Andrew Hague

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Independent investigation into
the death of Mr Andrew Hague,
on 15 October 2023, following
his release from HMP Wealstun
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 Andrew Hague died of acute heroin, flualprazolam and pregabalin toxicity on 15
October 2023, following his release from HMP Wealstun on 12 October 2023. He
was 33 years old. I offer my condolences to those who knew him.
5. HMPPS has a legal duty to refer prisoners to the local authority if they are at risk of
homelessness on release from prison. However, Mr Hague’s Community Offender
Manager did not refer him under this duty, and there were too few attempts to
engage with Mr Hague to plan for his release.
6. The current criteria for offering prison leavers naloxone on release from prison
relies too heavily on them having engaged with the prison’s substance misuse
team.
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The Investigation Process
7. HMPPS notified us of Mr Hague’s death on 15 October 2023.
8. The PPO investigator obtained copies of relevant extracts from HMP Wealstun’s
prison and probation records.
9. We informed HM Coroner for Wakefield of the investigation. He gave us the results
of the post-mortem examination. We have sent the Coroner a copy of this report.
10. We contacted Mr Hague’s mother to explain the investigation and to ask if she had
any matters she wanted us to consider. She did not have any questions but asked
for a copy of the report.
11. The initial report was shared with HM Prison and Probation Service (HMPPS) and
Practice Plus Group. HMPPS pointed out some factual inaccuracies and this report
has been amended accordingly.
12. Mr Hague’s mother received a copy of the draft report. She did not make any
comments.
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Background Information
HMP Wealstun
13. HMP Wealstun is a category C training and resettlement prison for men. Practice
Plus Group provides healthcare, including mental health services, at the prison.
Midlands Partnership NHS Foundation Trust provides substance misuse 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, as well as prepare reports to advise the Parole Board. They
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 (where applicable).
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Key Events
15. On 27 April 2021, Mr Andrew Hague was convicted of unlawful wounding and
possession of an offensive weapon. He was sentenced to 30 months in prison. Mr
Hague was released on licence a number of times. His last recall to prison was on 8
February 2023 and he was sent to HMP Leeds.
16. On 19 January 2023, prison Probation Service Officer made a housing referral for
him because it was known that he would be homeless on release.
17. On 9 February 2023, Mr Hague saw a member of the resettlement team at HMP
Leeds. He refused to engage in the interview and did not answer the questions. The
team member recorded that his COM should complete a Commissioned
Rehabilitative Service (CRS) referral for housing and a referral to the local authority
under the legal duty to refer those at risk of homelessness. The CRS work in
partnership with the Probation Service to support and enable rehabilitation when
someone is released from prison.
18. On 13 February 2023, a trainee probation officer emailed Mr Hague to invite him to
meet her by video link the next day to discuss his recall. Mr Hague did not attend,
so she sent a second email asking him to write back if he wanted to engage.
19. On 27 February, Mr Hague saw St Giles (a national charity which aims to support
people held back by homelessness, unemployment and the criminal justice
system). They advised Mr Hague to present as homeless to the local authority on
release and that a referral to HMPPS’ Community Accommodation Service Tier 3
(CAS3) had been made. However, Mr Hague was being released following the
completion of his sentence so did not qualify for assistance from CAS3. (CAS3 is
open to adult prison leavers who are at risk of homelessness on release from
prison. The service provides access to up to 84 days of accommodation. However,
CAS3 is not available to those released from custody once their sentence has
expired.)
20. On 4 May 2023, Mr Hague was transferred to HMP Wealstun.
21. During his healthcare reception screen, Mr Hague told the nurse that he had used
drugs in the past, but he had not had any problems with alcohol or drugs in the
previous three months.
22. Mr Hague told the nurse that he had mental health problems for which he was
taking medication.
23. On 11 May, a drug and alcohol inclusion worker from the drug and alcohol
rehabilitation service (DARS) visited Mr Hague. He asked him if he wanted support
from DARS. Mr Hague told him that he did not need any.
24. On 28 May and 2 June, a mental health nurse met Mr Hague to discuss his mental
health. He told her that he had misused drugs and alcohol in the past, including
heroin. She concluded that the mental health team should continue to monitor and
support him.
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25. The nurse regularly saw Mr Hague in relation to his mental health issues, and the
prison psychiatrists assessed him on 6 June and 26 September.
26. In August, DARS sent Mr Hague leaflets about minimising the harm from substance
misuse and a service referral form which he could use to access the service in the
future.
27. On 10 August, the COM tried to meet Mr Hague by video link, but he did not attend.
28. During a psychiatric assessment on 26 September, a psychiatrist spoke to Mr
Hague about substance misuse and told him that the dangers of using illicit drugs
included the risk of accidental death and a deterioration in his mental health. He
also warned him about the risk of accidental overdose because of a reduced
tolerance to drugs. After the assessment, the psychiatrist recommended that Mr
Hague should be referred to the community mental health team and that he should
receive further advice about the dangers of using illicit drugs.
29. On 28 September, a nurse met Mr Hague to give him his mental health medication
by depot injection, which is a slow-release, long-acting medication method. She
discussed his release plans with him. Mr Hague confirmed that he had no
accommodation in place.
30. During early October, a nurse contacted a number of agencies to help Mr Hague
find accommodation and to ensure that he could access mental health support once
he was released. She also arranged an appointment for Mr Hague to register with a
GP.
