Dean Holland

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Dean Holland,
on 22 December 2023, following
his release from HMP
Featherstone.
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, 2024
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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 Dean Holland died of diabetic ketoacidosis on 22 December 2023, following his
release from HMP Featherstone on 14 December 2023. He was 40 years old. We
offer our condolences to those who knew him.
5. We did not find any issues of concern relating to the pre and post release planning.
We make no recommendations.
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The Investigation Process
6. HMPPS notified us of Mr Holland’s death on 24 January 2024.
7. The PPO investigator obtained copies of relevant extracts from Mr Holland’s prison
and probation records.
8. We informed HM Coroner for Birmingham of the investigation. He gave us the
results of the post-mortem examination. We have sent the Coroner a copy of this
report.
9. The Ombudsman’s office contacted Mr Holland’s family to explain the investigation
and to ask if they had any matters, they wanted us to consider. They did not
respond.
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Background Information
HMP Featherstone
10. HMP Featherstone is a closed category C training and resettlement prison. It is
managed by HMPPS. The physical healthcare provider is Practice Plus Group, and
the mental health provider is Inclusion (Midlands Partnership NHS Trust).
Probation Service
11. 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
12. On 27 September 2021, Mr Dean Holland was convicted of drug offences and was
sentenced to 27 months in prison. He was sent to HMP Bristol.
13. Mr Holland had diabetes and he was prescribed with appropriate medication to
manage this condition. He also had a history substance misuse.
14. On 25 October, Mr Holland had a diabetic retinopathy screening (a procedure that
involves checking the small blood vessels around part of the eye called the retina).
His next appointment was arranged for 17 November, but Mr Holland did not attend.
15. On 23 November, a GP at the prison saw Mr Holland for a diabetic review. The GP
gave Mr Holland a testing kit so that he could monitor his blood sugar levels
independently. Over the months that followed, healthcare staff reviewed Mr Holland
regularly. However, he was not always compliant with taking his medication and
often failed to attend appointments to review his diabetes.
16. On 14 April 2022, Mr Holland was sent to Channings Wood.
17. A nurse completed Mr Holland’s initial health screening and noted he needed to
attend diabetic reviews to monitor his condition. Mr Holland attended his diabetes
review on 24 August. Over the months that followed, healthcare staff continued to
support Mr Holland with managing his diabetes.
18. On 17 June 2023, Mr Holland was released on Home Detention Curfew (HDC - a
scheme which allows some people to be released early from custody if they have a
suitable address) to BASS (Bail Accommodation Support Service) accommodation.
19. On 20 July, BASS staff contacted Mr Holland’s community offender manager
(COM) and told her that during a routine spot check of Mr Holland’s room, they
found seven spoons that they suspected were linked to heroin use, around 200g of
cannabis and other drug paraphernalia. Mr Holland had also purchased a second
phone and did not inform his COM. Mr Holland had breached his licence conditions
and was recalled to prison that day. However, he was unlawfully at large (when an
offender’s licence has been revoked but they fail to take all the necessary steps to
return to prison). The police arrested him on 14 August, and he was sent to HMP
Birmingham the next day. He was due to be released on 14 December.
20. On 2 September, Mr Holland was transferred to HMP Featherstone. A nurse
completed his initial health screen and noted that he had diabetes and referred him
for a diabetic pack from the kitchen. He was provided with the diabetic packs with
his meals to support his unstable sugar levels. He also received support from the
substance misuse service.
21. On 4 September, a nurse made a note in Mr Holland’s medical record that had not
managed his diabetes correctly while in the community and that he needed to
attend the diabetes review clinic. Healthcare staff reviewed Mr Holland’s diabetes
regularly and provided him with insulin, and equipment to test his blood sugar
levels. They continued to advise him on how to manage his diabetes effectively and
the importance of taking his insulin properly.
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22. In preparation for Mr Holland’s release, he was referred to Change Grow Live (CGL
– a community drug and alcohol service) for ongoing support in the community. He
also secured supported living accommodation. Mr Holland was required to register
with a GP following his release for help with managing his diabetes.
23. On 14 December, Mr Holland was released from Featherstone at the end of his
sentence. This meant that he was not subject to any licence conditions and did not
need to engage with the Probation Service following his release. Healthcare staff
provided Mr Holland with sufficient insulin to last him until he was able to register
with a GP and he was provided with a naloxone kit (which can reverse the effects of
an opioid overdose).
Circumstances of death
24. On 22 December, a member of the public discovered Mr Holland unconscious in a
local park. They called the police and ambulance service. The paramedics
attempted cardiopulmonary resuscitation but it was unsuccessful and they
confirmed that Mr Holland had died. Mr Holland’s blood glucose level was high, and
he had ketones, suggesting diabetic ketoacidosis.
Post-mortem report
25. The post-mortem concluded that Mr Holland died of diabetic ketoacidosis.
Findings
Management of Mr Holland’s diabetes
26. We are satisfied the prison supported Mr Holland with managing his diabetes in
prison. The healthcare team at Featherstone reviewed him regularly, continued to
provide advice on how to manage his diabetes and ensured they gave him a
sufficient amount medication to last him in the community until he was able to
register with a GP on his release.
27. We make no recommendations.
28. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find and factual inaccuracies.
29. Mr Holland’s family received a copy of the initial report. They did not raise any
further issues or comment on the factual accuracy of the report.
Inquest
30. The coroner concluded that no inquest would be required.
Adrian Usher
Prisons and Probation Ombudsman July 2024
Prisons and Probation Ombudsman 5
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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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