Carl Sheldon

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Independent investigation into
the death of Mr Carl Sheldon,
a resident of Wharflane House
Approved Premises,
on 8 March 2021
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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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.
My office carries out investigations to understand what happened and identify how the
organisations whose actions we oversee can improve their work in the future.
Mr Carl Sheldon died on 8 March 2021, while a resident at Wharflane House Approved
Premises. His cause of death is currently unknown pending the results of the post-mortem
examinations. He was 33 years old. I offer my condolences to Mr Sheldon’s family and
friends.
The COVID-19 pandemic has presented approved premises with enormous challenges.
The safety of staff and residents has, naturally, been prioritised and numerous measures
have been instigated to reduce the risk of transmission of the virus. Keyworkers now work
from home, residential staff are advised to remain in their offices, wherever possible, and
staff interaction with residents has reduced significantly as a result. At the same time,
communal areas within premises have been closed to preserve social distancing and it is
not unusual for residents to spend most of the day in their rooms. While I appreciate that
these measures are important, I am concerned that residents of approved premises are no
longer receiving appropriate supervision and support on site.
I am concerned that appropriate priority was not given on his arrival to informing Mr
Sheldon about his reduced tolerance to drugs and the increased risk of overdose. I am
also concerned that he was not challenged when staff identified that he had likely been
smoking cannabis in his room, and no one considered searching his room for illicit drugs.
This version of my report, published on my website, has been amended to remove the
names of staff and residents involved in my investigation.
Elizabeth Moody
Deputy Prisons and Probation Ombudsman November 2021
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 5
Findings ........................................................................................................................... 8
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Summary
Events
1. On 2 March 2021, Mr Carl Sheldon was released from prison to live at Wharflane
House Approved Premises. On the afternoon of his arrival, he received an
induction from his keyworker which was conducted through a video conferencing
platform due to restrictions in place during the COVID-19 pandemic.
2. At around 2.00am on 7 March, a residential worker identified a very strong smell of
cannabis coming from Mr Sheldon’s room. No one spoke to Mr Sheldon about this
in the following days and it was listed to be discussed at a pre-arranged meeting
with his offender manager and keyworker later in the week.
3. On 8 March, Mr Sheldon briefly left the premises late in the morning. At 12.55pm,
he returned to his room having spent ten minutes smoking outside. This is the last
time he was seen. At a whole premises’ curfew check at 11.00pm, a residential
worker found that he had died.
Findings
Substance misuse
4. We found that the likelihood of reduced drug tolerance and increased risk of
overdose were not discussed sufficiently with Mr Sheldon on his first day at
Wharflane House, as national instructions specify. We also found that his
suspected cannabis use was not appropriately challenged and that no one
considered searching his room for illicit drugs.
COVID-19
5. The COVID-19 pandemic has had a significant impact on the work of approved
premises. Keywork is conducted remotely and residential workers at Wharflane
House told us that their relationships with residents have suffered because of
measures introduced to reduce face-to-face interaction. There is no evidence that
anyone had any significant face-to-face contact with Mr Sheldon during his time at
Wharflane House. The safety of staff and residents must, of course, be a priority,
but we are concerned that residents are not receiving proper supervision and
support during the pandemic.
Curfew checks
6. During Mr Sheldon’s time at Wharflane House, residents were no longer required to
sign for their individual curfews (Mr Sheldon’s was at 7.00pm) as they had been
judged ‘non-essential’ during the pandemic. Since his death, the Approved
Premises Manager has reinstated this requirement.
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Recommendations
• The National Approved Premises Team should ensure that all new residents are
told about their reduced drug tolerance and increased overdose on arrival at the AP,
in line with the expectations of the Approved Premises’ Manual.
• The National Approved Premises Team should ensure that residents suspected of
using illicit drugs in the premises are appropriately challenged and that staff search
their room in line with current guidelines.
• The National Approved Premises Team should ensure that residents receive
appropriate supervision and support during the COVID-19 pandemic.
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The Investigation Process
7. The investigator issued notices to staff and residents at Wharflane House informing
them of the investigation and asking anyone with relevant information to contact
him. No one responded. He obtained relevant extracts from Mr Sheldon’s
probation records.
8. The investigator interviewed six members of staff at Wharflane House in April 2021.
All the interviews were conducted by video because of the COVID-19 restrictions.
9. We informed HM Coroner for Stoke-on-Trent of the investigation. He gave us the
results of the toxicology examination. We have sent the Coroner a copy of this
report.
10. The Ombudsman’s family liaison officer contacted Mr Sheldon’s parents and sister
to explain the investigation and to ask if they had any matters they wanted us to
consider. Mr Sheldon’s family asked why he was not seen for ten hours before his
death and whether he was checked by Approved Premises staff in line with
requirements.
