Wesley Andrew

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Independent investigation into
the death of Mr Wesley Andrew,
a prisoner at HMP Wymott, on
11 August 2024
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, 2026
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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 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.
Mr Wesley Andrew died on 11 August 2024 at HMP Wymott. He was 47 years old. I offer
my condolences to Mr Andrew’s family and friends. The cause of Mr Andrew’s death will
be determined at the inquest. However, the post-mortem toxicology results showed the
presence of synthetic cannabinoids in his system.
Mr Andrew had a longstanding history of substance misuse and, during his time at
Wymott, was actively working with the substance misuse team to address his issues.
However, Mr Andrew was found under the influence of psychoactive substances (PS) on
several occasions. Wymott appropriately supported him after such occasions and
repeatedly warned him about the risks and dangers associated with PS use.
Over the course of the weekend of Mr Andrew’s death, staff responded promptly and
appropriately to an unusually high number of incidents on K wing (where Mr Andrew lived)
involving prisoners under the influence of illicit substances. All staff involved worked
diligently to mitigate the likelihood of further incidents and to manage the potential risk of
harm this posed to prisoners. Unfortunately, a particularly potent batch of PS had already
circulated around the wing, and despite their efforts, Wymott were unable to prevent Mr
Andrew’s death.
Regrettably, as with other prisons, the trading of PS remains an intractable problem that
threatens the stability, safety and security of Wymott. I am satisfied that the prison is
committed to tackling this issue and has made considerable efforts to combat drug supply
and demand, both before and since Mr Andrew’s death. I make no recommendations.
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 2025
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 6
Findings ......................................................................................................................... 13
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Summary
Events
1. Mr Wesley Andrew had a significant criminal history, largely acquisitive offending in
order to fund his drug habit.
2. On 3 October 2019, Mr Andrew was sentenced to six years imprisonment for
robbery. In September 2022, he was released from prison. In February 2023, he
was recalled to prison for breaching his licence conditions.
3. On 2 June 2023, Mr Andrew moved to HMP Wymott. Mr Andrew was allocated a
substance misuse recovery practitioner from Delphi, the prison’s substance misuse
provider.
4. Over the next eight months, despite regular engagement with Delphi, Mr Andrew
was found under the influence of illicit substances on several occasions. Each time,
Mr Andrew said he had taken psychoactive substances (PS). He was given ongoing
support by Delphi recovery practitioners which included repeated warnings about
the risks associated with PS and advice on how he could keep himself safe, and
prevent potential overdose situations.
5. On 15 February, Mr Andrew moved to K wing. On 26 February, he began a drug
rehabilitation programme on the Therapeutic Community (TC), based on K wing.
6. On 4 March, Mr Andrew asked to be deselected from the TC. He said he did not
feel safe on K wing or anywhere in the prison due to his unpaid drug debts. On 7
March, after receiving support and encouragement from staff, Mr Andrew rejoined
the TC.
7. On 27 March, a prisoner entered Mr Andrew’s cell and assaulted him. Mr Andrew
moved to another cell on K wing where he said he wanted to self-isolate. The next
day, despite further support from staff, Mr Andrew again deselected from the TC. In
June he applied to transfer to another prison; this had not happened before his
death.
8. Over the weekend of 10/11 August, officers on K wing radioed over 20 separate
emergency medical alerts after finding multiple prisoners unresponsive and/or
under the influence of illicit substances.
9. On the evening of 11 August, staff found Mr Andrew lying unresponsive on the floor
of his shower. Staff were unable to resuscitate Mr Andrew and, at 9.40pm,
paramedics pronounced life extinct.
Findings
10. Mr Andrew had a history of substance misuse. While he was at Wymott, he was
seen regularly by the substance misuse team who took appropriate steps to support
his long-term recovery. They encouraged him to participate in substance misuse-
related offending behaviour programmes, supported his engagement in the TC,
ensured he was aware of the risks and dangers associated with drug use, and
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advised him on how he could minimise these risks. We are satisfied that Wymott did
all they could to manage the risks associated with Mr Andrew’s substance misuse.
11. Wymott has recognised that, similarly with other prisons, PS continues to be the
primary drug of choice among prisoners and poses the greatest threat to the
prison's stability. In response, Wymott has developed a comprehensive drug
strategy that incorporates the most up-to-date concerns and outlines a proactive
approach to addressing emerging drug threats and trends. Wymott has taken
considerable measures to reduce supply and demand for drugs at the prison, and
these measures are ongoing. For this reason, we make no recommendation.
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The Investigation Process
12. HMPPS notified us of Mr Andrew’s death on 11 August 2024.
13. The investigator issued notices to staff and prisoners at HMP Wymott informing
them of the investigation and asking anyone with relevant information to contact
her. No one responded.
