William Bissett

PFD Report All Responded Ref: 2025-0046
Date of Report 27 January 2025
Coroner Nicholas Rheinberg
Response Deadline ✓ from report 18 March 2025
All 2 responses received · Deadline: 18 Mar 2025
Coroner's Concerns (AI summary)
Severe systemic failures in release planning for a vulnerable, elderly prisoner, including delayed engagement, inadequate accommodation arrangements, and insufficient emotional support, resulted in a tragic outcome.
View full coroner's concerns
(1) Evidence was heard to the effect that in the 8-month period before a prisoner is released arrangements for release are the responsibility of the Community Offender Manager with the Prison Offender Manager acting as a conduit of information. Further it was said that the Community Offender Manager should arrange an early meeting with the prisoner. Mr Bissett a man aged 88 in failing health only saw his Community Offender Manager on 5th October 2023, 8 days before his release.

(2) On 23rd June 2023 Mr Bissett was informed of the terms of his licence upon release. He was informed that he would not be allowed to return home. No sufficient attempt was made to engage with Mr Bissett to discuss accommodation in the event that he was unable to find a place to live himself. (3) 56 days before release, it being clear that Mr Bissett had nowhere to go, planning for accommodation should have been commenced with Fylde Borough Council who would have the duty to provide temporary housing and who would have engaged with Mr Bissett to discuss his requirements. (4) 56 days before release HMP Wymott should have informed the Fylde Coast Local Authorities that Mr Bissett would be homeless upon release so that his name appeared on the agenda for the monthly Prison Release Meeting. This was not done.

(5) Lack of planning for release and lack of engagement left Mr Bissett only with the knowledge that he would probably have to live the rest of his life separated from his wife. No attempt was made to help him come to terms with this reality.
Responses
HM Inspectorate of Prisons Regulator / Inspectorate
30 Jan 2025
Noted
HM Inspectorate of Prisons acknowledges the report and states that the issues raised are covered by their inspection criteria. They will keep the findings on file and follow up as appropriate during the next inspection of HMP Wymott. (AI summary)
View full response
Dear Mr Rheinberg,

WILLIAM CAMPBELL BISSETT – Prevention of Future Deaths Report

Thank you for sharing your regulation 28 report to prevent future deaths with His Majesty’s Inspectorate of Prisons (HMI Prisons). We are saddened to learn of the findings of your investigation.

HMI Prisons is an independent inspectorate. We provide scrutiny of the conditions for and treatment of prisoners and other detainees and report publicly on our findings. HMI Prisons’ inspections are carried out against published inspection criteria known as Expectations. Many of the issues highlighted in your report are covered via our Expectations, and are therefore matters which our inspectors will consider on each inspection. For example, in relation to preparation for release, our expectations state: “Helping prisoners to work towards and prepare for the day of release is understood as a central purpose of the establishment.”

Other issues raised in your report such as prisons recognising the importance of family ties and that prisoners should have a named member of staff who knows them well and provides support with resettlement issues are also covered via our Expectations.

Some of the particular concerns you raise in Mr Bissett’s case around a lack of adequate contact between prison offender managers and community offender managers and prisoners being released homeless are sadly issues on which we have reported all too often recently and on which we have raised concerns in our most recent annual report.

We will keep your findings on file so that, when we next inspect HMP Wymott, inspectors are aware of this information and can follow up as appropriate.
HMPPS and NW Probation Service Central Government
4 Apr 2025
Action Taken
HMPPS and NW Probation Service amended and re-issued the OMiC POM to COM Handover Guidance in March 2024. They are also undertaking a review of the quality of POM to COM handovers and commissioned a resettlement review. There is also a new safeguarding policy statement for Practitioners. (AI summary)
View full response
Dear Mr. Rheinberg,

Re: William Bissett (deceased) Regulation 28 Preventing Future Deaths Response

Thank you for your Regulation 28 Report, issued following the Inquest into the death of Mr William Bissett. I know that you will share a copy of this response with the family, and I would first like to express my sincere condolences for their loss. You have raised concerns which you summarised as follows: - Where it becomes known that a prisoner is likely to be homeless on release, consideration be given to instituting a regime whereby a meeting takes place, not less than 56 days before the release date, such meeting to include the prisoner and representatives from the prison Offender Management Unit, Healthcare and the Local Authority Housing Department which will bear responsibility for discharging a duty to rehouse, in order to put in place arrangements to support the prisoner in the prisoner’s transition from custody back to the community In response, a number of changes have taken place. The OMiC (Offender Management in Custody) POM to COM Handover Guidance was amended and re-issued in March 2024. This provides clear instructions about the requirements for the handover process from a prison-based offender manager (POM) to a community based offender manager (COM). The Guidance sets out very clear instructions on the timing of this meeting, who should attend and record keeping so that what is discussed forms the basis of planning for release.