11. We shared the initial report with the National Approved Premises Team. They did
not identify any factual inaccuracies.
12. We also shared the initial report with Mr Sheldon’s family. They raised some
additional points which we have addressed in separate correspondence.
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Background Information
Wharflane House Approved Premises (AP)
13. Approved Premises (formerly known as probation and bail hostels) accommodate
offenders released from prison on licence and those directed to live there by the
courts as a condition of bail. Their purpose is to provide an enhanced level of
residential supervision in the community, as well as a supportive and structured
environment. Residents are responsible for their own health and are expected to
register with a GP.
14. Wharflane House, in Stoke-on-Trent, is managed by HM Prison and Probation
Service (HMPPS). Each resident is allocated a keyworker to oversee his progress
and wellbeing, and to ensure that they adhere to licence conditions and the AP’s
rules. HMPPS employees are on duty at Wharflane House 24 hours a day.
15. During the COVID-19 pandemic, the testing of residents of approved premises for
the use of illicit drugs was suspended. This was because of the increased risk of
transmission of the virus when collecting samples for testing.
Previous deaths at Wharflane House
16. Mr Sheldon is the first resident to die at Wharflane House since 2011. There are no
significant similarities between his death and that of the previous resident.
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Key Events
17. On 1 June 2017, Mr Carl Sheldon was remanded in prison to HMP Dovegate. He
was later sentenced to seven and a half years in prison for robbery.
18. During his time in prison, staff frequently recorded that he was under the influence
of drugs or was suspected of using illicit substances. There were also periods
when he abstained from drugs. In his last months in prison, staff recorded that he
often used psychoactive substances (PS). Mr Sheldon was also diagnosed with a
personality disorder (which affects how an individual thinks, feels, behaves and
relates to others).
19. On 17 February 2021, an offender manager met Mr Sheldon ahead of his upcoming
release to Wharflane House Approved Premises. She recorded that he said that he
had “no issues” with drugs. Mr Sheldon also said that he may struggle to abstain
from cannabis in the community but would “try his best”.
20. On 18 February, a probation service officer who was to be Mr Sheldon’s keyworker
at Wharflane House, completed a risk management plan. She recorded that Mr
Sheldon had used drugs both in the community and in prison, and that approved
premises staff should observe him for signs of substance misuse.
21. On 25 February, a substance misuse service practitioner at Dovegate referred Mr
Sheldon to the Stoke-on-Trent Community Drug and Alcohol Service (CDAS) so
that they could provide support following his release from prison. The substance
misuse practitioner recorded that Mr Sheldon was happy to engage with their
services.
22. On 2 March, Mr Sheldon was released on licence from Dovegate. His licence
conditions required him to live at Wharflane House and to present himself at a
probation office for drug testing, if required. Mr Sheldon was subject to a curfew
which required him to be in Wharflane House from 7.00pm every night. The only
medication he was prescribed were antihistamines for a dust allergy and an inhaler
for asthma.
Wharflane House Approved Premises
23. On the afternoon of his arrival, Mr Sheldon had a pre-arranged telephone
conversation with his offender manager. Mr Sheldon said that he felt nervous and
overwhelmed due to his release from prison. They discussed the pathway to Mr
Sheldon seeing his children, via a social care risk assessment, which he said he
understood. Mr Sheldon’s offender manager also told him that she had referred
him to the local Criminal Justice Mental Health Team.
24. On the same day, Mr Sheldon’s keyworker completed an AP induction with Mr
Sheldon. During the COVID-19 pandemic, probation service officers have worked
from home rather than in approved premises. Mr Sheldon’s induction was therefore
completed by means of a video conferencing service rather than in person.
Residents are given an induction pack to keep in their room that explains various
aspects of living in, and the rules of, the approved premises. The pack highlights
that using or bringing illegal drugs into the approved premises is against the rules
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and that “action will be taken” when staff know it is happening. The pack also
includes a warning about the risks of reduced tolerance for drugs and alcohol in
people released from prison, and states that overdose, sometimes leading to death,
is common. Mr Sheldon signed the induction pack.
25. Mr Sheldon’s keyworker told us that Mr Sheldon appeared to “play down” his mental
ill health and that she thought she would have to explore this further in future key
work sessions. She said that she could not remember discussing substance
misuse with Mr Sheldon, although she thought that she would have done as it was
her practice to read over the sections of the induction form that the resident must
sign. The keyworker said that she did not think they went into any depth on the
matter because of the substantial amount of material that needed to be covered in
the session.
26. On 3 March, Mr Sheldon met his offender manager at the local probation office.
She recorded that Mr Sheldon said that he had felt anxious and overwhelmed on
release but was doing okay.
