Stephen McIntyre

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Independent investigation into
the death of Mr Stephen McIntyre,
on 14 October 2024,
following his release from
HMP Doncaster
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 Stephen McIntyre died from ischaemic heart disease on 14 October 2024
following his release from HMP Doncaster on 3 October 2024. This was caused by
coronary artery atheroma (a build-up of a fatty substance in the inner lining of the
arteries). Mr McIntyre had also used cocaine which contributed to but did not cause
his death. Post-mortem toxicology results found low levels of cocaine, high levels of
bromazolam (a designer benzodiazepine) and therapeutic levels of pregabalin. Mr
McIntyre was 49 years old. We offer our condolences to those who knew him.
5. We did not identify any significant learning relating to Mr McIntyre’s pre-release
planning or post-release supervision and we make no recommendations.
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The Investigation Process
6. HMPPS notified us of Mr McIntyre’s death on 16 October 2024.
7. The PPO investigator obtained copies of relevant extracts from Mr McIntyre’s prison
and probation records.
8. As part of the investigation, the PPO investigator interviewed Mr McIntyre’s
community offender manager.
9. We informed HM Coroner for Gateshead and Tyneside of the investigation. They
gave us the results of the post-mortem examination. We have sent the Coroner a
copy of this report.
10. Mr McIntyre did not have a named next of kin and we were therefore unable to
contact anyone about our investigation into his death.
11. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
12. HM Coroner told us that there would not be an inquest into Mr McIntyre’s death as
he had died of natural causes in the community.
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Background Information
HMP Doncaster
13. HMP Doncaster is a category B resettlement prison which holds men who have
been convicted or remanded into custody. It is managed by Serco. Practice Plus
Group provides healthcare, including mental health and substance misuse 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
appropriate. Post-release, the Probation Service supervises people throughout their
licence period and post-sentence supervision.
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Key Events
Background
15. On 16 August 2024, Mr Stephen McIntyre was convicted of theft and sentenced to
18 weeks in prison. He was sent to HMP Doncaster.
16. On 19 August, during an initial health screen, he told healthcare staff that he heard
voices and used substances, including unprescribed pregabalin. Mr McIntyre’s urine
tested positive for benzodiazepines. He was referred to the mental health and
substance misuse team for psychosocial support.
17. That day, Mr McIntyre saw a nurse. He told her that he was dependent on
diazepam and gabapentin and used it recreationally. His most recent overdose had
been in February. Mr McIntyre disclosed a history of seizures following a brain
haemorrhage over 20 years earlier.
18. On 20 August, Mr McIntyre was prescribed a reducing dose of diazepam for
withdrawal and the substance misuse team monitored him.
19. On 23 August, Mr McIntyre saw a nurse, who noted that Mr McIntyre was
progressing well on his detoxification.
20. On 28 August, Mr McIntyre accepted support from the prison’s substance misuse
team, and agreed to be referred for community substance misuse support.
21. On 12 September, Mr McIntyre told a prison offender manager (POM), who was not
Mr McIntyre’s assigned POM, that he had his own accommodation post-release.
She logged this on the probation system to notify Mr McIntyre’s community offender
manager (COM).
22. On 26 September, the COM arranged a video-link with Mr McIntyre. They
discussed licence conditions and referring him to community substance misuse
services. She also gave Mr McIntyre the details of their first appointment after his
release.
23. On 30 September, the prison’s substance misuse team completed a referral for Mr
McIntyre to access community substance misuse support at North Tyneside
Recovery Partnership.
24. On 1 October, the substance misuse team gave Mr McIntyre his appointment letters
for release, and noted in prison records that he knew where to attend. They
discussed the risks of his reduced tolerance to drugs post-release. That day, Mr
McIntyre was referred to the Probation Notification and Actioning Project (a national
initiative aimed at improving communication between prison substance misuse
teams and community probation providers) for drug testing.
Release from HMP Doncaster
25. On 3 October, Mr McIntyre was released from Doncaster. He reported no thoughts
of suicide or self-harm. Mr McIntyre was not released with naloxone as he had not
disclosed a history of opiate use.
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26. That day, Mr McIntyre reported to the probation office for his initial appointment with
his COM. Mr McIntyre signed his licence, which included a drug testing condition
and one which required him to address his drug dependency. When they discussed
his personal wellbeing, he told her that he struggled with substance misuse and
wanted support to address it.
27. The day after, a staff member at North Tyneside Recovery Partnership called the
COM and told her that Mr McIntyre had failed to attend his initial appointment with
them at 10.00am.
28. On 10 October, Mr McIntyre failed to attend his probation appointment. The COM
issued a warning letter.
Circumstances of Mr McIntyre’s death
29. On 14 October, Mr McIntyre’s son called the police at 10.23am, after he found Mr
McIntyre dead on a sofa at his home. There was no evidence of drugs or alcohol at
the scene or any indication of self-harm. Police and paramedics arrived at the home
and the paramedics pronounced life extinct at 12.25pm.
Post-mortem report
30. The post-mortem report concluded that Mr McIntyre died from ischaemic heart
disease, caused by coronary artery atheroma. Mr McIntyre had used cocaine which
had contributed but not caused his death.
31. Post-mortem toxicology results found elevated levels of bromazolam (a designer
benzodiazepine), low levels of cocaine and pregabalin at a therapeutic level. The
Coroner noted that while Mr McIntyre had a high level of bromazolam in his blood,
his death was unlikely to have been caused by the drugs identified in the post-
mortem toxicology results.
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Findings
32. Mr McIntyre died from ischemic heart disease. We saw no evidence that Mr
McIntyre presented with any symptoms of heart disease during his time in prison
and healthcare staff could therefore not reasonably have identified or addressed
any heart problems.
33. Although Mr McIntyre’s death was unlikely to have been caused by drug use, post-
mortem toxicology results found that Mr McIntyre had elevated levels of
bromazolam, and low levels of cocaine in his system. Healthcare staff appropriately
identified that Mr McIntyre was detoxing while initially in custody and kept him under
observation. It is regrettable that Mr McIntyre did not receive any psychosocial
support from the substance misuse service to address his specific needs and risks.
34. Like many leaving prison, Mr McIntyre had received a short sentence which meant
that there was not enough time to meaningfully complete the work needed to
address his substance misuse issues. Doncaster’s substance misuse team
appropriately referred Mr McIntyre to community substance misuse services. As
there was no evidence that Mr McIntyre had a history of opioid use and died from
natural causes, naloxone would not have affected the outcome for him. We make
no recommendations.
35. Mr McIntyre had his own private accommodation in place so did not require housing
support from Doncaster or the Probation Service.
Adrian Usher
Prisons and Probation Ombudsman May 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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