Warren Heller

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Independent investigation into
the death of Mr Warren Heller on
1 September 2024, following his
release from HMP Bullingdon
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 Warren Heller died from a multiple drug overdose on 1 September 2024,
following his release from HMP Bullingdon on 22 August. He was 38 years old. We
offer our condolences to those who knew him.
5. We found that Mr Heller received good support with his substance misuse issues at
Bullingdon. Substance misuse support was also put in place for when he was
released from prison.
6. We make no recommendations.
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The Investigation Process
7. HMPPS notified us of Mr Heller’s death on 11 October 2024.
8. The PPO investigator obtained copies of relevant extracts from Mr Heller’s prison
and probation records.
9. We informed HM Coroner for Milton Keynes of the investigation. They gave us the
results of the post-mortem examination. We have sent the Coroner a copy of this
report.
10. The Ombudsman’s office contacted Mr Heller’s next of kin, his sister, to explain the
investigation and to ask if she had any matters she wanted us to consider. She
asked whether Mr Heller:
• Was ever prescribed pregabalin and/or methadone, either while in prison or
while in the community.
• Was warned about the dangers of drug use, particularly the risks of mixing illicit
substances with methadone and alcohol, and how this increases the likelihood
of overdose.
• Was supported by substance misuse services whilst in prison, and whether prior
to his release, they referred him to a substance misuse service in the community
for ongoing support.
We have addressed these issues within the report.
11. We shared our initial report with HMPPS. They found no factual inaccuracies.
12. We sent a copy of our initial report to Mr Heller’s sister. She did not notify us of any
factual inaccuracies.
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Background Information
HMP Bullingdon
13. HMP Bullingdon is a local and resettlement prison, serving the courts of
Oxfordshire, Berkshire, Buckinghamshire and Wiltshire. Practice Plus Group
provides healthcare services and Cotswold Medicare Ltd provides GP 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.
HM Inspectorate of Prisons
15. The most recent inspection of HMP Bullingdon was in November 2022. Inspectors
reported that substance misuse services were good overall, and prisoners were
positive about the support provided. The teams were well-led and worked in an
integrated way. Inspectors observed skilled and caring staff who received regular
supervision and appropriate training. Pre-release planning was good, focusing on
relapse prevention, harm minimisation and continuing treatment if required.
Naloxone (to reverse the effects of opiate overdose) was offered on release where
appropriate.
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Key Events
Background
16. On 5 April 2024, Mr Warren Heller was arrested for assaulting an emergency
worker and remanded to HMP Bullingdon.
Pre-release planning
17. When Mr Heller arrived at Bullingdon, he told a nurse that he was experiencing
withdrawal symptoms from both alcohol and heroin. He was prescribed methadone
(to manage heroin withdrawal symptoms) on a detoxification programme (where the
dose reduces over time so that the individual eventually becomes drug-free), along
with diazepam (to alleviate the effects of alcohol withdrawal). He was not prescribed
pregabalin. Mr Heller was added to Inclusion’s caseload, the substance misuse
service at Bullingdon.
18. On 9 April, Mr Heller attended an initial substance misuse assessment with
Inclusion recovery worker. During the session, he said he would like to receive
substance misuse support from Inclusion while at Bullingdon. They explored the
available support and treatment options, and a full assessment was scheduled for
the following week.
19. On 15 April, Mr Heller attended a full substance misuse assessment with his
recovery worker. Mr Heller said that, after he was last released from Bullingdon in
January, he relapsed into daily alcohol, heroin and crack cocaine use, and dropped
out of treatment with the community substance misuse service. Mr Heller said he
wanted help to get stable while at Bullingdon.
20. They discussed the risks associated with taking drugs, and the recovery worker
gave Mr Heller advice to minimise the risk of overdose which included not using
drugs alone, only using small amounts to test their strength, and to smoke heroin
rather than inject it (as injecting increased the risks of overdose). He also warned
Mr Heller about the dangers of mixing drugs with alcohol and how this could further
increase the risks of overdose. He gave Mr Heller information on tolerance levels
and overdose awareness, including how to recognise the signs and symptoms of an
overdose, and what to do in the event of one. He noted that Mr Heller showed a
good understanding of these risks. He created a care plan focused on Mr Heller’s
heroin and crack use, helping him identify triggers, reduce his usage, and work
towards decreasing dependency. Additionally, Mr Heller was provided with in-cell
workbooks on these topics, which he later completed to a high standard. When
asked, Mr Heller said that he was already trained in the use of naloxone (a
medication used to reverse the effects of opioid overdose) and agreed to be given a
naloxone kit on his release.
