Steven McGuire

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Steven McGuire
on 26 June 2022, following his
release from HMP Humber.
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, 2024
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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.
If my office is to best assist HM 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.
Mr Steven McGuire died in hospital on 26 June of a cardiac arrest caused by heroin and
cocaine intoxication, following his release from HMP Humber on 25 June 2022. He was 41
years old. I offer my condolences to Mr McGuire’s family and friends.
Mr McGuire was released on licence from HMP Humber on 22 June 2023 and was
required to reside at Victoria House Approved Premises. Mr McGuire was found
unresponsive in a house after taking a drug overdose.
Mr McGuire had a history of substance misuse and staff provided naloxone training and a
take-home naloxone kit prior to his release.
When Mr McGuire failed to arrive at Victoria House, staff took appropriate action and
decided he should be recalled to prison.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Adrian Usher
Prisons and Probation Ombudsman April 2024
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 2
Background Information ................................................................................................... 3
Key Events ....................................................................................................................... 4
Findings ........................................................................................................................... 6
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Summary
Events
1. In December 2020, Mr Steven McGuire was sentenced to three years and two
months in prison for robbery and was sent to HMP Hull. He was transferred to HMP
Humber on 11 April 2021.
2. Mr McGuire had a history of substance misuse and received support from the Drug
and Alcohol Support Team (DART). He completed a methadone detoxification
programme and attended the peer support group on the drug recovery unit.
3. In October 2022, Mr McGuire’s Prison Offender Manager and Community Offender
Manager started to plan for Mr McGuire’s release.
4. A pre-release review took place on 14 June 2023. Staff made a referral to a
community drug and alcohol service and Mr McGuire completed naloxone (used to
reverse an opioid overdose) training.
5. On 22 June, Mr McGuire was released on licence to live at Victoria House
Approved Premises (AP). A nurse at the prison gave Mr McGuire a take-home
naloxone kit before his release.
6. Mr McGuire did not attend the AP in accordance with his licence conditions. Staff
reported Mr McGuire to the out of hours manager who decided that he had
breached his licence conditions and should be recalled to prison. Staff reported Mr
McGuire to the police as unlawfully at large.
7. At 9.30am on 26 June, the police attended Victoria House and informed probation
staff that Mr McGuire had died in hospital. The police also informed Mr McGuire’s
next of kin of his death.
8. The post-mortem examination confirmed that Mr McGuire had died from a cardiac
arrest caused by heroin and cocaine intoxication.
Findings
9. Mr McGuire had a history of substance misuse and staff made a referral to the
community drug and alcohol service prior to his release from prison. Mr McGuire
completed naloxone training and staff gave him a take-home naloxone kit.
10. He was released with settled accommodation in an AP but did not ever arrive to
take up the place.
11. When Mr McGuire breached the conditions of his licence, AP staff took appropriate
action and recalled him to prison.
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The Investigation Process
12. HMPPS notified us of Mr McGuire’s death on 26 June 2022.
13. The investigator issued notices to staff and prisoners at HMP Humber and Victoria
House Approved Premises informing them of the investigation and asking anyone
with relevant information to contact her. No one responded.
14. The investigator obtained copies of relevant extracts from Mr McGuire’s prison and
medical records.
15. The case was suspended while we waited for the outcome of the police
investigation.
16. We informed HM Coroner for Hull and East Riding of the investigation. The Coroner
gave us the results of the post-mortem examination. We have sent the Coroner a
copy of this report.
17. We wrote to Mr McGuire’s wife to explain the investigation and to ask if she had any
matters she wanted us to consider. She did not ask any questions but asked for a
copy of the investigation report.
18. Mr McGuire’s wife received a copy of the initial report. She did not raise any further
issues, or comment on the factual accuracy of the report.
19. 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 Humber
20. HMP Humber is a category C prison that holds up to 1,062 men. City Health Care
Partnership provides healthcare services from 7.00am to 8.30pm and there is no
healthcare service during the night. It also provides substance misuse, mental
health, pharmacy and dental services but during core hours only.
HM Inspectorate of Prisons
21. The most recent inspection of HMP Humber was in October and November 2020.
Inspectors reported that pre-release preparation for prisoners was good and
included medications to take with them, help to find a GP in the community, harm
minimisation advice and naloxone as necessary.
Victoria House Approved Premises
22. Approved Premises (or APs, formerly known as probation and bail hostels)
accommodate offenders released from prison on licence and those directed to live
there by the courts as a condition of bail. Their purpose is to provide an enhanced
level of residential supervision in the community, as well as a supportive and
structured environment. Residents are responsible for their own healthcare and are
expected to register with a GP.
23. Victoria House is staffed by Probation Service employees who are on duty 24 hours
a day. Sodexo provides security staff and cleaners. AP staff keep each resident’s
medication locked away and administer it as required. Victoria House staff are not
clinically trained other than to distribute medication.
24. Residents are subject to AP rules in addition to any licence conditions they have
been given. They are subject to a curfew between 11.00pm and 6.00am.
Previous deaths at Victoria House Approved Premises
25. There were no deaths at Victoria House in the three years prior to Mr McGuire’s
death.
