James Murphy

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Independent investigation into
the death of Mr James Murphy,
on 23 April 2024, following his
release from HMP Brixton
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 Murphy died from bilateral pneumothoraces (a rare condition where both lungs
suddenly collapse) on 23 April 2024, following his release from HMP Brixton on 22
April 2024. The pathologist found that asthma and smoking synthetic cannabinoids
also contributed to his death. He was 42 years old. We offer our condolences to
those who knew him.
5. We are satisfied that Mr Murphy’s community offender manager appropriately
prepared for his release. Mr Murphy was released with accommodation in place.
We found that the appropriate accommodation referrals to homelessness support
services were made.
6. We found that Mr Murphy accessed satisfactory support for his substance misuse
issues at Brixton.
7. Mr Murphy did not report any concerns about his physical health in the lead up to,
or on the day of his release. He told healthcare staff he felt well and declined a
nurse taking his clinical observations on the day of his release.
8. We did not identify any significant learning relating to the pre-release planning or
post-release supervision of Mr Murphy. We make no recommendations.
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The Investigation Process
9. HMPPS notified us of Mr James Murphy’s death on 25 April 2024.
10. The PPO investigator obtained copies of relevant extracts from Mr Murphy’s prison
and probation records.
11. We informed HM Coroner for West London of the investigation. She gave us the
results of the post-mortem examination. We have sent the Coroner a copy of this
report.
12. The Ombudsman’s Office contacted Mr Murphy’s next of kin, his sister, to explain
the investigation and to ask if she had any matters she wanted us to consider. She
had questions relating to Mr Murphy’s healthcare and the day of his release. Her
questions have been addressed in this report and in separate correspondence.
13. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
14. Mr Murphy’s family received a copy of the draft report. They did not make any
comments.
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Background Information
HMP Brixton
15. HMP Brixton is a category C prison which holds convicted and remanded male
prisoners. Practice Plus Group provides healthcare services. Barnet, Enfield and
Haringey NHS Trust provide mental health services and Forward Trust provide
substance misuse services.
The Probation Service
16. 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, prepare reports to advise the Parole Board and have links
with local partnerships to which they refer people for resettlement services, where
appropriates. Post-release, the Probation Service supervises people throughout
their licence period and post-sentence supervision.
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Key Events
HMP Wormwood Scrubs
17. On 15 February 2021, Mr Murphy was convicted of drug offences and sentenced to
four years imprisonment. He was released on 15 August 2022. On 23 May 2023,
having been recalled and released for further offences previously, Mr Murphy was
again recalled to prison following convictions for theft offences while subject to
licence conditions. He was sent to HMP Wormwood Scrubs.
18. During his first reception screening, Mr Murphy told healthcare staff that he had a
history of Chronic Obstructive Pulmonary Disease (COPD - a lung condition that
causes breathing difficulties), asthma and depression. Mr Murphy told the nurse
that he used heroin and crack cocaine in the community. He was unable to provide
a urine sample for a drug test. Mr Murphy was taken to the segregation unit due to
a positive body scanner result (suggesting he had concealed drugs).
19. During a secondary reception screening the following day, Mr Murphy provided a
urine sample which tested positive for opiates, cannabinoids and cocaine. He
produced two further positive body scanner results that day. On 25 May, Mr Murphy
provided a negative body scanner result and moved from the segregation unit.
20. On 25 May, Mr Murphy saw a nurse for a substance misuse assessment. He said
that he had last used heroin and cocaine on 21 May and rarely smoked cannabis.
Mr Murphy was prescribed methadone (a medication used to treat heroin
dependence). He declined support from Forward Trust (a substance misuse
service).
21. On 29 May, Mr Murphy attended a five day substance misuse review and agreed to
his methadone dose being increased from 30mg to 40mg. On 7 June, a nurse
requested that Mr Murphy was prescribed inhalers.
22. On 19 June, a prison GP prescribed Mr Murphy mirtazapine (an antidepressant
medication) and inhalers for his asthma.
23. On 21 June, Mr Murphy attended a substance misuse review with a nurse. The
nurse recorded that Mr Murphy remained on 40ml of methadone but was having
stomach cramps, flushes and aches and pains. She prescribed a gradually
increasing dose of methadone to 50ml over the following weeks. He also saw a
Forward Trust worker on the same day and told them that he had changed his mind
and wanted substance misuse support. The Forward Trust worker told him that
because he was due to be released soon, they would refer him to a community
substance misuse service to continue his treatment. (This was incorrect – Mr
Murphy was not due to be released. It seems the error arose due to Mr Murphy’s
multiple recalls and Forward Trust working towards the wrong release date.)
24. On 12 July, a Forward Trust worker noted that they had completed a referral as Mr
Murphy had spoken to them on the wing requesting support. He was added to a
waiting list.
