Stephen Rees

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Independent investigation into
the death of Mr Stephen Rees,
on 18 March 2023, following his
release from HMP Parc
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 process failures.
4. Mr Stephen Rees died of bronchopneumonia with combined use of opiates and
severe fatty degeneration of the liver on 18 March 2023, following his release from
HMP Parc. He was 43 years old. We offer our condolences to those who knew
him.
5. Prior to his conviction in February 2023, Mr Rees engaged with the probation
service and received support from other professional agencies for his drug and
alcohol misuse. He was diagnosed with schizophrenia and was prescribed
medication to manage this.
6. On 1 March, Mr Rees’ Community Offender Manager (COM) and Prison Offender
Manager (POM) discussed release plans. The POM requested that the prison
mental health team arrange a follow up review in the community for Mr Rees on
release from custody. Mr Rees had a history of substance misuse and, while this
did not include opiate-based drugs, he was offered and accepted naloxone prior to
his release.
7. Mr Rees died three days after his release from prison.
8. We did not find any issues of concern and make no recommendations.
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The Investigation Process
9. We were informed of Mr Rees’ death on 27 March 2023.
10. The PPO investigator obtained copies of relevant extracts from Mr Rees’ prison
and probation records.
11. We informed HM Coroner for Swansea and Neath of the investigation. They gave
us the results of the post-mortem examination. We have sent the Coroner a copy
of this report.
12. The Ombudsman’s family liaison officer contacted Mr Rees’ next of kin to explain
the investigation and to ask if they had any matters they wanted us to consider.
They did not respond.
13. Mr Rees’ family received a copy of the initial report. They did not report any factual
inaccuracies in the report.
14. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS found two factual inaccuracies in the report, which have been amended
accordingly.
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Background Information
HMP Parc
15. HMP Parc is a medium security private prison run by G4S. It holds around 1,600
adult and young adult men who are either on remand or convicted. It also has a
unit for up to 60 young people aged under 18. NHS Provide provides primary
physical and mental healthcare services. There is 24-hour general healthcare
service. A local GP practice provides GP services, including a daily clinic and out
of hours cover.
Probation Service
16. The Probation Service work with all individuals subject to custodial and community
sentences. HMPPS in Wales became an early adopter of the Resettlement Model
in June 2021. In the model, resettlement planning for all prisoners was brought
forward to 7.5 months pre-release and included embedded dedicated resettlement
staff. In line with the Offender Management in Custody (OMiC) model,
Resettlement Staff would commence working with an individual from the point of
the Prison Offender Manager (POM)/Community Offender Manager (COM)
handover and would be a support to the COM and the prisoner through to release.
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Key Events
17. On 16 February 2023, Mr Rees was convicted of sexual offences and was
sentenced to 10 weeks in prison. He was transferred to HMP Parc. At the
reception health screening, Mr Rees said that he had been diagnosed with severe
social anxiety and schizophrenia, for which he was prescribed medication. Mr
Rees was also prescribed medication for epilepsy. He had a history of alcohol and
substance misuse and was referred to the alcohol brief intervention service.
18. On 28 February, healthcare staff called Ty Einon (community mental health
resource) and spoke with a worker, who confirmed that Mr Rees was under
primary care. They arranged for an appointment for Mr Rees on his release from
Parc.
19. Healthcare staff also booked Mr Rees for weight and medication reviews, as he
was falling sleep before eating his meals and was losing weight. They also
requested mental health support for Mr Rees on his release from prison in relation
to this.
20. On 1 March, Mr Rees’ Community Offender Manager (COM) had a video meeting
with the Prison Offender Manager (POM). They discussed release plans for Mr
Rees. The POM also requested that the mental health team arrange a follow up
mental health review for Mr Rees on release from custody, as Mr Rees had
missed a previous community appointment due to having been in custody.
21. The COM also met Mr Rees on 1 March. At the meeting, Mr Rees said he had
some worries about his personal safety if he returned to his home. (Mr Rees held
his own tenancy with Swansea Council.) She noted that she also had some
concerns in respect of his risk to others. She requested that his housing officer
consider a transfer for Mr Rees and advised him that his housing officer would visit
him to discuss this.
22. The COM said that there were no known concerns about opiate use for Mr Rees.
She said that at the point of sentence and throughout supervision, alcohol,
amphetamine and cannabis use were recognised as Mr Rees’ substances of
choice.