14. The investigator visited Wymott on 22 August. She obtained copies of relevant
extracts from Mr Andrew’s prison and medical records and interviewed two
prisoners. In September, the investigation was reallocated to another investigator.
15. NHS England commissioned a clinical reviewer to review Mr Andrew’s clinical care
at the prison. She and the investigator jointly interviewed seven members of staff at
Wymott on 6 and 7 November. The investigator interviewed one further member of
staff in December.
16. We informed HM Coroner for Lancashire and Blackburn of the investigation. The
Coroner gave us the results of the post-mortem examination and toxicology tests.
However, the cause of death will be determined at inquest. We have sent the
Coroner a copy of this report.
17. The Ombudsman’s office contacted Mr Andrew’s next of kin, his mother, to explain
the investigation and to ask if she had any matters she wanted us to consider. She
asked several questions about the events leading up to his death and the
circumstances of his death. These have been answered within this report.
18. Mr Andrew’s mother received a copy of the initial report. She raised a number of
questions that do not impact on the factual accuracy of this report and have been
addressed through separate correspondence.
19. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS pointed out some factual inaccuracies, and this report has been amended
accordingly.
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Background Information
HMP Wymott
20. HMP Wymott is a category C training prison for convicted adult men. Over half of
the population is made up of men who have been convicted of sexual offences.
Physical and mental health care services are provided by Greater Manchester
Mental Health NHS Foundation Trust, who also provide substance misuse
treatment alongside Delphi Medical.
HM Inspectorate of Prisons
21. The most recent inspection of HMP Wymott was in December 2023. Inspectors
reported that drugs and the availability of other illicit items continued to be a
significant risk to safety and well-being. It was a concern that far more prisoners
with mental health problems said they had developed a drug problem while at the
prison. On average, over the previous year, one in five prisoners who had been
tested were found to have been positive for drugs. Most tested positive for PS,
cannabis, and opiates. There was an up-to-date drug strategy and action plan, and
partnership working with prison staff was good. Leaders were taking some steps to
prevent drugs from getting into the prison, including joint operations with the police
and regional search teams. However, this was undermined by a lack of technology
to detect drugs and no enhanced gate security as seen in many other prisons.
22. Inspectors found that the therapeutic community on K wing provided a structured,
therapeutic environment for prisoners with substance dependency issues and was
highly valued by its community members. It had ‘recovery peers’ helping to support
and mentor those undertaking the programme.
Independent Monitoring Board
23. Each prison has an Independent Monitoring Board (IMB) of unpaid volunteers from
the local community who help to ensure that prisoners are treated fairly and
decently. In its latest annual report, for the year 2023 to 2024, the IMB expressed
concern about the spikes in the use of illicit substances, particularly following any
reported drone drops. However, the IMB recognised that much was being done to
try to reduce the use of illicit drugs, including the work of the drug and alcohol
rehabilitation service (DARS).
Previous deaths at HMP Wymott
24. Mr Andrew was the thirty-first prisoner to die at Wymott since August 2021. Three of
the previous deaths were self-inflicted and 27 were from natural causes. None of
these previous investigations raised issues relevant to this investigation.
25. Up to the end of January 2025, there had been six further deaths at Wymott since
the death of Mr Andrew. Four of these deaths were from natural causes and two
were self-inflicted.
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Psychoactive substances (PS)
26. The term psychoactive substances is a broad term that refers to a drug or other
substance that affects mental process. Synthetic cannabinoids and synthetic
opioids (including nitazene) are substances that mimic the effects of traditional
controlled drugs such as cannabis, cocaine, heroin and amphetamines. Synthetic
cannabinoids and synthetic opioids can be difficult to detect as the compounds
used in their manufacture can vary and use of these substances presents a serious
problem across the prison estate.
27. PS can affect people in a number of ways, including increasing heart rate, raising
blood pressure, reducing blood supply to the heart and vomiting. Prisoners under
the influence of these substances can present with marked levels of disinhibition,
heightened energy levels, a high tolerance of pain and a potential for violence.
Besides emerging evidence of such dangers to physical health, the use of PS is
associated with the deterioration of mental health, suicide and self-harm. Testing for
PS is in place in prisons as part of existing mandatory drug testing arrangements.
Therapeutic Community
28. The therapeutic community (TC) based on K wing is a community-led, living and
learning environment that seeks to address drug and/or alcohol addiction and helps
to promote social, psychosocial, and behavioural change. The TC is a 12-month
intensive structured programme. The aim is to prepare prisoners for living and
working on release and reduce substance related offending.
29. To be eligible for the TC programme, prisoners must have demonstrated a three-
month period without any disciplinary warnings, must not be misusing substances,
and must not be on any opiate substitution medication. The TC accepts prisoners
both from other prisons and already at Wymott. Due to the increasing prison
population, the TC unit also accommodates ‘lodgers’ - prisoners who are not
participating in the programme but reside on the unit and follow the prison’s
standard regime.