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Key Events
HMP Humber
26. On 2 November 2020, Mr Steven McGuire was found guilty of attempted robbery
and was sent to HMP Hull. He was sentenced to three years and two months
imprisonment on 4 December. On 11 April 2021, Mr McGuire was transferred to
HMP Humber. He had been in prison before. Mr McGuire was allocated a single cell
on the drug recovery wing.
27. A nurse at the prison completed Mr McGuire’s initial health assessment. Mr
McGuire had a history of substance misuse (heroin, crack cocaine, psychoactive
substances and cannabis). He told the nurse that he suffered from anxiety and
depression and took antidepressant medication. The nurse referred him to the
substance misuse service (SMS) and the mental health team.
28. On 12 April, a Drug and Alcohol Support Team (DART) worker created a
methadone detoxification care plan. Mr McGuire successfully completed the
detoxification programme on 21 September. He continued to receive support from
DART throughout his time at Humber and attended the peer recovery support group
on the wing every day.
29. Also on 12 April, a mental health nurse assessed Mr McGuire and created a mental
health care plan. This said that Mr McGuire needed regular therapeutic contact with
the mental health team to monitor his levels of anxiety, depression and
antidepressant medication. Mr McGuire said that he used illicit substances in the
community when his stress levels were increased. The mental health team
continued to monitor him and noted that he engaged well in the recovery group
sessions and was compliant with his medication.
30. On 21 October, Mr McGuire was allocated a Community Offender Manager (COM).
31. On 2 December, a meeting took place with the COM, Mr McGuire’s DART worker
and his Prison Offender Manager (POM), to start the release planning process in
preparation for Mr McGuire’s release on 22 June 2022.
32. On 2 February 2022, Mr McGuire was discharged from the mental health team. His
levels of anxiety were low, and he told a mental health nurse that he was feeling
positive.
33. Further release planning took place on 8 February and the POM, and the COM,
noted that Mr McGuire would be released on licence to reside at Victoria House AP.
34. On 14 June, Mr McGuire had a pre-release review. Staff made a referral to a drug
and alcohol service and Mr McGuire said he would be attending Narcotics
Anonymous. Mr McGuire completed naloxone training (used to reverse an opioid
overdose) with a SMS nurse. Mr McGuire was taught how to recognise the signs of
an opioid overdose and how to administer naloxone. He told DART staff that he felt
motivated to remain drug free and to live a normal life in the community.
35. At 10.54am on 22 June, Mr McGuire was released from Humber. A nurse at the
prison gave him a take-home naloxone kit.
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36. Mr McGuire’s licence conditions said that he should reside at Victoria House AP
and arrive there by 3.30pm on the day of his release. He was required to stay there
between 5.00pm and midnight every day until his electronic tag was installed unless
otherwise authorised by his supervising officer.
Victoria House AP
37. By 3.30pm, Mr McGuire had not arrived at Victoria House. At 7.55pm, the out of
hours manager decided that Mr McGuire had breached his licence condition by
failing to reside at the AP. His licence was revoked, and Mr McGuire was recalled to
prison. Staff reported Mr McGuire to the police as unlawfully at large.
38. At 9.30am on 26 June, the police attended Victoria House and informed probation
staff that Mr McGuire had died in hospital. The police also notified Mr McGuire’s
wife of his death.
Information received following the police investigation
39. At around 4.45pm on 25 June, the police were asked by the Ambulance Service to
attend an address in Hull because a man, who was subsequently identified as Mr
McGuire, had suffered a cardiac arrest. Ambulance staff took Mr McGuire to
hospital.
40. A man and a woman at the address told the police that Mr McGuire had been at the
house since 24 June. The police investigation did not establish where Mr McGuire
went after his release from HMP Humber. The police found evidence of drug use in
the address and a substance which was identified as heroin in Mr McGuire’s
pocket.
41. The police noted an injury on Mr McGuire’s forehead. The man and woman were
arrested on suspicion of actual bodily harm. After Mr McGuire’s death, they were re-
arrested on suspicion of murder.
42. The police investigation concluded that there was no evidence that the man and
woman were responsible for Mr McGuire’s death.
Post-mortem report
43. A pathologist gave Mr McGuire’s cause of death as complications of an out of
hospital cardiac arrest caused by heroin and cocaine intoxication. The pathologist
said that there was evidence of heroin and cocaine use prior to Mr McGuire’s death.
44. There was no evidence of any serious injuries, specifically, Mr McGuire did not
have a significant head injury.
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Findings
45. Mr McGuire had a history of substance misuse and was referred to the community
drug and alcohol service on his release from prison. Staff gave him information
about the risk of drug overdose and training on the use of naloxone. A nurse issued
Mr McGuire with a take-home naloxone kit prior to his release.
46. Mr McGuire was released with a place in an AP, which would have provided him
with additional support to manage the first weeks out of prison. When Mr McGuire
breached the conditions of his licence, AP staff took appropriate action and recalled
him to prison.
Inquest
47. The inquest, heard on 5 October 2023, concluded that Mr McGuire’s death was
related to drugs/alcohol.
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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