27. On 6 March, Mr Sheldon’s keyworker spoke to him by telephone to check how he
had settled into Wharflane House. She recorded that Mr Sheldon said he was okay
at the approved premises. The keyworker told us that he was not as talkative as
when she spoke to him earlier in the week and that he did not appear to want to
have a conversation. She said that she did not have any concerns about Mr
Sheldon’s wellbeing.
28. At around 2.00am on 7 March, a residential worker recorded that she had identified
a very strong smell of cannabis coming from Mr Sheldon’s room. She went into the
room and noted that Mr Sheldon appeared asleep and that the smell of cannabis
was evident. The approved premises manager told us that Mr Sheldon’s offender
manager and keyworker had planned to discuss this event with Mr Sheldon at a
meeting scheduled for 10 March.
8 March 2021
29. Two residential workers were on duty from 8.00am to 8.00pm on 8 March. The
approved premises manager was also present for some of the day.
30. At 11.37am, Mr Sheldon left Wharflane House. The approved premises manager
signed him out of the premises and recorded that he said that he was going to a
cashpoint. At 11.50am, Mr Sheldon returned to the premises. A residential worker
signed him in. She told us that Mr Sheldon was pleasant and chatty at the time,
and that she had no concerns for his welfare.
31. At 12.45pm, Mr Sheldon left his room to go to the premises’ smoking shelter. He
returned to his room at 12.55pm. This was the last time that Mr Sheldon left his
room or was seen by anyone.
32. Staff at Wharflane House are required to complete a check of residents every two
hours during the day (from 9.00am to 9.00pm) to identify which residents are in the
premises. The approved premises manager told us that before the COVID-19
pandemic, these checks were completed by seeing the resident. (This could be
done by watching CCTV footage rather than directly in person.) During the
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pandemic, seeing the resident is not required and their presence can be
ascertained by checking the signing out sheet and identifying whether their keys
have been handed in. (Residents are required to hand in their room key when they
leave the premises.) One of the residential workers told us that he completed most
of the entries to confirm Mr Sheldon’s presence during his shift on 8 March.
33. Mr Sheldon’s individual curfew was at 7.00pm. Until January 2021, residents were
required to come to the staff office to sign to confirm their presence at their
individual curfew times. The approved premises manager told us that from January
2021, practice had “drifted” because of concerns of transmissibility of the new
COVID-19 variant and residents no longer signed for their individual curfew.
Instead, staff checked for their presence using the same methods as at other times.
34. Wharflane House also has a general curfew for all residents from 11.00pm to
6.00am. At these times, staff complete a full check of residents and account for
everyone’s presence by sight.
35. Two residential workers worked overnight from 8.00pm. At 11.03pm, residential
worker A went to Mr Sheldon’s room to complete the curfew check. He told us that
he found Mr Sheldon sitting against the radiator, with mucus coming from his nose
and vomit on the carpet next to him. He said that there were no signs of life from
Mr Sheldon. The residential worker summoned his colleague, who told us that his
view was that Mr Sheldon had died.
36. At 11.04pm, residential worker B telephoned for an ambulance. At 11.09pm,
paramedics arrived at Wharflane House and confirmed that Mr Sheldon had died.
37. Staffordshire Police subsequently arrested two residents on suspicion of supplying
drugs to Mr Sheldon. They were released pending investigation and recalled to
prison custody.
Contact with Mr Sheldon’s family
38. On 9 March, officers from Staffordshire Police visited Mr Sheldon’s sister and told
her of his death. The approved premises manager contacted Mr Sheldon’s sister
and offered assistance with funeral expenses, in line with national guidelines.
Support for residents and staff
39. After Mr Sheldon’s death, the approved premises manager spoke to the staff
involved and offered them support. Residents were informed of Mr Sheldon’s death
and offered support.
Post-mortem report
40. The post-mortem report and cause of death was not available when we issued our
initial report. The toxicology examination did not detect any drugs, including
psychoactive substances.
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Findings
Substance misuse
Induction
41. Probation Instruction (PI) 32/2014, Approved Premises’ Manual, says that one of
the main causes of deaths among residents of approved premises is drug
overdose, often due to reduced tolerance after release from prison. The Manual
instructs that, on the day of release, the offender manager should make the resident
aware of the risks of overdose should they return to using drugs at the same level
as before they went into custody. Mr Sheldon’s offender manager told us that she
discussed engaging with CDAS with Mr Sheldon before his release from prison.
She said that her understanding was that harm reduction work (following release)
would be completed by his drug and alcohol support worker.
