Thomas Dowson

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Thomas
Dowson on 2 September 2023,
following his release from
HMP/YOI 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, 2024
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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 Thomas Dowson died of combined drug toxicity on 2 September 2023 following
his release from HMP Doncaster on 29 August. He was 43 years old. We offer our
condolences to those who knew him.
5. We did not find any issues of concern related to the support Mr Dowson received
pre and post his release from prison and we make no recommendations.
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The Investigation Process
6. HMPPS notified us of Mr Dowson’s death on 11 October 2023.
7. The PPO investigator obtained copies of relevant extracts from Mr Dowson’s prison
and probation records.
8. We informed HM Coroner for Doncaster of the investigation. He 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 Dowson’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.
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/YOI Doncaster
11. HMP/YOI Doncaster is a local category B and resettlement prison which holds male
and young adult male prisoners who have either been convicted or are on remand.
It is managed by Serco. Care UK are the providers for Physical health, mental
health and substance misuse services.
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 and
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
13. On 28 February 2023, Mr Dowson was charged with aggravated taking of a vehicle
and was remanded to HMP Doncaster.
14. That day, a nurse completed Mr Dowson’s initial health screen. Mr Dowson said
that he was withdrawing from alcohol, opiates, and benzodiazepines. He said he
had injected drugs the previous day. She made a referral to the substance misuse
team and took a urine sample. Mr Dowson tested positive for benzodiazepines,
cocaine, cannabinoids and opiates.
15. On 1 March, a nurse saw Mr Dowson. He said that he had injected 10 bags of
heroin every day and spent £50 per day on crack. He also said he used ‘street
vallies’ (diazepam) when he could obtain them.
16. Mr Dowson was put on methadone detoxification therapy and was monitored for
alcohol withdrawal. Mr Dowson was prescribed 10ml of methadone for three days,
increasing to 20ml for one day and increasing again thereafter to 30ml.
Pre-release planning
17. On 21 March, a practitioner in the substance misuse team met with Mr Dowson and
completed a psychosocial assessment. During this assessment Mr Dowson
consented to the practitioner referring him to Changing Lives so they could provide
follow on support in the community when he was released. (By the time Mr Dowson
was convicted, he had already discharged himself from the substance misuse team
and therefore no appointment was arranged for his release.)
18. On 19 April, the substance misuse practitioner completed a structured psychosocial
intervention with Mr Dowson as Mr Dowson said he was ready to reduce his
methadone dosage. They agreed on a plan that he would reduce his methadone by
5ml and maintain on 25ml. This was implemented the following day.
19. On 1 May, Mr Dowson refused to take his methadone and said he did not want it
anymore. A pharmacy technician documented this on his medical records.
20. The following day, the substance misuse practitioner went to visit Mr Dowson to ask
him why he had refused his methadone. Mr Dowson said that he had had enough of
putting poison into his body and was not going to do it anymore. Mr Dowson said he
was fine and was not having any withdrawal symptoms. The practitioner made him
aware that he would be taken off his methadone script if he missed it for three
consecutive days, and Mr Dowson said he was fine with that.
21. On 2 May, Mr Dowson was taken to the segregation unit for disobeying staff orders
and presenting with threatening behaviour. Mr Dowson started to display odd
behaviour; he refused to put clothes on, threatened staff, and would not engage in
any meaningful conversations. As a result, three officers had to be present when his
door was unlocked.
22. On 13 May, a nurse from the mental health team completed a mental health review
on Mr Dowson. She was unsure if his behaviour was due to him taking illicit drugs,
but Mr Dowson was unable to provide a urine sample to confirm this.
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23. On 26 May, the substance misuse practitioner saw Mr Dowson once he was
relocated to a standard wing. Mr Dowson said that he felt fine after stopping his
methadone. Mr Dowson said he thought his behaviour in the segregation unit was
due to a reaction to some prescribed medication. During this conversation, Mr
Dowson said that he wanted to be discharged from the substance misuse team
because he was drug free and he signed a disclaimer to that effect.
24. Mr Dowson was on remand at the time of disengaging with the substance misuse
team. The substance misuse practitioner no longer tracked him in preparation for
his release, and as a result, he was not put on the list for naltrexone (a medication
used to manage alcohol and opioid use) for release.