Robust Recovery
30. Every time a prisoner is suspected of being under the influence (UTI) of drugs or
alcohol at Wymott, they are expected to see a member of the Delphi Drug and
Alcohol Rehabilitation service (DARS) for a ‘robust recovery’ meeting. In the robust
recovery meeting, the incident will be explored, and the prisoner will be given
appropriate advice and support. Each incident is then discussed at the weekly
multidisciplinary team meeting where they will decide upon any further appropriate
actions and support.
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Key Events
Background
31. Probation records note that Mr Wesley Andrew had a significant history of
substance misuse during which he intermittently engaged with relevant support
services. He had an extensive criminal history, primarily offences to fund his drug
misuse.
32. In July 2019, Mr Andrew was remanded to prison after being charged with robbery.
In October, he was sentenced to six years imprisonment.
33. On 27 September 2022, Mr Andrew was released from HMP Berwyn to Highfield
House Approved Premises (AP – accommodation run by probation), on licence. Mr
Andrew spent five months in the community during which time he repeatedly broke
AP rules, provided positive drugs tests, and breached his licence conditions.
Subsequently, in February 2023, Mr Andrew’s community offender manager (COM)
assessed that he could no longer be managed safely in the community. They
recalled Mr Andrew and, on 27 February, he was taken to HMP Preston.
34. On 2 June 2023, Mr Andrew moved to HMP Wymott.
HMP Wymott, 2 June 2023 - 11 August 2024
35. On his arrival at Wymott, Mr Andrew agreed to be referred to the substance misuse
service, Delphi. Mr Andrew was located on E wing, a standard residential wing.
36. On 13 June, Mr Andrew attended his initial substance misuse assessment with a
Delphi recovery practitioner. Mr Andrew said that while in the community, he had
misused amphetamines and cannabis and while at Wymott, he would like to
complete the drug recovery programme on the Therapeutic Community (TC) unit,
on K wing. After the assessment, Mr Andrew was assigned a Delphi recovery
practitioner.
37. On 20 June, the recovery practitioner saw Mr Andrew to complete a triage
assessment. Mr Andrew again expressed his interest in the TC programme, and
she told him how he could apply. Mr Andrew said that he was fed up with the
repetitive cycle of substance misuse, offending and prison sentences. Mr Andrew
said he was currently drug free and wanted help to ensure he remained drug free
when released. They agreed on a substance misuse care plan which included
monthly individual sessions around coping strategies and harm minimisation.
38. The following week, the recovery practitioner helped Mr Andrew complete an
application to the TC (he had difficulties with reading and writing). They sent this to
K wing for consideration.
39. On 28 June, the recovery practitioner told Mr Andrew that he was not yet eligible for
the TC (he needed to be three months free from any prison disciplinary warnings)
and, as a result, they had declined his application.
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40. On 24 August, another Delphi recovery practitioner saw Mr Andrew to complete a
‘robust recovery’ after he was found under the influence (UTI) of an illicit substance
a few days previously. Mr Andrew admitted to being UTI and said that he had
smoked psychoactive substances (PS) in a pipe. Mr Andrew said he would benefit
from having some additional support with his substance misuse issues and would
discuss this with his recovery practitioner in his next appointment.
41. On 29 August, Mr Andrew told his recovery practitioner that he was having
difficulties with his current cellmate who used PS regularly and the temptations this
brought, especially after hearing bad news. They agreed that Mr Andrew needed to
develop other coping mechanisms when in a stressful situation and would benefit
from completing some structured work around this. They agreed to start this work in
two weeks’ time. She warned Mr Andrew about the risks associated with PS and
they explored ways to reduce harm and prevent potential overdose situations.
42. On 5 September, Mr Andrew was suspected to be UTI. At his robust recovery
meeting with another Delphi recovery practitioner two days later, Mr Andrew said
that he was not currently working as the workshop had temporarily closed for
maintenance. He said he had used PS out of boredom. Mr Andrew said he had
applied to do maths and English courses in education but was awaiting a response.
She warned Mr Andrew about the risks and dangers associated with PS and they
discussed ways to reduce the risk of overdose.
43. On 12 September, Mr Andrew completed a structured psychosocial intervention
session about stimulant drugs. His recovery practitioner noted that he engaged well
and reflected insightfully on his past drug use.
44. On 5 October, a programmes facilitator completed an initial Thinking Skills
Programme (TSP) interview with Mr Andrew. TSP is an accredited offending
behaviour programme which aims to enhance prisoners’ emotional self-
management and problem-solving abilities. Mr Andrew said he was very keen to
start TSP so he signed the TSP compact and agreed to adhere to the required
behaviours when attending programmes. He was added to the next course which
started on 10 November.