21. On 14 May, Mr Heller was convicted of the assault of an emergency worker and
sentenced to 28 weeks in prison. He returned to Bullingdon.
22. On 30 May, Mr Heller attended a substance misuse review in which he said he felt
stable on his methadone dosage. He was given advice regarding harm minimisation
and raised no further concerns.
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23. On 20 June, Mr Heller did not attend an Inclusion workshop on triggers to
substance misuse and relapse prevention.
24. On 17 July, during a care plan review, Mr Heller told his recovery worker that he still
felt stable on his methadone programme and did not wish to complete additional
substance misuse workbooks or attend workshops. The recovery worker reiterated
the risks associated with drug use and provided harm reduction guidance, including
ways to minimise the risk of overdose. Mr Heller stated that he no longer wanted
regular substance misuse appointments while at Bullingdon but requested a referral
to a community substance misuse service in preparation for his release.
25. On 7 August, the recovery worker sent a referral to Addiction Recovery Community
(ARC), a community substance misuse service in Milton Keynes, in preparation for
Mr Heller’s upcoming release.
Release from HMP Bullingdon
26. On 22 August, a nurse saw Mr Heller prior to his release from prison. The nurse
gave him a naloxone kit with instructions on how to use it, and a letter detailing his
appointment with ARC for 11.30am the following day. Mr Heller said he would be
living with his father.
27. At 2.00pm, Mr Heller attended his initial appointment at Milton Keynes Probation
Office. His community offender manager (COM) completed his induction, went
through his licence conditions, and Mr Heller signed a copy to say that he
understood them.
28. The next day, Mr Heller attended his appointment with ARC, where he was issued a
prescription for his ongoing methadone detoxification program. He was told that,
moving forward, his appointments would take place every Friday. Mr Heller was not
prescribed pregabalin upon his release from prison.
29. On 28 August, Mr Heller attended his scheduled appointment with his COM. Mr
Heller spoke positively about his release and raised no concerns. He told his COM
that he had a good relationship with his ARC recovery worker, felt stable on his
methadone script, was not having any cravings, and was hoping to gradually reduce
his dosage. The COM issued his next appointment for 4 September and gave him a
travel warrant to ensure he could attend.
Circumstances of Mr Heller’s death
30. On the evening of 31 August, Mr Heller and his girlfriend were staying at his father’s
house. According to police records, his girlfriend became concerned that he had
taken illicit methadone and pregabalin. Fearing he might overdose, she hid the
remaining methadone before they went to bed. The next day, at approximately
3.30pm, she woke to find Mr Heller unresponsive, with fluid coming from his nose.
She immediately went downstairs to alert his father, who checked on him before
calling emergency services. At 3.51pm, paramedics arrived and pronounced life
extinct.
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Post-mortem report
31. The post-mortem report concluded that Mr Heller's death resulted from central
respiratory depression due to the toxic effects of heroin/morphine, methadone, and
pregabalin. Additionally, the pathologist detected cocaine in his bloodstream, which
he noted may have contributed to his death by causing cardiotoxicity (heart
damage).
Findings
Substance misuse support
32. Mr Heller had a history of substance misuse. During his time at Bullingdon, he was
appropriately supported by Inclusion, the prison’s substance misuse service, and
warned about the risks and dangers associated with substance misuse. The prison
promptly and appropriately referred Mr Heller to ARC to ensure the continuity of his
methadone detoxification programme, and so that he had access to substance
misuse support upon release. He was also trained in the use of naloxone and
released with a supply of this.
33. We are satisfied that Mr Heller’s COM took appropriate measures to address his
substance misuse upon his release from prison. This included adding licence
conditions to comply with any requirements relating to addressing their substance
misuse issues.
34. We are satisfied that both the prison and probation services did all they could to
manage the risks associated with his substance misuse.
35. We make no recommendations.
Adrian Usher
Prisons and Probation Ombudsman May 2025
Inquest
The inquest, held on 18 July 2025, concluded that Mr Heller’s death was drug related.
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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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