25. On 4 July, Mr Dowson was convicted of aggravated taking of a vehicle and was
sentenced to 12 months in prison. He stayed at Doncaster.
26. Mr Dowson’s allocated Community Offender Manager (COM) did not refer Mr
Dowson to Changing Lives as part of the release planning. He said that he had
looked on Delius (Probation records) and it (wrongly) appeared Mr Dowson had not
been on a methadone script or engaged with the substance misuse team in prison
prior to release.
27. On 25 July, the COM contacted the housing officer to confirm if Mr Dowson would
be able to return to the property he had prior to going to prison. She confirmed he
was still the tenant for the property.
28. On 23 August, the COM completed a video link appointment with Mr Dowson in
preparation for his release. Mr Dowson said it was the last time he was going to be
in prison, and he wanted to change. Mr Dowson also said he was keen to engage
with the Integrated Offender Management Team (Multi-agency partnership to
manage persistent, repeat offenders).
29. On 29 August, Mr Dowson was released on licence from Doncaster. Because he
was not engaged with substance misuse services at the time, Mr Dowson was not
released with naloxone.
30. Mr Dowson had two additional conditions on his licence, these were:
• To comply with any requirements specified by the supervising officer for the
purpose of ensuring that he addressed his alcohol and drug problems.
• To comply with drug testing as and when required by the supervising officer.
Post-release management
31. On 29 August, Mr Dowson attended his initial probation appointment with the duty
officer, as his COM was on leave. During this appointment, it was noted that Mr
Dowson did not want to stay long, and he was getting agitated. He said he had a lot
to do that day and needed to go to the job centre and make a claim. Mr Dowson
understood his licence conditions and signed his licence.
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32. On 30 August, Mr Dowson was accepted onto the Integrated Offender Management
cohort and was allocated to a PC. However, the PC never met Mr Dowson before
he died.
Circumstances of Mr Dowson’s death
33. On 1 September, Mr Dowson went to his friend’s house (his friend said with the
intention of using drugs together). His friend left his property and when he returned
at approximately midnight, he found Mr Dowson unconscious. The paramedics
attended and confirmed that Mr Dowson had died. They found a used syringe on
the toilet seat next to Mr Dowson.
34. The police concluded there were no suspicious circumstances surrounding Mr
Dowson’s death.
Post-mortem report
35. The post-mortem report concluded that Mr Dowson died of combined drug toxicity.
36. At the inquest held on 19 January 2024, the coroner concluded that Mr Dowson’s
death was drug related.
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Findings
Substance misuse services
37. The substance misuse team at Doncaster supported Mr Dowson with his illicit drug
use. While on remand, he was referred to the substance misuse team, and they
addressed his needs. They placed him on a detoxification programme and referred
him to Changing Lives, a community drug and alcohol service, for continued
support after release. However, Mr Dowson stopped taking methadone and then,
having decided he no longer needed support from the substance misuse team, was
discharged from the service. As a result, he was no longer tracked in the pre-
release period or put on the list for naltrexone or naloxone on release and no further
referrals were made to Changing Lives.
38. Currently, COMs across the Probation Service have high caseloads working with
complex individuals, and providing support and prioritising need is imperative, and
this was the case for the COM who had overall responsibility for Mr Dowson’s risk
management. The COM was only allocated the case on 10 July, six weeks before
Mr Dowson’s release. He wrongly thought that Mr Dowson did not require any
substance misuse support and so did not refer him to community drugs services.
39. Mr Dowson had a history of drug use, and although the COM knew he was
abstinent from drugs at the time of his release, he put two additional licence
conditions in place relating to drug use, as a precautionary measure, in case Mr
Dowson relapsed while in the community.
40. The COM said a referral to Changing Lives could have been completed as part of
Mr Dowson’s sentence planning, once he was released, or if Mr Dowson relapsed
into using drugs again. However, this was never completed or discussed with Mr
Dowson because Mr Dowson died before attending his next appointment with
probation. Given Mr Dowson’s request to disengage from substance misuse
support in prison, we consider that a referral to community drugs services pre-
release would have been unlikely to have changed the outcome for him.
41. We make no recommendations.
Adrian Usher
Prisons and Probation Ombudsman June 2024
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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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