45. On 1 November, Mr Andrew attended his appointment with his recovery
practitioner, in which he said he was doing well and was looking forward to starting
TSP. They completed some relapse prevention work, and she warned Mr Andrew
about the dangers associated with amphetamine and PS misuse. They discussed
how Mr Andrew’s tolerance levels would be lower after a period of abstinence and
explored ways to reduce the risk of overdose. This included avoiding using
substances when alone in case he required urgent medical attention and starting
with small amounts to test the drugs’ potency. She noted that Mr Andrew engaged
well and had a good understanding of their discussions.
46. On 10 November, Mr Andrew failed to attend his first TSP session. On 13
November, Mr Andrew failed to attend the second TSP session. When questioned
about his absence, Mr Andrew said he no longer wanted to attend the course and
he would prefer to complete it in the community after his release from prison. The
programme facilitator encouraged Mr Andrew to remain on the course and
explained how it would benefit him in managing his behaviour. However, Mr Andrew
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was adamant he did not want to attend the course and was subsequently
deselected from the programme.
47. On 12 December, staff suspected Mr Andrew was UTI. The next day, a Delphi
recovery practitioner completed a robust recovery in which Mr Andrew admitted to
taking PS. The recovery practitioner reiterated the dangers associated with taking
PS and reminded Mr Andrew of ways to keep himself safe when using. Mr Andrew
said he would like some extra support with his substance misuse, and this was
subsequently relayed to his recovery practitioner after the session.
48. The following day, Mr Andrew told his recovery practitioner that he had relapsed
several times recently after finding out about the death of his friend. They discussed
alternative coping mechanisms, and she asked if he would reconsider joining the
TC, to which Mr Andrew said he would think about. As requested, she agreed to
see Mr Andrew on a more regular basis for extra support.
49. On 18 December, the recovery practitioner told Mr Andrew that due to his recent
drug use, it was unlikely that he would be considered suitable for release at his
upcoming parole hearing with the Parole Board (who decide whether a prisoner is
suitable to be released from prison after serving the minimum portion of their
sentence). She explained that the TC would provide the additional support he
needed and would reflect positively on him in any further parole hearings. Mr
Andrew said he would wait until the outcome of his parole hearing in February
before making any decisions regarding the TC.
50. On 10 January 2024, Mr Andrew told his recovery practitioner that he was still using
PS intermittently as he was apprehensive about his upcoming parole hearing and
the outcome of this. They discussed distraction techniques, and she reminded Mr
Andrew of ways to minimise the risk of overdose.
51. On 9 February, Mr Andrew attended his oral hearing with the Parole Board.
52. On 13 February, Mr Andrew saw his recovery practitioner on E wing landing and
asked if he could speak to her in private. He told her he was in debt to prisoners on
E wing, felt vulnerable, and wanted to move to K wing. He said he now wanted to
complete the programme with the TC. She helped Mr Andrew submit a TC
application and informed the officers on E wing of Mr Andrew’s concerns. On 15
February, Mr Andrew moved to K wing whilst he awaited the outcome of his TC
application.
53. On 22 February, during a welfare check, Mr Andrew told his recovery practitioner
that his debt issues had followed him to K wing, and he felt vulnerable when not in
his cell. He said that he did not want officers to speak to him about it as he did not
want other prisoners to know that he had spoken to staff. He just wanted wing staff
to be aware. She relayed this to K wing officers, submitted an intelligence report
and wrote in the wing observation book.
54. On 26 February, Mr Andrew received notification from the Parole Board that he was
not yet deemed suitable for release. The Board advised that he would benefit from
completing further work around his substance misuse to support his rehabilitation
before his next hearing. The same day, his TC application was accepted, and he
started the programme.
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55. The next day, the recovery practitioner completed a welfare check on Mr Andrew.
Mr Andrew said he felt in a much better place since starting the TC and felt safe to
move around the wing. She discharged him from the care of the Delphi team and
explained that he would be allocated a new recovery practitioner, based on the TC.
56. On 4 March, Mr Andrew asked to deselect from the TC. He said he did not feel safe
on K wing or anywhere in the prison. The next day, staff started a Challenge,
Support and Intervention Plan (CSIP) investigation. CSIP is a process used to
support and manage prisoners who are considered to pose a risk to (and in some
prisons to support those who are a victim of violence). On 7 March, after
encouragement from staff, Mr Andrew rejoined the TC.
57. On 27 March, a prisoner from K wing entered Mr Andrew’s cell and assaulted him
by hitting his face with the back of a plug socket. Prison intelligence received at the
time suggested that Mr Andrew was assaulted as he was in debt to another
prisoner for drugs and vape cartridges. Mr Andrew sustained head and facial
injuries and attended hospital for further assessment. On his return, Mr Andrew was
moved to another cell on K wing where he said he wanted to self-isolate. (Self-
isolation is when a prisoner chooses to isolate themselves from the prison’s regime
and remain locked in their cell for an extended period.)