2 OFFICIAL OFFICIAL

There has also been a review commissioned by the Area Executive Director to look at the quality of POM to COM handovers which proposes relevant recommendations to improve timeliness and quality in respect of the exchange and sharing of information with stakeholders both in the prison and the community. Locally, anyone managed by the Blackpool Probation Office in custody who is without a release address is discussed at the local Prison Leavers Meetings which are attended by Probation, Prison, and the Local Authority. A list of cases for discussion at these meetings is generated from the Probation case management system – NDelius, using the “No Fixed Abode” recorded status. The Prison Leavers Meetings are chaired by the Probation Delivery Unit (PDU) Senior Probation Officer which ensures they have insight into the pre-release work required/being undertaken by their teams in a timely manner and have the links with the housing workers to facilitate assessments and discuss need, including duty to refer situations. In the North West Probation Region, I have commissioned a resettlement review and the consistency of arrangements for multi-agency pre-release meetings will be considered as part of this review. We also have a number of PDU’s where housing workers are co-located at our offices and early indications are that this improves working relationships and the sharing of information. In other PDUs Local Authority housing workers regularly attend the Probation Offices to work with Probation Practitioners to support them with addressing prison leaver accommodation needs. These arrangements are demonstrating improved outcomes such as helping to understand when to make referrals under the Duty to Refer and referrals being assessed in a timely manner with each Service understanding need. There is also a new policy statement for Practitioners in respect of safeguarding adults at risk - The Safeguarding Adults at Risk in the Community Probation Service Policy Statement and care and support needs should be discussed at the POM to COM handover meeting. I can also confirm that there is an expectation that the case management system NDelius should be updated within twenty-four hours of all contacts taking place and recording of contact outcomes is currently being monitored at weekly performance meetings led by senior probation officers. Thank you for bringing these matters of concern to my attention. Please be assured that learning from the circumstances of this tragic death will also be shared more widely with colleagues across the Probation Regions.
Sent To
  • HMPPS
  • HMP Wymott
Response Status
Linked responses 2 of 2
56-Day Deadline 18 Mar 2025
All responses received
About PFD responses

Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.

Source: Courts and Tribunals Judiciary

Report Sections
Investigation and Inquest
On 26th October 2023 an inquest into the death of William Campbell Bissett born 21st April 1935 was opened. The investigation concluded at the end of the inquest on 22nd January 2025. The conclusion of the inquest was that on 13th October 2023 at some time between midnight and 5.10 am William Campbell Bissett died by hanging. He died by suicide in cell 2/12 on the Haven Unit at HMP Wymott. A failure of advance planning prior to 5th October 2023 for accommodation for Mr Bissett on release and insufficient engagement with him by prison offender management and the probation service may have contributed to his death.
Circumstances of the Death
Mr Bissett was serving a long sentence at HMP Wymott in respect of historic sex crimes. On 13th October 2023 at the age of 88 he was due to be released on licence. The terms of his licence included an exclusion zone the effect of which meant that he was not allowed to return to his home and as a result upon release would be living separate from his wife of 56 years. On 6th March 2023 his Prison Offender Manager met with his Community Offender Manager in order to hand over responsibility for release arrangements. Mr Bissett was not present at the handover meeting and was only seen by his Community Offender Manager for the first time on 5th October 2025. An application for emergency accommodation was lodged on 6th October and on 11th October 2023 Mr Bissett was interviewed by housing officers from Fylde Borough Council.
Action Should Be Taken
Where it becomes known that a prisoner is likely to be homeless on release, consideration be given to instituting a regime whereby a meeting takes place, not less than 56 days before the release date, such meeting to include the prisoner and representatives from the prison Offender Management Unit, Healthcare and the Local Authority Housing Department which will bear responsibility for discharging a duty to rehouse, in order to put in place arrangements to support the prisoner in the prisoner’s transition from custody back to the community
Related Inquiry Recommendations

Public inquiry recommendations addressing similar themes

Service change continuity plans
Vale of Leven Inquiry
Care and discharge planning
Continuing responsibility for care
Mid Staffs Inquiry
Care and discharge planning
Follow up of patients
Mid Staffs Inquiry
Care and discharge planning
Death in Custody Checklist
Baha Mousa Inquiry
Mentally unwell prisoner support
HMP Maghaberry lessons learned
Billy Wright Inquiry
Prison Overcrowding & Staff Vacancies

Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.