42. The Approved Premises’ Manual also instructs that the risks of overdose should
always be covered at induction and advice given to all approved premises residents
on reduced drug tolerance following release from custody. Mr Sheldon’s keyworker
told us that she thought that she read the appropriate section of the induction pack
to Mr Sheldon but that she did not discuss the subject further due to time
constraints in the induction session. She told us that the induction session covers a
lot of different subjects and residents often “switch off” during the session. The
keyworker said that conducting these sessions remotely during the COVID-19
pandemic made it more difficult still to cover the induction material appropriately.
She told us that a learning point for her from Mr Sheldon’s death was to concentrate
more on highlighting the dangers of reduced tolerance, particularly for residents
with a history of substance misuse.
Suspected cannabis use
43. The Approved Premises’ Manual says that staff must always challenge illegal
substance misuse. It says that signs of substance misuse on the premises should
lead to appropriate enforcement action, and that room searches should be carried
out when it is suspected that illicit drugs are present in the premises.
44. Standard Operating Procedures for Approved Premises’ during the COVID-19
pandemic say that room searches (for residents who are not self-isolating) must
only be completed when social distancing can be achieved and where there is
direct suspicion that contraband is being concealed in rooms.
45. Early in the morning of 7 March, Wharflane House staff strongly suspected that Mr
Sheldon had used cannabis in his room. While the matter was due to be discussed
with Mr Sheldon at a pre-arranged meeting with his offender manager and
keyworker later in the week, no one considered speaking to or challenging him at
the first opportunity the next day and there was no consideration to searching his
room for illicit drugs. We make the following recommendations:
The National Approved Premises Team should ensure that all new residents
are told about their reduced drug tolerance and increased overdose on arrival
at the AP, in line with the expectations of the Approved Premises’ Manual.
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The National Approved Premises Team should ensure that residents
suspected of using illicit drugs in the premises are appropriately challenged
and that staff search their room in line with current guidelines.
COVID-19
46. The COVID-19 pandemic has had a significant impact on the work of approved
premises. Probation Service Officers and keyworkers now work remotely. As well
as meaning that their interactions with residents are completed virtually rather than
in person, Mr Sheldon’s keyworker also told us that not working on site meant that
she relied on staff highlighting risk issues to her rather than making her own
observations as she had done when based in the premises.
47. Staff at Wharflane House told us that procedures designed to reduce the risk of
transmission of the virus meant that they could not build relationships with residents
as they had done previously. For instance, staff remain in their office whenever
possible and only go into the residential areas when they have a specific reason to
do so. As we will discuss later, some presence and curfew checks at Wharflane
House no longer require the resident to be observed. At the same time, communal
areas (such as lounges and games rooms) have been closed to help maintain
social distancing. We were told that it was not unusual for residents to spend nearly
all day in their rooms. During his time at Wharflane House, there is no evidence
that anyone had a significant face-to-face conversation with Mr Sheldon, and no
one identified that he had not been seen for around ten hours when he died.
48. Measures such as these are obviously important. There have been several
residents at Wharflane House who have tested positive for COVID-19 and the
safety of staff and residents should clearly be a priority. However, this does put
staff and residents in a very difficult position. We are concerned that residents are
not receiving proper support and communication from and interaction with staff,
while at the same time, staff do not have the same opportunity to carry out proper
supervision or identify important risk issues and other matters. We make the
following recommendation:
The National Approved Premises Team should ensure that residents receive
appropriate supervision and support during the COVID-19 pandemic.
Curfew checks
49. When Mr Sheldon lived at Wharflane House, checks on residents were not
conducted in the same way as before the COVID-19 pandemic. Whole premises’
curfew checks (at 6.00am and 11.00pm) were still conducted as previously, by
seeing a resident. Individual curfews (such as Mr Sheldon’s at 7.00pm) previously
required the resident to sign at the staff office but were now completed by checking
whether they had signed out of the premises or handed in their keys (and did not
therefore require the resident to be seen). Two-hourly presence checks were
completed using the same methods, whereas previously they had required the
resident to be observed. As noted, these changes meant that Mr Sheldon was not
seen for around ten hours before staff found that he had died when they conducted
the whole premises’ curfew check.
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50. The approved premises manager told us that COVID-19 guidance suspended ‘non-
essential’ checks of residents, but that this raised the question of which checks
were essential. He told us that whole premises’ curfew checks were essential but
two-hourly presence checks were not. We agree that this is a reasonable
interpretation of the guidance. The approved premises manager told us that he
also viewed individual curfews as essential checks but that the practice at
Wharflane House had “drifted” during the pandemic so that they were now
completed using the same methods as non-essential checks. Since Mr Sheldon’s
death, the approved premises manager has reinstated the requirement for residents
to sign in at their individual curfew times. We do not therefore make a
recommendation.
Inquest
51. The inquest into Mr Sheldon’s death concluded on 7 January 2025, and returned a
verdict of natural causes.
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