58. The next day, Mr Andrew told a TC recovery practitioner that he wanted to deselect
from the TC. Mr Andrew was encouraged to stay but he was adamant that he
wanted to deselect and transfer to another prison. His former recovery practitioner
was re-allocated to him.
59. On 29 March, Mr Andrew’s sister rang Wymott’s Safer Living helpline with concerns
for his welfare. As a result, wing staff visited Mr Andrew in his cell to complete a
welfare check before returning the call and reassuring Mr Andrew’s sister of the
measures in place to support him.
60. On 4 April, an administrator working in Safer Living emailed a Custodial Manager
(CM) informing her that Mr Andrew’s CSIP investigation had been concluded and
that it was to be progressed to a full CSIP. The administrator requested that the CM
complete the CSIP. She advised the administrator that she was about to begin a
period of night duties and so the CSIP should be allocated to someone else. There
is no evidence that this was actioned, and the CSIP investigation was later closed.
61. On 24 June, an officer assisted Mr Andrew in completing an inter-prison application,
as he said he wanted to transfer to another prison. They sent this to the Offender
Management Unit.
62. On 17 July, Mr Andrew’s prison offender manager (POM) spoke to Mr Andrew
about his prison transfer request. The POM advised him that the request was being
held with the Offender Categorisation and Assessment unit (OCA, a department
within the prison’s Offender Management Unit responsible for identifying suitable
prisoners for transfer). Mr Andrew had not received any updates on the transfer
before his death.
63. On Friday 9 August, officers on K wing radioed three separate code blues
(indicating a prisoner is either unresponsive or having difficulty breathing) after
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finding prisoners UTI. (Wymott’s local UTI policy instructs staff to either radio a code
blue or call healthcare to attend every time a prisoner is suspected to be UTI.)
64. On 10 August, officers on K wing radioed approximately ten separate code blues
after finding multiple prisoners unresponsive and/or UTI. This was far more than
normal on the wing. Healthcare staff attended each incident and assessed the
prisoners for signs of clinical deterioration. Although ambulances were automatically
called by the control room, they were stood down and the prisoners concerned were
placed on 15-minute welfare checks. Wing staff removed suspected drug
paraphernalia from prisoners throughout the day including vape pens and pieces of
paper thought to be soaked in PS.
Events of 11 August
65. The investigator watched CCTV footage, body worn video camera (BWVC) footage
and listened to staff radio communications from 11 August. She also obtained
information from the North West Ambulance Service. The following account has
been taken from all sources.
66. In the morning, staff told prisoners on K wing that a reduced regime would be in
effect for the duration of the day. This included a more controlled association period
to limit the number of individuals out of their cells simultaneously, thereby reducing
the potential for drug trading.
67. Throughout the day, there were approximately ten code blue incidents on K wing
attributed to prisoners UTI. As with the previous day, healthcare staff assessed the
affected prisoners while wing staff confiscated drug-related paraphernalia from their
cells and conducted regular welfare checks. Additionally, these prisoners were
prohibited from attending afternoon association, and four prisoners were relocated
to the Care and Separation Unit. (CSU, where prisoners are separated from the
general prison population.)
68. At 4.41pm, CCTV shows Mr Andrew waiting at the landing gate to collect his
evening meal. Approximately four minutes later, Mr Andrew returned to his cell
where he was locked in for the remainder of the evening. Nobody else entered or
left his cell after that time.
69. At approximately 8.45pm, an Operational Support Grade (OSG) began her night
shift on K wing. She received a full handover from the previous officer in charge
who told her about the drug related incidents and that several prisoners had been
moved to the CSU as a result. She made a list of the empty cells on K wing before
starting her roll count (a visual check of all prisoners) at approximately 8.55pm.
70. Around 9.00pm, the OSG reached Mr Andrew’s cell. As she could not see him, she
called out and banged on the door. She waited a few moments before going to the
wing office to double check the prisoner roll board, which confirmed that Mr Andrew
should be present in his cell. She returned to Mr Andrew’s cell before shouting and
banging on his door. As she still had not received a response, at 9.05pm, she
radioed an officer to attend the cell to assist her. At interview, she explained that,
given the high number of wing moves that day, she was still unsure whether Mr
Andrew’s cell was occupied or not, so she radioed the officer for clarification.
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71. At approximately 9.08pm, three officers arrived at Mr Andrew’s cell and spoke to the
OSG about her concerns. At 9.10pm, staff decided to enter the cell and found Mr
Andrew lying unresponsive on the floor of his shower (the shower was not turned
on) with a broken vape pen next to him. An officer immediately radioed a code blue,
and the other two officers took it in turns to give cardiopulmonary resuscitation
(CPR). The control room immediately requested an ambulance.