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HMP Brixton
25. On 1 August 2023, Mr Murphy transferred to HMP Brixton. He attended a reception
screening with a nurse and was prescribed 50ml of methadone.
26. On 2 August, Mr Murphy was discussed during a multi-disciplinary team meeting
(MDT) with mental health staff as he wanted counselling for bereavement. He was
added to the waiting list.
27. On 3 August, Mr Murphy attended an initial assessment with Forward Trust. He told
the Forward Trust worker that he was settled on his methadone dose and would like
to eventually reduce his dose.
28. On 22 August, a healthcare worker noted that Mr Murphy would start the living
safely programme with Forward Trust that week.
29. On 12 September, Mr Murphy saw a nurse and Forward Trust staff. A plan was
made to reduce his methadone dose by 5ml each week with regular reviews to
monitor this.
30. On 4 October, Mr Murphy was given a COVID-19 booster vaccination.
31. On 10 October, Mr Murphy started auricular acupuncture (ear acupuncture) with
Forward Trust as part of his drug treatment. The next day, a nurse recorded that Mr
Murphy was on 30ml of methadone and reported no withdrawal symptoms.
32. On 26 October, staff reduced Mr Murphy’s methadone dose to 20ml.
33. On 27 October 2023, Mr Murphy was convicted of theft offences and sentenced to a
24 week concurrent sentence in prison (when you serve more than one sentence at
the same time).
34. On 9 November, Mr Murphy told healthcare staff that he was struggling on 10ml of
methadone and wanted a slow reduction. It was agreed that he would have a 1ml
reduction every three days. No other issues or concerns were raised.
35. On 16 November, A new case manager was allocated to Mr Murphy with Forward
Trust. On 23 November, a nurse recorded that Mr Murphy had requested a
healthcare appointment regarding his detox and wanted pain relief medication. The
nurse referred Mr Murphy to the GP. On the same day, the GP prescribed Mr
Murphy paracetamol.
36. On 30 November, Mr Murphy started counselling with the mental health team for
bereavement issues. On 21 December, Mr Murphy discussed in a counselling
session that he had stopped taking methadone completely, which had been difficult
for him. In February 2024, Mr Murphy was discharged from counselling having
completed his six sessions.
37. On 21 January, Mr Murphy was allocated a new key worker. (Keyworkers provide
prisoners with an allocated officer that they can meet regularly to discuss how they
are and any day-to-day issues they would like to address.) The keyworker saw Mr
Murphy for monthly key work sessions.
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In their last session, at the end of March, Mr Murphy said that he was enjoying
working which had kept him busy and did not raise any issues or concerns.
38. On 31 January 2024, Mr Murphy attended a video link appointment with his
community offender manager (COM) to prepare for his oral hearing and discuss
release plans. (Oral hearings are held by the Parole Board to decide whether it is
safe to release a prisoner). On 13 March, the COM completed a referral to St
Mungo’s for homelessness support.
39. On 26 March, Mr Murphy had an asthma control test. The nurse noted that Mr
Murphy had experienced one asthma exacerbation (severe asthma symptoms) in
the past year and received fifteen reliever inhalers per year. Mr Murphy told the
nurse that he experienced very few symptoms and rated his asthma as ‘well
controlled’.
40. In the same appointment, Mr Murphy also discussed his COPD and agreed to a
self-management plan. He told the nurse that his COPD was well controlled, he had
no recent exacerbations and was managing well with his inhalers. Mr Murphy also
agreed to try and stop smoking in the community. His oxygen saturation levels were
97% which is within the normal range.
Pre-release planning
41. On 25 March, Mr Murphy’s COM referred Mr Murphy to the local authority as he
would be homeless when released. The COM was also asked by a Public
Protection Casework Section (PPCS) case manager to complete a Community
Accommodation Service Tier 3 referral (CAS3, a service open to adult prison
leavers who are at risk of homelessness on release from prison which provides
access to up to 84 days of accommodation). On 27 March, Mr Murphy was
accepted into CAS3 accommodation when his release date was confirmed.
42. Mr Murphy attended an oral hearing on 3 April. On 4 April, the Parole Board
decided that Mr Murphy would be granted executive release (where a prisoner can
be released from prison before the end of their recall period) with the date to be
confirmed.
43. On 9 April, Forward Trust staff provided feedback to the COM that they had
completed an initial assessment with Mr Murphy over the phone, following a referral
for community substance misuse support. Forward Trust staff agreed to follow up
with the COM to arrange substance misuse support in the community.
