Daniel Berry

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Independent investigation into
the death of Mr Daniel Berry,
on 28 August 2022, following
his release from HMP Lewes
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. From 6 September 2021, the PPO is investigating post-release deaths that occur
within 14 days of the prisoner’s release.
3. If my office is to best assist HM 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 Daniel Berry died of morphine toxicity on 28 August 2022, following his release
from HMP Lewes two days earlier. He was 39 years old. I offer my condolences to
his family and friends.
5. We were not notified of Mr Berry’s death until May 2023, which meant that our
investigation was significantly delayed.
6. Mr Berry had a history of substance misuse and had completed a methadone
detoxification programme at Lewes. Mr Berry was not offered naloxone (medication
to reverse the effects of opiate overdose) on release. The Head of Healthcare has
since reviewed the process for the issue of naloxone and implemented changes to
ensure prisoners with a history of substance misuse are trained in the use of
naloxone and released with a supply.
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The Investigation Process
7. On 22 May 2023, the PPO was informed of Mr Berry’s death.
8. The PPO investigator obtained copies of relevant extracts from Mr Berry’s prison
and probation records.
9. We informed HM Coroner for East Sussex of the investigation. He gave us the
results of the post-mortem examination. We have sent the Coroner a copy of this
report.
10. The Ombudsman’s family liaison officer wrote to Mr Berry’s brother to explain the
investigation and to ask if he had any matters he wanted us to consider. Mr Berry’s
brother wanted to know how Mr Berry died and what happened to him between
being released and his death.
11. We shared the initial report with HM Prison and Probation Service. There were no
factual inaccuracies.
12. We shared the initial report with Mr Berry’s brother. He did not respond.
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Background Information
HMP Lewes
13. HMP Lewes is a local prison serving the courts of East and West Sussex. It holds
about 600 men. Practice Plus Group provides primary care, mental health and
substance misuse services.
HM Inspectorate of Prisons
14. The most recent inspection of HMP Lewes was in August 2022. Inspectors reported
that primary healthcare lacked effective clinical leadership and was too dependent
on agency staff, leading to gaps in patient care.
15. Despite staffing pressures, inspectors reported that work to progress prisoners in
their sentence was reasonably good. Almost all eligible prisoners had an initial
assessment of their risk and needs. Most sentence plans were relevant and of
reasonable quality. The frequency, and quality, of contact between prison offender
managers (POMs) and prisoners had improved since the last inspection and was
some of the best they had seen recently. Only about 65% of sentenced prisoners
left the establishment with accommodation to go to on their first night of release.
16. In February 2023, inspectors carried out an independent review of progress and
found that the retention of prison officers and the ability to deploy those still in post
had become critical problems. Aside from activity such as gym sessions or social
visits at least half the prison population spent about 23 hours in their cells every
day.
17. Inspectors reported that healthcare was more encouraging. Many of the failures
they identified in their full inspection had been addressed, and despite the departure
of some managers, staffing had improved.
Probation Service
18. The Probation Service work 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 and
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.
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Key Events
19. On 25 January 2021, Mr Daniel Berry was remanded to HMP Lewes. On 4 June, Mr
Berry was sentenced to one year and seven months in prison for driving offences.
During his time at Lewes, Mr Berry completed a methadone detoxification
programme (for opiate dependence).
20. On 10 June, Mr Berry was allocated a community offender manager (COM).
21. On 14 June, Mr Berry was transferred to HMP Rochester, and, on 10 November, he
was released on licence.
22. On 14 March 2022, Mr Berry’s licence was revoked, and he was recalled to Lewes.
23. A nurse carried out Mr Berry’s initial health screen and noted that he had a history
of heroin and crack cocaine use and engaged with the community drug team. She
noted that Mr Berry was a heavy drinker evidenced by his score of 20 on the
alcohol use disorders identification test (AUDIT), which indicated potential alcohol
dependence.
24. A substance misuse nurse saw Mr Berry and noted that he had previous extensive
interaction with their substance misuse team. She noted that Mr Berry said that he
had relapsed into illicit drug use in the community three weeks before his recall and
had sought help from Change Grow Live (CGL - substance misuse service) and
STAR (the local community drug and alcohol recovery team) in Hastings. She noted
that Mr Berry’s daily drug use included smoking cocaine three times a day, daily
consumption of amphetamines and cannabis and drinking a litre of brandy. A GP at
Lewes prescribed Mr Berry diazepam and methadone (for opiate dependence).
25. Healthcare staff reviewed Mr Berry daily for symptoms of drug and alcohol
withdrawal.
26. On 15 March, Mr Berry was allocated a prison offender manager (POM) and met Mr
Berry to explain her role.
27. On 19 March, a substance misuse nurse reviewed Mr Berry, giving him harm
reduction advice and explaining the risks of reduced tolerance on his release. She
created a methadone reduction care plan. On 22 March, Mr Berry completed his
methadone detoxification programme.
28. On 30 March, a nurse saw Mr Berry for a psychosocial session, during which Mr
Berry told him about his history of drug misuse. He set Mr Berry recovery goals to
help him build self-esteem, confidence and social skills.