31. On 11 October, the nurse met Mr Hague. She told him that she had made an
appointment for him to see a GP and had arranged for him to have a telephone call
with the Saviours Trust (an accommodation provider) on 12 October.
32. On 12 October, Mr Hague was released homeless. Before he left prison, the nurse
met Mr Hague in reception to facilitate the call to the Saviours Trust. There was no
answer, so she gave him their address. Mr Hague was given information about
agencies that could support him with homelessness and mental health.
33. Mr Hague was not given a naloxone kit. (Naloxone is medication to reverse the
effects of opiate overdose.) This is because the substance misuse team had not
undertaken a comprehensive assessment of his substance misuse history as Mr
Hague had not engaged.
34. As Mr Hague’s sentence had expired, he was not subject to post-release
supervision by the Probation Service.
Circumstances of Mr Hague’s death
35. At 6.05am on 15 October, the police and Ambulance Service were called to a
property in Leeds. They found Mr Hague dead and evidence of substance misuse.
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Post-mortem report
36. The post-mortem report concluded that Mr Hague died of acute heroin,
flualprazolam and pregabalin toxicity in association with cocaine use.
Findings
Pre-release engagement and planning
37. Although probation staff tried to engage with Mr Hague after he was recalled into
custody in February 2023, he was reluctant to engage. Following the resettlement
team’s meeting with Mr Hague on 9 February, a member of the resettlement team
noted that Mr Hague’s COM would need to refer him to the CRS and to submit a
DTR. This information was recorded in the probation case management system,
and she would therefore have had access to view it.
38. The COM told the investigator that she was not made aware of the actions that she
was given following this meeting. She said that she therefore did not submit a
referral to the local authority under the legal duty to refer those at risk of
homelessness. She said that as a CRS referral had already been made, a second
referral was not needed.
39. The next attempt to contact Mr Hague to discuss his resettlement needs was not
made until August 2023, six months later and only two months before Mr Hague
was due to be released.
40. All of the COM’s attempts to meet Mr Hague were by video link and he did not
attend any. Mr Hague had significant mental health issues while in prison which
meant that he tended to self-isolate and did not always engage with staff or the
prison regime. Although she followed the basic standard process in contacting Mr
Hague, we consider that given his vulnerability and risk history, she should have
made further attempts to contact Mr Hague to try to engage him. And, if Mr Hague
persistently did not engage, she should have escalated the matter to her manager
for discussion and help. We make the following recommendations:
The Head of the Probation Delivery Unit should ensure that COMs escalate
their concerns about non-engagement to their manager to discuss and
identify what further action can be taken when prisoners repeatedly fail to
engage, and a COM cannot support their needs as they prepare for release.
Substance misuse services
41. During the reception health screen, Mr Hague said that he had used drugs in the
past but had not had any problems with drugs or alcohol for the previous three
months. He also declined support from DARS in May 2023. However, in June, he
disclosed to the mental health team that he had previously used heroin. This was
not identified by DARS because his initial health screen had preceded this meeting
and his case was not subsequently reviewed.
42. Due to a suspicion that Mr Hague may have used spice (synthetic cannabinoids)
while in custody, he was offered but declined substance misuse support at HMP
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Wealstun. A further opportunity for him to access support was made in August 2023
and he was advised about the risks of illicit drug use on a number of occasions
during the months before his release.
43. On the day of his release, Mr Hague was given information about the support
services available to him and was reminded to abstain from all illegal and illicit
substances. However, he was not given a naloxone kit. The investigator was told
that this was because Mr Hague had not engaged with the substance misuse
service, and they had not been able to complete a comprehensive assessment of
his previous drug use (which he later revealed included regular use of heroin).
44. The local policy at Wealstun states that a prisoner’s entitlement to a naloxone kit is
based on a need being identified during the assessment. As Mr Hague chose not to
engage, he did not meet the criteria for a naloxone kit.
45. While staff adhered to the naloxone policy, Mr Hague had a number of risk factors,
including previous opiate use, homelessness and mental health problems and he
therefore may have benefitted from being offered naloxone on release. While the
local policy was followed, we note the wide regional differences in approach to and
criteria for distributing naloxone on release and make the following
recommendation:
The Head of Healthcare should work in partnership with Practice Plus Group,
the regional Health and Justice Leads and regional drug providers to satisfy
themselves that:
• the local policy on the offer and issue of naloxone on release captures
prisoners with previous opiate use and other relevant risk factors; and
• they are collaboratively engaging with individuals who are persistently
difficult to engage to achieve better outcomes for them.
Good practice
46. A nurse tried to help Mr Hague find somewhere to live, even though this fell outside
the remit of her role. She also contacted a number of agencies to try to ensure that
Mr Hague could access healthcare services. Her efforts to support Mr Hague went
above and beyond what could have been expected of her.
47. Mr Hague was well supported by the mental health team at Wealstun.
Adrian Usher
Prisons and Probation Ombudsman July 2024
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Inquest into Mr Hague’s death
48. The inquest into Mr Hague’s death was held on 23 October 2024 and a verdict of
misadventure was recorded. The coroner concluded that Mr Hague’s death was
due to acute heroin, flualprazolam and pregabalin toxicity with cocaine use.
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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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