72. At approximately 9.15pm, two nurses arrived with a defibrillator (a device that gives
shocks to the heart to restore a normal heartbeat) and continued efforts to revive Mr
Andrew. After taking some initial observations, a nurse concluded that Mr Andrew
was showing clear signs of death (his fingers and toes were blue in colour and his
body was rigid) and resuscitation attempts were therefore futile. At 9.23pm, the
nurse advised staff to cease CPR.
73. At 9.39pm, paramedics arrived and one minute later, pronounced life extinct.
Contact with Mr Andrew’s family
74. On the evening of Mr Andrew’s death, following discussion between the prison and
local police, the police attended his mother’s address and broke the news of Mr
Andrew’s death. At 9.00am the next morning, a chaplain was allocated as the family
liaison officer. A few hours later, he and the Drug Strategy Lead visited Mr Andrew’s
mother at her home to explain processes and offer their condolences. The prison
offered a contribution to Mr Andrew’s funeral costs in line with national guidance.
Support for prisoners and staff
75. Postvention is a joint HMPPS and Samaritans initiative that aims to ensure a
consistent approach to providing staff and prisoners support following all deaths in
custody. Postvention procedures should be initiated immediately after every self-
inflicted death and on a case by case basis after all other types of death. Key
elements of postvention care include a hot debrief for staff involved in the
emergency response and engaging Listeners (prisoners trained by the Samaritans
to provide confidential peer-support) to identify prisoners most affected by the
death.
76. After Mr Andrew’s death, a CM debriefed the staff involved in the emergency
response to ensure they had the opportunity to discuss any issues arising, and to
offer support. The staff care team also offered support. A few hours later a senior
prison manager rang all staff involved to check on their welfare and offer further
support.
77. The prison posted notices informing other prisoners of Mr Andrew’s death, and
offering support. Prisoners on the wing told us they felt supported by staff following
Mr Andrew’s death. TC staff organised a reflection session, providing an opportunity
for the wing to come together and speak about Mr Andrew.
Post-mortem report
78. Mr Andrew was subject to a digital autopsy (when the autopsy is conducted by a
scan rather than the physical examination of the body). The post-mortem author did
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not have the results of the toxicology tests at the time of writing but concluded that –
if there was no evidence that substances had caused Mr Andrew’s death – left
ventricular hypertrophy (when the heart does not pump efficiently) could be the
cause of death.
79. The toxicology results showed the presence of synthetic cannabinoids, but no other
unprescribed substances. Severe toxic effects of synthetic cannabinoids include
chest pains, stroke and psychosis and death has been known to occur due to
arrhythmia, convulsion and multi-organ failure.
80. The cause of Mr Andrew’s death will be established by the Coroner at inquest.
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Findings
Substance misuse support
81. While the cause of Mr Andrew’s death has not yet been ascertained, given the
presence of synthetic cannabinoids in his body, we have considered it likely that his
death was drug related.
82. Mr Andrew had a history of substance misuse. On his arrival at Wymott, Mr Andrew
was promptly allocated a Delphi recovery practitioner. She saw Mr Andrew for
regular recovery sessions in which she responded appropriately and
compassionately to his concerns. She proactively took measures to help Mr Andrew
understand and address his substance misuse issues. She also consistently
warned Mr Andrew about the risks and dangers associated with substance misuse,
focusing specifically on PS. Finally, she advised him how he could keep himself
safe and reduce the risk of overdose if he did choose to misuse drugs whilst in
prison.
83. In February 2024, Mr Andrew moved to K wing to start a drug rehabilitation
programme on the therapeutic community (TC). After being assaulted on K wing in
early March, Mr Andrew made the decision to deselect from the programme. Staff
encouraged Mr Andrew to remain on the TC and tried to make him feel safer whilst
residing on K wing. Despite this, Mr Andrew was adamant that he wished to be
removed from the programme and this was actioned the same day.
84. Overall, we are satisfied that Wymott did everything they reasonably could to
manage the risks associated with Mr Andrew’s substance misuse and appropriately
supported him. The clinical reviewer concurs with this view.
Measures taken after the death of Mr Andrew
85. Over the weekend of Mr Andrew’s death, staff on K wing radioed over 20 code
blues in response to prisoners being UTI. This was an exceptionally high number to
occur in a single weekend. Overall, we found that the situation was handled well by
both prison senior leaders and officers on the wing. Even under significant
pressure, staff on K wing followed the correct procedures for prisoners found UTI,
and managers took measures to minimise the potential for further drug trading and
mitigate any risk of further harm. Those who were persistently causing issues or
being found UTI were moved off the wing to the CSU and a restricted regime was
enforced on K wing for the weekend to minimise the opportunities for drug trading.
Healthcare attended each code blue to assess and provide appropriate medical
intervention, and all prisoners considered UTI were subject to a period of monitoring
by wing staff to ensure their ongoing welfare.
