Stephen Dixon

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Independent investigation into
the death of Mr Stephen Dixon
on 23 April 2024, following his
release from HMP Nottingham
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
This report is licensed under the terms of the Open Government Licence v3.0. To view this licence,
visit nationalarchives.gov.uk/doc/open-government-licence/version/3
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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 Stephen Dixon died from methadone (a synthetic opioid used to treat heroin
addiction) and alcohol toxicity on 23 April 2024, following his release from HMP
Nottingham on 22 April. He was 57 years old. We offer our condolences to those
who knew him.
5. Mr Dixon had a history of drug and alcohol misuse. He was on a methadone
programme in prison and was offered naloxone (a medication that rapidly reverses
opioid overdose) on release but declined it.
6. We did not identify any issues with or learning from the pre-release planning or
post-release supervision of Mr Dixon.
7. We make no recommendations.
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The Investigation Process
8. HM Coroner for Derbyshire notified us of Mr Dixon’s death on 12 September 2024.
9. The PPO investigator obtained copies of relevant extracts from Mr Dixon’s prison
and probation records.
10. The Coroner for Derbyshire 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 Dixon’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. We shared our initial report with HMPPS. They found no factual inaccuracies.
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Background Information
HMP Nottingham
13. HMP Nottingham is a reception and resettlement prison serving the courts of
Nottinghamshire and Derbyshire. It is managed by His Majesty’s Prison Service.
Nottinghamshire Healthcare Foundation Trust provides healthcare services.
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 24 January 2024, Mr Stephen Dixon was sentenced to 12 weeks in prison for an
assault on an emergency worker. He was sent to HMP Nottingham.
16. Mr Dixon had a history of drug and alcohol abuse. He received support from the
prison’s substance misuse team and was on a methadone maintenance
programme. (Methadone is a synthetic opioid that is used to treat heroin addiction
as it reduces withdrawal symptoms.)
17. On 21 February, Mr Dixon was released from Nottingham under the early release
scheme for prisoners. Mr Dixon was released to temporary accommodation under
the Community Accommodation Service Tier 3 (CAS3) scheme, which provides
accommodation to prison leavers to prevent street homelessness at point of
release.
18. Two days later, the Probation Service decided to recall Mr Dixon as he had missed
an appointment to fit his electronic tags and an appointment with the community
substance misuse team, Derbyshire Recovery Partnership.
First recall to Nottingham
19. On 2 March, Mr Dixon was arrested by the police and returned to Nottingham.
20. On 28 March, Mr Dixon’s community offender manager (COM) completed a Duty to
Refer to Derby Council as Mr Dixon was no longer eligible for CAS3
accommodation and was due to be homeless on release.
Release from Nottingham
21. On 2 April, Mr Dixon was released from Nottingham. He was released homeless. Mr
Dixon attended Chesterfield Probation Office and they told him to present at the
local homeless persons unit (though he did not attend).
22. On 3 April, Mr Dixon failed to attend Derbyshire Recovery Partnership to collect his
methadone prescription. The next day, he failed to attend an appointment with his
COM.
23. On 5 April, the Probation Service decided to recall Mr Dixon for the second time for
non-compliance and failing to attend the above appointments.
Second recall to Nottingham
24. On 9 April, Mr Dixon was arrested by the police and returned to Nottingham.
25. On 11 April, Mr Dixon was offered naloxone by the prison’s substance misuse team
but he declined it. He gave no reason for this.
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26. On 15 April, the substance misuse team referred Mr Dixon to Derbyshire Recovery
Partnership in preparation for his release.
27. On 16 April, Mr Dixon’s COM completed another Duty to Refer to Derby Council.
Release from Nottingham
28. On 22 April, Mr Dixon was released from Nottingham. He was released homeless.
He reported to Derby Probation Office on the day of his release.
29. Later that day, Mr Dixon attended his appointment with Derbyshire Recovery
Partnership. They offered Mr Dixon naloxone but he declined it.
30. Mr Dixon reported to Chesterfield Town Hall Homeless Persons Unit.
Circumstances of Mr Dixon’s death
31. On 23 April, Mr Dixon was found dead at the property of an associate. There were
no suspicious circumstances.
Post-mortem report
32. The post-mortem report concluded that Mr Dixon died from combined alcohol and
methadone toxicity. Mr Dixon’s blood alcohol level was high, but below the fatal
range. However, methadone has similar effects on the body to alcohol, causing
drowsiness, coma and respiratory depression and would have added to the effects
of alcohol, increasing the risk of death.
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Findings
33. Mr Dixon was released homeless on 22 April. He had previously been released to
CAS3 accommodation but due to his non-compliance, was no longer eligible. We
are satisfied that the COM completed a duty to refer to the council to try to prevent
Mr Dixon from being street homeless upon release. The council’s provision of
accommodation to prison leavers is an issue outside the COM’s control.
34. Mr Dixon was supported by substance misuse services at Nottingham and was
referred to the community substance misuse services prior to release. He was
offered naloxone both prior to his release and after release but declined on both
occasions.
35. We make no recommendations.
Adrian Usher
Prisons and Probation Ombudsman January 2025
Inquest
36. The inquest, held on 4 March 2025, concluded that Mr Dixon’s death was alcohol
and drug related.
6 Prisons and Probation Ombudsman
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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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