29. On 1 April, the COM completed an offender assessment system report (OASys) of
Mr Berry’s risks and needs. She noted that Mr Berry had a pattern of driving under
the influence of drugs and committing crime to finance his substance misuse. She
noted that when Mr Berry was recalled to prison, he lost his room at Merrick House
(supported living provider) and that his keyworker found Mr Berry’s room strewn
with drug paraphernalia. She noted that Mr Berry could be released homeless if
they were not able to secure accommodation for him. She recorded that she would
complete a duty to refer (DTR – the Homelessness Reduction Act 2017 requires
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prisons and probation services to refer anyone who is homeless or at risk of
becoming homeless within 56 days to a local housing authority), a Commissioned
Rehabilitative Services referral (CRS – who support prisoners with accommodation)
and a Community Accommodation Service referral (CAS3 – provides temporary
accommodation for up to 84 nights for homeless prison leavers) before his release.
30. On 26 May, the COM had a telephone appointment with Mr Berry, who was angry
because he had been recalled to prison. Mr Berry told her that he would be
released homeless and that he had no intention of engaging with or accepting
support from the Probation Service to secure release accommodation.
31. On 29 July, the COM completed Mr Berry’s pre-discharge report. She noted that Mr
Berry would be released on supervision on 26 August, and that he would be
homeless because he was declining accommodation support. She noted that Mr
Berry would be required as part of his licence conditions to attend CGL/STAR to
address his drug use and for drug testing.
32. On 12 August, the COM interviewed Mr Berry by telephone. Mr Berry said that he
was now happy for her to make accommodation referrals. Mr Berry declined to be
referred to CGL/STAR because he said that he was clean from drugs and did not
need their support.
33. Mr Berry also said that he had two offers of work and the COM noted that, in prison,
Mr Berry had completed his construction skills certification scheme (CSCS)
qualification, to enable him to work on construction sites.
34. On 18 August, in response to the DTR the COM completed, Mr Bailey told her that
the rough sleeper’s initiative would potentially support Mr Berry with
accommodation.
35. That same day, a self-employment and small business support advisor told the
COM that Mr Berry had two offers for work as a labourer and that she could send
him vouchers to buy work clothing.
36. On 26 August, a nurse put Mr Berry’s discharge medication (all of which were for
minor ailments) in his property for his release. Healthcare staff did not offer Mr
Berry naloxone (used to reverse the effects of opiate overdose) prior to his release.
Post-release
37. On 26 August, Mr Berry was released on post sentence supervision. Mr Berry
arrived three hours late for his 12.00pm appointment at the Hastings probation
office and said that this was due to train delays. The COM noted that Mr Berry had
drunk three cans of beer before attending the meeting. Mr Berry said that he had
left his belongings with a friend in Hastings. She completed the induction paperwork
and Mr Berry signed that he understood the conditions of his supervision period.
38. Mr Berry did not have any release accommodation and was therefore released
homeless. The COM told us that there was no CAS3 accommodation available in
the area at the time and that his CRS referral was still open. However, at their first
meeting, she told Mr Berry that his keyworker had offered to re-house Mr Berry in
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Merrick House. Mr Berry said he would attend the premises after their meeting. She
told Mr Berry that his next appointment was at 11.00am on 30 August.
Circumstances of Mr Berry’s death
39. At 12.12am on 28 August, the occupants of a flat in in St Leonards on Sea, East
Sussex found Mr Berry dead. His death was confirmed by ambulance paramedics.
Police officers went to the address and found drug paraphernalia near to his body.
The occupants of the address told the police officers that Mr Berry had been
drinking and taking illicit drugs with them that evening. One of the occupants said
that earlier in the evening Mr Berry had left the flat and when he came back said
that he had taken heroin, cocaine and pregabalin (used to treat epilepsy and
anxiety and also to treat nerve pain). A police officer found a wrap containing a
brown substance in Mr Berry’s sock, which when tested was found to be
diamorphine.
40. The COM said that the address where Mr Berry died was CAS3 accommodation
occupied by another prison leaver subject to licence conditions.
Post-mortem report
41. A post-mortem examination established that Mr Berry died from morphine (heroin)
toxicity.
42. A consultant pathologist said that the level of morphine detected in Mr Berry’s blood
was consistent with severe toxicity and may be consistent with fatal toxicity
particularly if the morphine detected was derived from heroin. Toxicology tests also
detected cocaine in Mr Berry’s blood consistent with that typically seen during
recreational use, and pregabalin consistent with therapeutic levels.
Support for staff
43. After Mr Berry’s death, the COM’s manager reminded her of the available support
services.
Contact with Mr Berry’s family
44. Police officers told Mr Berry’s brother that he had died.
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Findings
Substance misuse services
45. Mr Berry had a history of substance misuse. At Lewes, Mr Berry engaged with the
substance misuse service and completed a methadone detoxification programme.
Mr Berry was not offered naloxone (medication to reverse the effects of opiate
overdose) on release. The Head of Healthcare said that shortly after she started
working at Lewes in January 2023, she identified some issues with the process for
providing naloxone education and supply on release. She said that they have since
implemented a more robust process and naloxone training is included in the
induction of all prisoners with a substance misuse history. She said that medical
record alerts now prompt healthcare staff to supply naloxone on release and the
discharge template records when naloxone has been issued.
Inquest
46. The inquest into Mr Berry’s death concluded on 26 August 2025, and concluded
that his death was drug related.
Adrian Usher
Prisons and Probation Ombudsman February 2024
Prisons and Probation Ombudsman 7
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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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