86. After the death of Mr Andrew, Wymott took appropriate steps to contain the batch of
suspected PS to K unit by temporarily implementing a restricted regime whereby
prisoners on K wing were not permitted to leave the unit and were only permitted to
associate in small cohorts on their individual spurs. Staff tried to locate the source
of the PS and remove it from the wing through targeted cell searches with the
support of drugs dogs, and the analysis of drug related intelligence reports. The
intelligence suggested that a prisoner who transferred to Wymott on 8 August
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brought a significant quantity of PS with him. Further intelligence suggested that
another prisoner on K wing had purchased a significant amount of this PS and gave
it away to drug users on the wing to cause maximum disruption and distress to staff.
A prison manager explained that upon being notified of this information, staff
investigated fully and the prisoners involved were identified and transferred to
another prison. Additionally, several individuals were deselected from the TC
programme and moved off the wing, and approximately five further prisoners were
transferred to other prisons to disrupt drug dealing activities.
87. Finally, each prisoner on K wing was drug tested, given additional keywork sessions
and seen for a one-to-one appointment by a DARS practitioner who warned them
about a potentially dangerous batch of PS present on the wing, gave them harm
reduction advice, and offered ongoing support. We consider the prison’s response
to have been an example of good practice.
Drug supply and demand at Wymott
88. Wymott’s drug strategy for the years 2023-2025 notes that PS continues to be the
most popular drug. When incidents of PS use spike, there is a correlation with a
spike in violence, self-harm and other debt related issues, causing real concerns for
safety and stability within the prison.
89. We spoke to a prison manager about drug supply and demand at Wymott. He
reiterated that PS continues to be the most popular drug at Wymott due to how
cheap, readily available, and undetectable it is. He said that PS-soaked paper burnt
in a vape is still the most popular method of ingesting PS. Drug ingress routes into
the prison include packages being thrown over the wall, being delivered via drones
or through the external post. They also enter the prison via families and friends on
visits or through members of staff.
Restricting Supply
90. Wymott takes a zero-tolerance approach to anyone they identify as supplying drugs
into the prison or those trafficking drugs within the prison. They use a variety of
methods to prevent drugs entering the prison which include:
• Ensuring that staff working with incoming mail are well trained, follow
procedures and utilise all tools available to them to detect drugs coming into the
prison via post. All domestic mail is routinely photocopied and the validity of
legal mail is checked via the use of a Rapiscan machine (which detects the
presence of drugs). Property parcels are not permitted to be sent in directly from
family, and additional property can only be obtained via one of the prison’s
authorised catalogues.
• The use of enhanced measures to detect drugs on any individual entering the
prison. Body scanners are used on new receptions entering Wymott to detect for
secreted items. If the scanner detects a secreted item, the prisoner is located in
the CSU until he produces a negative scan, preventing the drugs being
circulated within the prison. For social visits, the officer in charge receives a
daily intelligence brief and area drugs dogs are used to support the staff carrying
out the searches of the visitors.
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• The installation of window grills to act as physical barriers to prevent passing
between windows and restrict drone access. A prison manager told us that
currently, most of the cell windows on the outer side of the prison have window
grills, however most of the inward facing windows do not. He said that although
they have manufactured the grills to cover the inner windows, they are waiting
for funding to have them installed.
• The possibility of borrowing specialist drone detection equipment. The prison
manager explained that Wymott rely solely on human sightings and reviewing
CCTV to detect drone activity at Wymott, meaning that they have no means of
tracking drone activity unless physically spotted. As drone detection equipment
is very expensive and predominantly reserved for use in the high security estate,
Wymott are currently in negotiations with HMP Garth (situated next door to
Wymott) and the local police to fund the borrowing of the police’ drone detection
equipment, which will be shared between the two prisons. This will enable the
early detection of drone activity and provide a more accurate intelligence picture
on the use of drones in the trafficking of illicit items into Wymott.
• The use of external wall checks and patrols prior to unlock and prisoner
movement to ensure the fence and external wall is undamaged, and to look for
any potential throw overs.
• The use of external CCTV monitoring of the perimeter and other vulnerable
areas within the prison with bids submitted for additional CCTV for evidential
purposes and the detection of offences.
• A clear searching strategy to proactively disrupt the trade of drugs within
Wymott. This includes the use of intelligence led, targeted searches supported
by drugs dogs, when available.
• Effective use of mandatory drug tests with new drug testing processes
implemented.
• A focus on improving the quality of intelligence to create a more accurate
intelligence picture of drug supply and demand at Wymott. Wymott holds a
variety of weekly and monthly security meetings to discuss responses to
emerging drug trends and agree on actions to combat the risks associated with
these. The Tactical Tasking and Coordination Group uses intelligence to
establish areas of conveyance and identify (and close) any gaps.
• An established relationship with all key stakeholders to effectively work together
using intelligence strands to respond to emerging drug threats. This includes
working with the serious organised crime unit to identify key organised crime
nominals as well as the sharing of intelligence between the local police force to
determine and disrupt local supply routes.
