Sonny Tote

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Independent investigation into
the death of Mr Sonny Tote,
on 18 June 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 been investigating 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 Sonny Tote died of multi-organ failure, caused by cocaine toxicity, on 18 June
2024 following his release from HMP Northumberland on 6 June. He was 28 years
old. I offer my condolences to those who knew him.
5. We did not identify any issues of concern in the pre-release planning or post-
release support and we do not make any recommendations.
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The Investigation Process
6. HMPPS notified us of Mr Tote’s death on 11 September 2024.
7. The PPO investigator obtained copies of relevant extracts from Mr Tote’s prison
and probation records.
8. We informed HM Coroner for Newcastle of the investigation. She gave us the
results of the post-mortem examination. We have sent the Coroner a copy of this
report.
9. The Ombudsman’s office contacted Mr Tote’s father to explain the investigation and
to ask if he had any matters he wanted us to consider. He did not respond to our
letter.
10. 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 Northumberland
11. HMP Northumberland is a category C training and resettlement prison holding
convicted male prisoners. It is managed by Sodexo.
Probation Service
12. The Probation Service work with all individuals subject to custodial and community
sentences. During a person’s imprisonment, they oversee their sentence plan to
assist in rehabilitation, as well as prepare reports to advise the Parole Board. They
have links with local partnerships to whom, where appropriate, they refer people for
resettlement services. Post-release, the Probation Service supervise people
throughout their licence period and post-sentence supervision.
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Key Events
Background
13. On 18 April 2022, Mr Sonny Tote was convicted of malicious wounding and was
sentenced to two years and two months in prison.
14. On 16 May 2023, Mr Tote was released from HMP Holme House.
15. On 5 September 2023, Mr Tote was recalled to HMP Durham and sentenced to 16
weeks in prison for assaulting his partner.
16. Mr Tote had a history of crack cocaine and amphetamine misuse.
Pre-release planning
17. On 15 September 2023, Mr Tote was transferred to HMP Northumberland. A nurse
completed his initial health screen in reception. She noted that he had had a history
of amphetamine and crack cocaine misuse. However, he said that he had no
current substance misuse problems and he declined to complete a urine drug
screen. The Drug and Alcohol Recovery Team (DART) saw Mr Tote as part of his
induction process and recorded that he presented with no signs of withdrawal or
intoxication. The Primary Care Clinical Lead told us that DART saw all prisoners in
reception and offered to refer them for their services.
18. On 26 September, a Trainee Psychological Wellbeing Practitioner saw Mr Tote. He
told her that he had last used crack cocaine approximately two years earlier. She
told us that as there were no concerns about current substance misuse, Mr Tote
would not have been referred to DART following this conversation.
19. On 26 October, Mr Tote’s Prison Offender Manager introduced himself to Mr Tote.
20. On 29 February 2024, the Parole Board reviewed Mr Tote’s recall to prison and
concluded that he was due to be released on 9 June 2024 which was his sentence
expiry date.
21. On 5 April, a member of the Resettlement Team phoned Mr Tote to discuss his
release. She gave him a resettlement pack which included contact details for
community resources such as drug and alcohol misuse prevention services. She
emailed Mr Tote’s Community Offender Manager (COM) and told her that Mr Tote
had proposed living at a family friend’s address on his release.
22. On 22 May, a three-way telephone call took place between the COM, the member
of the Resettlement Team and Mr Tote. Mr Tote told them that he was drug-free
and was not working with the substance misuse team. The COM told us that they
discussed referring Mr Tote to community substance misuse services for relapse
prevention work. However, Mr Tote said this would be counterproductive as he was
concerned he would meet peers there and be tempted to misuse drugs again.
23. On 30 May, the member of the Resettlement Team told Mr Tote that he would be
released on Thursday 6 June, as 9 June fell on a Sunday, and he would be subject
to licence conditions for three days until his sentence expiry date.
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24. On 31 May, the COM arranged for address checks to be conducted on Mr Tote’s
proposed address.