23. Probation records note that Mr Rees was required to receive alcohol treatment
and to engage with Dyfodol (the community substance misuse service) for his drug
and alcohol use. He was also managed by WISDOM (Wales Integrated Serious
and Dangerous Offender Management) and supported in terms of his community
engagement, benefits and mental health. The offender personality pathway was
also consulted on how to best to engage with Mr Rees.
24. On 7 March, Mr Rees was referred by a local hospital to the hepatology service for
blood tests. It is not clear why the tests were requested.
25. Also on 7 March, Mr Rees attended a second pre-release meeting with the COM.
She told him about employment, finances, protective factors, and engagement
with Dyfodol. They also discussed his physical and mental health. She offered
harm reduction advice and offered a naloxone kit, which Mr Rees accepted.
(Naloxone is a drug that can reverse the effects of an opiate overdose.)
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26. The COM arranged a community appointment for Mr Rees with Swansea Dyfodol
for 16 March. (It is not clear from probation records if he attended this
appointment.)
27. On 10 March, the blood test results identified that Mr Rees had Hepatitis C. He
declined further blood tests, stating he was being released the following week and
would seek treatment from own GP.
28. On 14 March, Mr Rees had a mental health follow up. The mental health worker
gave him details of his community mental health appointment and how to access a
community GP. Mr Rees received discharge paperwork and was told how to
collect medication upon release. Staff issued Mr Rees with a travel warrant for the
journey to Swansea.
29. On the same day, Mr Rees met his prison key worker. The key worker said that Mr
Rees told him that he had periods of being "up and down in mood" and that his
medication that helped him with this. Mr Rees said that he had no family or friends
that he was in contact with but would make contact once released. He said that he
had a flat in Swansea that he was happy with. Mr Rees said that he struggled with
alcohol but was going to attend weekly meetings run by Dyfodol in the community.
Mr Rees also said that he had issues with drugs in the past but said this was many
years ago.
Post Release
30. On 15 March, Mr Rees was released from Parc. He attended a MAPPA (Multi-
Agency Public Protection Arrangements) meeting on the day of his release.
(MAPPA involves agencies such as the police, prison service and probation
working together to protect the public by managing the risks posed by violent and
sexual offenders living in the community.)
31. Mr Rees also attended his induction appointment at Swansea Probation Office.
His COM was not working that day, so a colleague met Mr Rees on her behalf. No
concerns were raised in respect of Mr Rees’ risk to himself at this appointment.
The colleague noted that Mr Rees was in good spirits and keen to engage and
comply.
32. On 17 March, the police visited Mr Rees’ home address. As Mr Rees was a
registered sex offender, he would receive visits from the police as standard
practice. Mr Rees’ public protection officer reported that he was in good spirits,
making future plans and had stated a desire to engage and comply.
Circumstances of Mr Rees’ death
33. On 18 March, Mr Rees was found deceased at the home of a friend. On attending
Mr Rees’ flat, the police found an amount of medication, some of which had been
prescribed to Mr Rees. They reported no sign of illicit drug use or paraphernalia.
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Post-mortem report
34. The post-mortem report concluded that Mr Rees died of bronchopneumonia (a
form of pneumonia that affects both the alveoli in the lungs and the bronchi) with
combined use of opiates, and severe fatty degeneration of the liver.
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Findings
35. Mr Rees received regular support and supervision during his time in prison and on
release from custody. Pre and post release engagement by staff with Mr Rees was
good and the support he had already been receiving from professionals in the
community was due to continue with appropriate referrals made to services.
36. Mr Rees had a history of substance misuse. He was appropriately referred to
community drugs teams and a post-release appointment was made, although it is
unclear whether he attended. Mr Rees was offered and accepted naloxone prior to
his release.
Good practice
37. On the day before his release, Mr Rees had a key work session at HMP Parc
which covered a variety of topics related to his release, including accommodation,
substance misuse and mental health. We consider arranging a key work session
shortly before release to be an example of good practice. It allowed Mr Rees an
opportunity to discuss any concerns he might have had about his release.
Inquest
38. The inquest into Mr Rees’ death concluded on the 29 January 2025. The coroner
reached a narrative conclusion. The deceased died of bronchopneumonia, a
natural cause, contributed to by aspirating gastric contents as a result of excessive
but not fatal levels of respiratory depressant drugs.
Adrian Usher
Prisons and Probation Ombudsman March 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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