsychotic medication), venlafaxine (antidepressant medication) and citalopram
(antidepressant medication). Shyrel engaged with a counselling psychologist, but
did not attend any psychosocial group sessions with the Inclusion team (national
organisation working with those affected by addiction, crime, or mental health).
Shyrel also completed a methadone detoxification programme while in prison.
Pre-release planning
26. On 6 January, a team manager from the Inclusion team visited Shyrel. They
discussed their mood, patterns of abuse and the support available for substance
misuse. The manager offered to refer Shyrel to Reconnect (a care after custody
service), which they accepted. The manager also told them about NA groups
(Narcotics Anonymous) in the community and also operating in some prisons, and
they agreed this would be beneficial for them. Following this appointment, the
manager added Shyrel to the waiting list for NA groups at Drake Hall.
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27. On 12 January, Shyrel’s allocated Prison Offender Manager (POM) met with them
for a planned supervision and discussed accommodation that had been found
through Changing Lives (an organisation supporting individuals with safe housing
and job training). Shyrel told the POM they had been put on the waiting list for NA
meetings. There is no evidence Shyrel attended any NA meetings in prison.
28. On 22 January, a women’s specialist custody practitioner from Changing Lives saw
Shyrel to discuss a video conference meeting that had been arranged with Myshon
Housing in Wolverhampton (an organisation that delivers specialist intensive
housing management and advice). The practitioner supported Shyrel with how to
make the most of the appointment.
29. On 5 February, a recovery worker in the mental health and psychosocial team met
with Shyrel and discussed their substance misuse history. Shyrel said that they did
not want to relapse in the community, and they would like to be referred to the
community substance misuse team. The recovery worker said she would refer them
to Telford Stars (an organisation providing support to those with drug or alcohol
issues) as they believed that they would be released to this area. She contacted the
custody practitioner for an update on Shyrel’s release address so that she could
refer them to the local drug and alcohol service.
30. On 7 February, Shyrel did not attend their appointment with Reconnect,
Staffordshire. The appointment was rebooked for 9 February, but they did not
attend that appointment either. The purpose of the appointment was to inform
Shyrel that Reconnect had not accepted their housing application because they did
not meet the criteria due to their risk. However, information about different support
services in the area was passed on to Shyrel.
31. On 13 February, the recovery worker referred Shyrel to Recovery Near You (drug
and alcohol service) in Wolverhampton instead of to Telford Stars. She chased up
the referral on 26 February but did not receive a response from them prior to Shyrel
being released and therefore they were not provided with an appointment.
32. On 22 February, the POM met with Shyrel for a planned supervision. She told
Shyrel that Myshon Housing had accepted them. Shyrel asked the POM if someone
from Changing Lives would take them to their accommodation on the day of
release. The POM said she would ask for them.
33. On 26 February, the recovery worker met with Shyrel to complete their release plan
and discuss harm reduction. Shyrel engaged well and said they would like to take
home a naloxone kit (a medication that reverses an opioid overdose).
34. On 1 March, the POM told Shyrel that a worker from Changing Lives would take
them to their accommodation on release and Changing Lives were looking into any
vouchers they were entitled too.
35. On 5 March, a GP in the prison saw Shyrel to discuss being referred to the
community mental health team, so they could access support on release. Shyrel
agreed. The GP called Dudley North community mental health team to refer Shyrel,
but they told him that Shyrel needed to be registered with a GP before they could
accept a referral and Shyrel’s GP would be able to make the referral once they had
been released.
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36. On 7 March, a member of staff visited Shyrel before their release and provided
them with a discharge letter for their GP, the telephone number for the Inclusion
team if they needed support with making referrals and local drug treatment services
and NA groups in the area.
Post-release management
37. On 7 March, Shyrel was released on licence (their sentence end date fell on a
Sunday and therefore they were released three days earlier). The worker from
Changing Lives met them at the gate and gave them a phone.
