Darren Docherty

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Darren Docherty,
on 10 August 2023, following his
release from HMP Stoke Heath
A report by the Prisons and Probation Ombudsman
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
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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 been investigating 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 Darren Docherty was found hanged on 10 August 2023, following his release
from HMP Stoke Heath on 4 August. He was 48 years old. We offer our
condolences to those who knew him.
5. Mr Docherty had a history of mental ill health and self-harm. He also had substance
misuse issues and was homeless following his release from prison. While we are
satisfied that prison and probation staff did what they could to try to identify
accommodation for Mr Docherty, it is possible that his homelessness, together with
his other risk factors, was a contributory factor in his death.
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The Investigation Process
6. We were informed of Mr Docherty’s death on 15 August 2023.
7. The PPO investigator obtained copies of relevant extracts from Mr Docherty’s
prison and probation records.
8. We informed HM Coroner for Stoke of the investigation, who provided the cause of
death. We have sent the Coroner a copy of this report.
9. The Ombudsman’s family liaison officer contacted Mr Docherty’s father to explain
the investigation and to ask if he had any matters he wanted us to consider. Mr
Docherty’s father said that he was concerned about the provision of release
accommodation for his son.
10. Mr Docherty’s family received a copy of the initial report. They raised one concern,
which has been addressed in separate correspondence.
11. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies. There are no recommendations.
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Background Information
HMP Stoke Heath
12. HMP Stoke Heath is a medium security prison in Shropshire that holds up to 782
adults and young adult men on eight residential wings. Healthcare is provided by
Shropshire Community Health NHS Trust.
Probation Service
13. 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 supervises people
throughout their licence period and post-sentence supervision.
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Key Events
14. On 6 April 2022, Mr Darren Docherty was remanded to HMP Dovegate for breach
of licence conditions. On arrival, he disclosed that he had taken an overdose that
morning. Healthcare staff assessed him, and he signed a disclaimer that he did not
want to go to hospital. Prison staff started suicide and self-harm prevention
procedures (known as ACCT), which they closed the following day.
15. Mr Docherty told prison staff that he used heroin daily and drank eight cans of
strong lager a day. He said that he had spent time homeless. Mr Docherty said that
he received a two-weekly depot injection (slow-release antipsychotic medication) in
the community. He said that he was diagnosed with schizophrenia and manic
depression.
16. On 13 April, Mr Docherty was sentenced to 16 months in prison for robbery. Around
a week later, he was transferred to HMP Stoke Heath.
17. On 5 December, Mr Docherty was released from prison on licence. A probation
officer said she helped Mr Docherty to obtain accommodation with a supported
housing provider, the Lyme Trust.
18. On 7 January 2023, Mr Docherty was recalled to prison because he had been
evicted from the Lyme Trust for taking illicit psychoactive substances. He was not
eligible for early release and his release date was 4 August 2023. Following his
arrival at Dovegate, a Reception nurse referred Mr Docherty to the mental health
team.
19. On 24 January, Mr Docherty was transferred to Stoke Heath. He had been under
secondary mental health care at Dovegate, and this continued at Stoke Heath.
20. On 2 February, healthcare staff recorded that Mr Docherty was not compliant with
his prescribed antipsychotic medication. They recorded that they would continue to
monitor Mr Docherty.
21. On 5 May, a member of the mental health team started ACCT procedures after Mr
Docherty said that he wished to take his own life. On 10 May, prison staff closed the
ACCT procedures and Mr Docherty said he was in a “better place”.
22. On 24 May, Mr Docherty attended an ACCT post closure review, at which he said
that his mental health was not good. Mr Docherty said he had no thoughts of self-
harm, but he was having “bad dreams and racist and strange thoughts”. Staff
arranged for Mr Docherty to see the psychiatrist.
23. On 26 May, Mr Docherty did not attend his probation Pre-Release Assessment. He
was offered another appointment in early June.
24. On 27 May, prison staff started ACCT procedures after Mr Docherty cut his left wrist
after “hearing voices”. At several ACCT case reviews, Mr Docherty spoke of
wanting his medication changed. A psychiatrist reviewed him and concluded that
there no basis on which to change the medication.
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25. On 19 June, Mr Docherty attended an ACCT case review at which the panel chose
to close the ACCT procedures. Mr Docherty said that he had no thoughts of suicide
or self-harm. Mr Docherty spoke about his upcoming release and said that he
wanted to return to accommodation with the Lyme Trust upon release. A
supervising officer from the resettlement team told Mr Docherty that he would
continue to follow up housing for him with his prison offender manager and would
keep Mr Docherty informed.
26. On 26 July, wing staff spoke to a supervising officer regarding Mr Docherty’s
release and his concerns about release accommodation. There was no
accommodation secured for Mr Docherty at that time, which was explained to him.
Probation Pre-release
27. Mr Docherty’s probation officer told us that, in March 2023, probation staff referred
him to commissioned rehabilitative services (CRS) via Nacro (who provide
supported housing for various groups, including prison leavers), to discuss Mr
Docherty’s housing needs in preparation for his release, and to complete referrals
to supported housing providers in Stoke-on-Trent. Probation staff told us they
referred Mr Docherty to CRS Nacro at the earliest opportunity as they were aware
that his housing needs would be an issue for his August release. While the
probation records do not contain any direct mention of Mr Docherty having been
managed under ACCT procedures, the probation officer also said that she
considered the negative impact that being homeless on release would have on Mr
Docherty’s mental health.