25. On 4 June, the COM arranged for further address checks as the only information
the police identified during the first check was related to Mr Tote rather than the
proposed address or tenant. She told us that the second checks produced the same
outcome, so the address was deemed suitable for Mr Tote on his release.
Release from HMP Northumberland
26. On 6 June, Mr Tote was released from HMP Northumberland with a seven-day
supply of medication. Mr Tote’s medical records note that he was given harm
reduction advice about his reduced tolerance to drugs following his time in custody.
Mr Tote did not have a history of opioid use and he was not offered naloxone, in line
with Northumberland’s local policy, which states that it is only offered to DART
patients.
27. Mr Tote attended his probation induction and discovered that the friend he was due
to live with was also a person on probation. In light of this new information, the
COM told Mr Tote that this address would not be approved long-term and
accommodation referrals would be completed at his next appointment. She told us
that she assessed that there were no immediate safeguarding concerns and the
likelihood of Mr Tote reoffending and/or using substances would increase if he were
homeless. She therefore concluded that he could temporarily live at the property.
She told us that she intended to discuss referrals to community services with Mr
Tote during his induction, but he presented with heightened anxiety because he
saw other people on probation selling drugs outside the probation office. She said
he told her that he did not want anything to do with drugs and left the appointment
early due to his anxiety. She told us that she intended to revisit a potential referral
to substance misuse services at his next appointment, but he failed to attend this as
he was in hospital.
28. On 7 June, the COM received notification that Mr Tote had been arrested for
breaching his restraining order and had been released from police custody on bail.
The Head of the Probation Delivery Unit for Northumberland told us that he would
not have recalled Mr Tote for this as he would have been released from prison two
days later once his licence ended.
29. On 9 June, Mr Tote’s supervision on licence ended. The COM told us that this
meant that Mr Tote would not have been eligible to be referred to the
Commissioned Rehabilitative Service (CRS) for accommodation support. She said
that she intended to tell him this and signpost him to alternative community services
such as the local council for housing and his GP at his next appointment.
Circumstances of Mr Tote’s death
30. On 13 June, Mr Tote failed to attend his planned appointment with the probation
service. The COM received information from the police that Mr Tote had failed to
appear in court as he was in hospital following an unintentional overdose. They told
her that Mr Tote had been admitted to hospital with seizures and was transferred to
the intensive care unit.
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31. On 18 June, Mr Tote’s condition deteriorated, and he had a cardiac arrest. Attempts
to resuscitate him were unsuccessful, and he died.
Post-mortem report
32. The post-mortem report concluded that Mr Tote died of multi-organ failure caused
by cocaine toxicity.
Inquest
33. At an inquest held on 21 August 2025, the Coroner concluded that Mr Tote’s death
was by misadventure.
Findings
34. We are satisfied that the COM arranged temporary accommodation for Mr Tote and
the correct checks were completed, although it unfortunately later came to light that
the accommodation was not appropriate. It is reasonable that she approved this
accommodation on a temporary basis and was planning to discuss permanent
accommodation options with Mr Tote at his next appointment.
35. As healthcare staff did not identify that Mr Tote had a current substance misuse risk
and Mr Tote told them that he wanted to continue to abstain from drugs, he was not
referred to substance misuse services in prison or in the community. When the
COM tried to discuss a referral to substance misuse community services, Mr Tote
was concerned it would be counterproductive due to the peers he would meet there.
It is reasonable that she was planning to discuss community substance misuse
services further with him at his next appointment after he left his induction early in a
heightened state of anxiety.
36. Mr Tote was not under the care of the substance misuse team at Northumberland,
and he was not offered naloxone. We recognise the wide regional differences in the
offer of naloxone on release. The PPO’s Learning Lessons Bulletin on post-release
deaths dated July 2024, concluded that Heads of Healthcare should consider
naloxone training for all prisoners with a substance misuse history, rather than just
those under the care of the substance misuse team. However, as there was no
evidence that Mr Tote had a history of opioid use and died from cocaine toxicity,
naloxone would not have affected the outcome for him. We therefore do not make a
recommendation about this.
Adrian Usher
Prisons and Probation Ombudsman April 2025
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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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