Reducing Demand
91. Wymott aims to reduce the demand for drugs by actively supporting and
encouraging prisoners into sustainable recovery through a wide range of clinical
services and non-clinical interventions. Programmes, such as the TC, offer an
intensive structured programme in which staff encourage prisoners to participate in
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a wide range of enrichment activities and services designed to alleviate boredom
and promote recovery. Substance misuse recovery peers, recovery focus groups,
and mutual aid support groups (such as Narcotics Anonymous) are used to support
and enhance the substance misuse services. Therapeutic activities such as art,
drama, music and ‘recovery gym’ exercise sessions are promoted, and prisoners
are encouraged to attend educational courses to support their resettlement.
92. Wymott also aim to reduce demand by balancing supporting prisoners found under
the influence of drugs with more punitive measures for those persistently using. On
the first occasion a prisoner is found under the influence, a DARS practitioner will
see them to offer harm reduction advice, warn them about the risks associated with
drug misuse, and signpost them to the appropriate avenues of support. Those
prisoners refusing to engage with support or persistently using however will be
subject to prison disciplinary procedures.
93. Overall, we recognise the significant challenges inherent in preventing drugs
entering Wymott. PS is especially prevalent in category C prisons because their
lower security measures and stable population allows for the maintenance of
distribution networks. In addition, Wymott has a substantial and diverse population,
a large perimeter and is situated in an open and accessible semi-rural area making
it vulnerable to throwovers and drones. The illicit drugs market in prison is
controlled by organised crime gangs and the scale of the problem requires a co-
ordinated approach. We found that Wymott fully recognises the above challenges
and has taken considerable steps to address them. The prison has both clinical and
operational staff dedicated to roles involving drug rehabilitation, strategy and
security, and those we spoke to were clearly passionate about their work and were
committed to delivering a safe, secure and stable environment.
94. Mr Andrews’ death was the first drug related death at Wymott in four years. This is
significantly lower than many other category C prisons with similar issues. Given the
proactive steps that Wymott are taking, we make no recommendation.
Challenge, Support and Intervention Plan (CSIP)
95. Challenge, Support and Intervention Plans (CSIP) are a violence reduction case
management model used to support and manage prisoners who are considered to
pose a risk to other prisoners. In some prisons, CSIPs are also used to provide
support to victims or suspected victims of bullying, intimidation, and those who self-
isolate.
96. At the time of Mr Andrew's death, Wymott’s violence prevention strategy outlined
that, upon receiving a CSIP referral, the wing CM would hold a face-to-face meeting
with the prisoner. Based on the findings of this meeting, the wing CM would decide
whether to initiate a full CSIP.
97. A CSIP referral for Mr Andrew was submitted to the Safer Living department in
March 2024, after he was assaulted by another prisoner on K wing. As per policy,
the department tasked the K wing manager with conducting a face-to-face meeting
with Mr Andrew to decide on an appropriate course of action. As she ell was due to
start two weeks of night duties, she was unable to complete this meeting. We found
no evidence that the CSIP was reallocated, and we have been unable to ascertain
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what happened with the investigation after this date. The CSIP appears to have
been closed on the prison computer system on 5 May.
98. After Mr Andrew’s death, Wymott introduced a single case manager approach to
CSIPs. Each prisoner now has a designated CSIP manager who will continue to be
responsible for the management of their CSIP, should they be moved to another
area of the prison. This places more accountability on individual case managers
and should minimise the likelihood of actions being missed. This is supported by a
quality assurance process in which spot checks are being undertaken to ensure that
staff and managers are following the procedures to the required standards. We
therefore make no recommendation.
Clinical care
99. The clinical reviewer found that the care Mr Andrew received at Wymott was of a
good standard and was equivalent to that which he could have expected to receive
in the wider community. She made no recommendations.
Governor to note
100. After Mr Andrew’s death, a box of pain relief medication prescribed to a different
prisoner (not one who had previously resided in the cell) was found in his cell. The
clinical reviewer advised that the medication was not known for illicit use or trading
and had no known desirable effects aside from managing pain. The toxicology tests
conducted did not test for the medication.
101. We do not know if Mr Andrew had obtained the medication illicitly. We bring the
matter to the Governor’s attention.
102. We note that it took staff around 10 minutes to go into Mr Andrew’s cell when he
could not be seen and did not respond during a routine roll check. We consider that,
in the circumstances of numerous cell and wing moves in response to the clear
issues on K wing that weekend, and uncertainty about whether Mr Andrew was in
the cell or not, this was not entirely unreasonable. However, the Governor will want
to be assured that staff understand their responsibility to quickly go into a cell in an
emergency.
Inquest
103. The inquest into Mr Andrews’ death ended on 16 December 2025. It concluded that
the medical cause of Mr Andrews’ death was synthetic cannabinoid toxicity and he
had died as a result of misadventure.
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