28. The probation officer said that due to Mr Docherty’s housing history and behaviour
within shared accommodation settings, and concerns surrounding his substance
misuse, a number of supported housing providers declined his referral due to him
requiring “too high support needs”. She contacted the Lyme Trust and attempted to
make representations for Mr Docherty, but the referral was still declined. She also
completed a Duty to Refer (under the Homelessness Reduction Act 2017, public
authorities have a duty to refer service users whom they believe to be homeless or
threatened with homelessness) to Stoke City Council on 23 July, to notify them that
Mr Docherty would be released from custody homeless.
29. The probation officer said that she also referred Mr Docherty to Community
Accommodation Service Tier 3 (CAS3 - designed to provide prison leavers with
short term accommodation while longer term solutions are sought). She said she
discussed the case with CAS3 management, but the referral was declined by them
due to concerns surrounding Mr Docherty’s previous housing history and substance
misuse.
30. Prior to his release, healthcare staff at Stoke Heath referred Mr Docherty to the
Sutherland Centre, a community mental health centre at which he had previously
been an outpatient.
Post-release
31. On 4 August, Mr Docherty was released from prison. He was released with a supply
of his medication.
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32. As it was the probation officer’s non-working day, she made arrangements for Mr
Docherty to report to the duty probation officer, who supported him to make a
Homeless Tonight Application with Stoke City Council. No accommodation was
available, and Mr Docherty was therefore homeless. He spent the night sleeping in
a tent, apparently provided by his father, near his family’s home.
33. On 8 August, the probation officer returned to work and attempted to contact Mr
Docherty. She spoke to Mr Docherty’s father and confirmed that Mr Docherty
should attend an appointment on 9 August. This was so she could check on Mr
Docherty’s welfare, follow up the referral to the council, and support him to register
with a GP.
34. On 9 August, the probation officer contacted a local GP practice, who said that Mr
Docherty could go in and fill in registration paperwork. She told us that once Mr
Docherty was registered with a GP, she could then follow up the community mental
health referral with the GP and the Sutherland Centre.
35. Mr Docherty attended the appointment on 9 August as requested. He expressed his
disappointment that the CAS3 referral had been declined. The probation officer
asked him about his mental health and Mr Docherty said that he was worried
because he had no housing. She asked Mr Docherty if he had his medication and
he confirmed he had.
36. On the same day, the probation officer obtained Mr Docherty’s consent to share
relevant probation risk information with Stoke City Council. She explained to Mr
Docherty that she would send the information to the council that day so that they
could assess and consider offering emergency accommodation (usually a hotel).
She sent the information to a Housing Needs Officer. No accommodation was
available for Mr Docherty. (We do not know why accommodation was not available
on this occasion.)
37. The probation officer was due to take annual leave, so arranged her next
appointment with Mr Docherty for 23 August. She gained Mr Docherty’s consent to
refer him to The Shaw Trust Activity Hub (a charity that provides activities, advice
and support to unemployed people) so he could have a place to attend between
their appointments. She obtained Mr Docherty a food bank voucher and texted the
information through to him. She offered Mr Docherty food and toiletries, but he
declined these items. She said that Mr Docherty left the probation office on 9
August, and she advised him how he could contact probation staff prior to his
appointment on 23 August, should he need to.
Circumstances of Mr Docherty’s death
38. On 10 August, Mr Docherty was found hanged in a woodland area near Stoke-on-
Trent.
Post-mortem report
39. The post-mortem examination identified that Mr Docherty died from ligature
suspension.
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Findings
40. Mr Docherty had risk factors for suicide and self-harm. He had previously harmed
himself and had been monitored under ACCT procedures several times in prison.
He was diagnosed with schizophrenia and was prescribed medication to manage
this condition. Mr Docherty had previously used drugs in the community.
41. These are significant risk factors by themselves. In addition, Mr Docherty was
released homeless from prison and spent almost a week before his death living in a
tent. While we cannot be certain, it is possible that this was a contributory factor to
his self-harm.
42. Homelessness on release from prison is a significant and complex challenge. While
prison and probation staff can submit referrals to local authorities and charities,
there are occasions when the individual does not meet the eligibility criteria for
housing. This means that these individuals are released homeless and are
expected to report to the local authority on the day of their release in the hope of
receiving emergency housing. Mr Docherty did so on 4 August, but emergency
accommodation was not available.
43. Although Mr Docherty was released from prison without any suitable
accommodation, we consider that the prison and probation staff suitably prepared
for his release by promptly completing accommodation referrals to local authorities
and homelessness charities. Nevertheless, this case is a reminder to prison and
probation staff that of the increased risk of suicide and self-harm of homelessness
on release.
44. Mr Docherty was known to probation and prison staff as a high suicide risk. While in
prison he had been managed under ACCT procedures more than once. Prior to his
release, probation staff contacted the prison to find out what medication Mr
Docherty would be released with. After Mr Docherty’s release, probation staff asked
him if he had his medication and he confirmed he had. Probation staff then found a
local health centre who said Mr Docherty could go in that day and register with
them. Probation staff said that if Mr Docherty was registered with a GP they could
then follow up the Community Mental Health Referral with the GP and Sutherland
Centre. However, probation records indicate Mr Docherty was found deceased
before this took place. There were no particular signs that Mr Docherty was
contemplating suicide in the time before his death and in the circumstances, we do
not think that probation staff could have done any more to support him.
Inquest
45. The inquest into Mr Docherty’s death concluded on the 8 April 2024. The coroner
confirmed that Mr Docherty died from suicide.
Adrian Usher
Prisons and Probation Ombudsman October 2025
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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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