38. The worker from Changing Lives took Shyrel to their initial probation appointment
with their allocated Community Offender Manager (COM). The COM spoke with
them about their drug use and the risks associated to this due to their lowered
tolerance levels. She encouraged Shyrel to register with a GP as soon as possible,
to ensure they received support in the community. She gave Shyrel her mobile
number and told them they could call her if they needed advice or support in the
future.
39. The worker from Changing Lives then took Shyrel to their accommodation. They
were given a TV and some food vouchers. That day, Shyrel had an appointment
with the Department for Work and Pensions and the worker advised them about
available grants and benefits.
Circumstances of Shyrel Grant’s death
40. On 7 March, Shyrel visited their friend. They told him they had taken pregabalin (a
medication that Shyrel was not prescribed and is often used illicitly) before arriving
at his house. Later that evening, Shyrel told their friend that they felt sick and then
they went to sleep.
41. Shyrel’s friend told paramedics he could hear them snoring on the sofa throughout
the night, and this continued into the next day and evening. Shyrel’s friend said he
went out during the day on 9 March and left them sleeping on the sofa and when he
returned, Shyrel was no longer snoring and was not breathing. Their friend called
999 and he started CPR until the paramedics arrived.
42. When the paramedics arrived they examined Shyrel and found rigor mortis was
present (the stiffening of the body after death). The paramedics pronounced life
extinct at 8.11pm.
Post-mortem report
43. The post-mortem report concluded that Shyrel died from bilateral aspiration
pneumonia (a bacterial infection of the lungs). No toxicology tests were conducted.
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Findings
Substance misuse
44. Shyrel had a history of substance misuse. While they were in prison, they were
seen regularly by the substance misuse team and were warned about the risks and
dangers of taking drugs. They were also trained in the use of naloxone and were
released with a supply of this. We are satisfied that Shyrel was offered appropriate
support to manage the risks associated with their substance misuse.
45. The substance misuse team had to wait until they knew where Shyrel was going to
live on release before they could refer them to the local drug and alcohol team.
While an appropriate referral was made to a community service, the substance
misuse team did not receive a response prior to Shyrel’s release despite chasing
the service. Shyrel was provided with information on local drug and alcohol services
and AA/NA groups to utilise on release because they wanted continued support.
Mental health
46. We found that Shyrel was well supported by the mental health services at Drake
Hall and treatment focused on developing strategies that would support them in the
community. They engaged well in one-to-one counselling and accepted the support
offered.
47. We are satisfied that the mental health team at Drake Hall tried to liaise with
community mental health services ahead of Shyrel’s release from prison to ensure
they would have mental health support in place for when they were released into
the community.
48. Although a referral was not made, we found this was not due to a lack of effort from
the mental health team at Drake Hall. Shyrel was encouraged to register promptly
with a GP to ensure they received appropriate mental health support and provided
with information they could utilise in the community for continued support.
Friday releases
49. On 29 June 2023, ministers passed the Offenders (Day of Release from Detention)
Bill. This gives prison governors the discretion to release prisoners early on a
Wednesday or a Thursday where release would naturally fall on a Friday or Bank
Holiday. Since January 2024, the discretion to release early to avoid Friday
releases has been used for those with mental health issues, substance misuse
problems or who have far to travel home.
50. Shyrel’s sentence expiry date fell on a Sunday, and so the governor at Drake Hall
released Shyrel on the preceding Thursday instead. This allowed them to access
certain support services and register with a GP before the weekend.
51. As Shyrel was released three days before their sentence expiry date, they had to
adhere to licence conditions for those three days. After their sentence expiry date,
they did not have to engage with probation and any engagement with community
services would have been voluntary.
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Good practice
52. A range of organisations worked closely with Shyrel to ensure they received as
much support as they could. Agencies worked together, giving Shyrel the
opportunity to succeed in the community.
53. Two people gave Shyrel their contact details, to offer ongoing support, even though
Shyrel was not directly working with either organisation. This shows a level of care
and compassion for Shyrel’s wellbeing, and both went above and beyond to make
them feel supported.
Adrian Usher
Prisons and Probation Ombudsman April 2025
The coroner concluded Shyrel Grants death was due to natural causes therefore an
inquest was not required.
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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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