44. On 10 April, a pharmacy technician prescribed Mr Murphy an inhaler and two future
prescriptions for inhalers dated 8 May and 13 May in preparation for his release. On
12 April, she prescribed a future prescription of mirtazapine dated 26 April 2024.
45. On 11 April, Mr Murphy saw a substance misuse worker to prepare for his release.
She noted that she provided reassurance and told Mr Murphy that she was
arranging him an appointment with community substance misuse services. Mr
Murphy told her that he was doing well and was looking forward to leaving prison.
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46. On 12 April, the substance misuse worker noted that she provided naloxone training
(naloxone is used to reverse the effects of an opioid overdose) and five days later
she completed a release plan.
47. On 15 April, Mr Murphy’s release date of 22 April was confirmed. The COM secured
him CAS3 accommodation from this date.
48. On 22 April, the day of his release, staff searched Mr Murphy’s cell due to
intelligence they had received and found a mobile phone. He was subject to
disciplinary charges. This may have delayed his release as it has not been possible
to establish any other reason why Mr Murphy was not released in the morning. The
COM emailed prison staff to ask what time Mr Murphy was being released. At
12.00pm, prison staff responded that he was currently being assessed by a nurse in
reception and would be released imminently. They also emailed the COM a GP
letter, hospital letter for a future appointment and list of medications he was on.
49. A nurse recorded that Mr Murphy declined having his clinical observations taken
prior to release (which involves checking body temperature, blood pressure, pulse
rate and breathing rate). Mr Murphy told the nurse that he was fit and well.
50. Mr Murphy was instructed to report to Richmond Probation Office at 2.00pm. He
was aware of his licence conditions, which had been agreed by the Parole Board.
Mr Murphy was released from HMP Brixton at 1.00pm.
Post-release management/release from HMP Brixton
51. Mr Murphy attended his appointment with his COM, as required, on 22 April. Mr
Murphy arrived at the probation office at 2.30pm. Mr Murphy signed his licence and
probation agreement and went through some of his induction paperwork. Due to
being released late, he could not attend his CAS3 induction at the property. The
COM told him to either return to the probation office the following day or telephone
Mr Parker to reschedule his induction.
52. Mr Murphy went to stay with his sister temporarily because he needed to attend an
induction before he could move into his accommodation.
Circumstances of Mr Murphy’s death
53. On the morning of 23 April, Mr Murphy collapsed while at his sister’s address. He
was taken to hospital, where he was pronounced dead. Mr Murphy’s sister called
the Probation Service to inform them of his death.
Post-mortem report
54. The pathologist concluded that Mr Murphy died from bilateral pneumothoraces
(where both lungs collapse). This is a rare condition which happens suddenly and
spontaneously. There was evidence that Mr Murphy had used synthetic
cannabinoids in the hours before he died. He also tested positive for cocaine and
morphine (which may have been due to taking morphine itself or another substance
such as heroin or codeine). The pathologist concluded that Mr Murphy’s pre-
existing asthma in combination with smoking synthetic cannabinoids had increased
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the likelihood of Mr Murphy developing pneumothoraces and were therefore
contributory factors in his death.
Inquest
55. At the inquest held on 8 January 2025, the Coroner concluded that Mr Murphy’s
death was drug-related.
Findings
Healthcare services
56. Mr Murphy attended appointments to review his asthma and COPD in March 2024
and no issues or concerns were raised. We are satisfied that Mr Murphy was
released with appropriate medication for his asthma and mental health needs. In
the lead up to, and on the day of Mr Murphy’s release, he did not report any
concerns about his physical health and was not observed to be physically unwell by
healthcare or prison staff. A nurse offered to take Mr Murphy’s clinical observations
on the day of his release but he declined as he said that he felt fit and well.
Accommodation
57. We consider that Mr Parker appropriately prepared for Mr Murphy’s release and
secured accommodation in a timely manner. We found that considerable efforts
were made by probation to prepare for his executive release. Mr Murphy was
unable to attend his accommodation on the day of his release as he was released
late from prison. Fortunately, Mr Murphy was able to stay at his sister’s address and
his COM made plans to contact Mr Murphy the following day to rearrange his
induction at his accommodation.
Substance misuse services
58. Mr Murphy took synthetic cannabinoids in the hours before he died, and the
pathologist concluded that this contributed to his death.
59. However, we are satisfied that Mr Murphy accessed satisfactory substance misuse
support at Brixton. We found that the COM put appropriate measures in place to
address Mr Murphy’s substance misuse issues when he was released from prison.
The COM identified that Mr Murphy’s offending was linked to his substance misuse,
and he included drug testing and engagement with community drug services as a
condition of his licence.
Good Practice
COM Liaison
60. From the evidence we have seen, the COM provided diligent and effective support
to Mr Murphy when he was in prison. He was tenacious in his attempts to secure Mr
Murphy’s release as soon as possible and with accommodation in place. This
should be commended.
8 Prisons and Probation Ombudsman
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Adrian Usher
Prisons and Probation Ombudsman April 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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