John Robinson

OFFICIAL - FOR PUBLIC RELEASE
Independent investigation into
the death of Mr John Robinson,
a prisoner at HMP Lancaster
Farms, on 14 December 2023
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
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
© Crown copyright, 2025
This report is licensed under the terms of the Open Government Licence v3.0. To view this licence,
visit nationalarchives.gov.uk/doc/open-government-licence/version/3
Where we have identified any third-party copyright information you will need to obtain permission
from the copyright holders concerned.
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
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.
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.
Mr John Robinson died on 14 December 2023 at HMP Lancaster Farms. He was 38 years
old. I offer my condolences to Mr Robinson’s family and friends. The post-mortem did not
establish the cause of Mr Robinson’s death. However, the post-mortem toxicology results
showed the presence of synthetic cannabinoids and concluded that his death was likely to
be drug related.
Mr Robinson had a history of substance misuse but often denied using illicit substances in
prison. Three days before he died, prison staff suspected that he was under the influence
of drugs. They acted appropriately by removing suspected drug paraphernalia, conducting
cell searches and monitoring Mr Robinson via regular welfare checks. They also offered
him support from the prison’s substance misuse service. I am satisfied that Lancaster
Farms did all they could to manage the risks associated with Mr Robinson’s substance
misuse. They have also made considerable efforts to combat drug supply and demand,
both before and since Mr Robinson’s death.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Adrian Usher
Prisons and Probation Ombudsman October 2024
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 6
Findings ......................................................................................................................... 12
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Summary
Events
1. On 24 February 2023, Mr John Robinson was remanded to custody and taken to
HMP Forest Bank, charged with violent offences. Mr Robinson had a history of
substance misuse and was prescribed detoxification medication.
2. Over the next few months, Mr Robinson was suspected to be under the influence of
illicit drugs on several occasions. He admitted to using psychoactive substances
(PS) and engaged with the substance misuse service (SMS) until 30 May.
3. On 15 September, Mr Robinson attended court and was sentenced to two years
imprisonment. He returned to Forest Bank. On 30 November, Mr Robinson moved
to HMP Lancaster Farms. Mr Robinson told a nurse that he did not have substance
misuse issues, and that he did not want to be referred to the prison’s SMS. The
next day, he repeated this to a SMS recovery worker.
4. On 11 December, staff suspected that Mr Robinson was under the influence of
drugs. They called a medical emergency code and more staff attended Mr
Robinson’s cell. As Mr Robinson refused to let a nurse take his medical
observations, the nurse asked prison staff to monitor him. Staff searched the cell for
drug paraphernalia and removed some suspicious pieces of paper. (These tested
positive for PS after Mr Robinson’s death.)
5. Thirty minutes later, staff found Mr Robinson with a telephone cord wrapped around
his neck. When questioned, Mr Robinson was disorientated and incoherent. Staff
started suicide and self-harm support procedures, known as ACCT. Mr Robinson
continued to behave erratically, and when he refused to give staff a suspicious
vape, they used force to retrieve it. Staff put Mr Robinson on regular observations
and found more suspicious paper when searching his cell.
6. On 12 December, staff put Mr Robinson’s ACCT into post-closure as he said he
had no thoughts of suicide and self-harm and had plans for the future.
7. On 14 December at approximately 6.54pm, a prisoner alerted an officer that Mr
Robinson was lying unresponsive on the floor of his cell. The officer went to Mr
Robinson’s cell, immediately called a medical emergency code, and started
cardiopulmonary resuscitation (CPR). Healthcare staff responded and continued
CPR.
8. At 7.18pm, paramedics arrived and took over Mr Robinson’s medical care. They
took him to hospital but at 8.01pm, hospital doctors pronounced that Mr Robinson
had died.
9. Toxicology tests found psychoactive substances (PS) in Mr Robinson’s system. The
post-mortem concluded that the cause of his death was unascertained but was
likely to be drug related.
Prisons and Probation Ombudsman 1
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Findings
10. Mr Robinson had a history of substance misuse. While he was at Forest Bank, he
was seen regularly by the SMS team and warned about the risks and dangers of
taking drugs. At Lancaster Farms, he was offered the opportunity to engage with
the substance misuse service three times but declined any help.
11. Lancaster Farms has taken considerable steps to try and reduce supply and
demand for drugs at the prison. We are satisfied that they did all they could to
manage the risks associated with Mr Robinson’s substance misuse. For this
reason, we make no recommendations.
2 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
The Investigation Process
12. HMPPS notified us of Mr John Robinson’s death on 15 December 2023.
13. The investigator issued notices to staff and prisoners at HMP Lancaster Farms
informing them of the investigation and asking anyone with relevant information to
contact him. No one responded.
14. The investigator obtained copies of relevant extracts from Mr Robinson’s prison and
medical records.
15. The investigator interviewed seven members of staff at Lancaster Farms on 29
February 2024, and one member of staff on 12 March.
16. On 22 April, the investigation was reallocated to another investigator.
17. NHS England commissioned a clinical reviewer to review Mr Robinson’s clinical
care at the prison.
18. We informed HM Coroner for Lancashire of the investigation. The Coroner gave us
the results of the post-mortem examination. We have sent the Coroner a copy of
this report.
19. The Ombudsman’s office contacted Mr Robinson’s next of kin, his mother, to
explain the investigation and to ask if she had any matters she wanted us to
consider. She asked for a copy of our report and if the coroner would carry out
toxicological tests. The toxicological findings have been included in this report.
20. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
21. Mr Robinson’s next of kin received a copy of the initial report. They did not make
any comments.
Prisons and Probation Ombudsman 3
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Background Information
HMP Lancaster Farms
22. HMP Lancaster Farms is a category C resettlement prison. Physical health care
and substance misuse treatment are provided by Spectrum Community Health CIC.
Mental health care is provided by Tees, Esk and Wear NHS Foundation Trust.
HM Inspectorate of Prisons
23. The most recent inspection of HMP Lancaster Farms was in August 2022.
Inspectors reported that access to and the quality of health care services was
reasonably good.
24. Inspectors reported that around 80 mental health referrals were received each
month and prisoners were routinely seen within four working days. Urgent cases
were reviewed on the day by a duty worker, which included attending all initial
ACCT reviews. A multidisciplinary team reviewed new cases each week and
patients were assigned to practitioners based on need and risk.
25. Every prisoner was offered support with substance misuse problems by the
psychosocial team and advised how they could self-refer. At the time of the
inspection, support was being provided to 202 prisoners and included harm
minimisation advice as well as self-directed help through the use of workbooks,
one-to-one work, group sessions and pre-release targeted support. Caseloads were
high and priority was given to patients receiving treatment and/or preparing for
release. This had led to some short waits for non-urgent care, but these were
reducing and support for prisoners was good. The team was competent and
motivated, and prisoners valued their support. Naloxone treatment (to prevent
opiate overdose) was routinely provided.
Independent Monitoring Board
26. Each prison has an Independent Monitoring Board (IMB) of unpaid volunteers from
the local community who help to ensure that prisoners are treated fairly and
decently. In its latest annual report for the year 2022 to 2023, the IMB reported that
the drug free wings provided a supportive environment where prisoners were
empowered and given ownership of their recovery. The IMB were impressed by the
drug programmes and the positive impact they had on prisoners.
Previous deaths at HMP Lancaster Farms
27. Mr Robinson was the third prisoner to die at Lancaster Farms since December
2020. Both the previous deaths were from natural causes. There were no issues
from those investigations relevant to the death of Mr Robinson
4 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Assessment, Care in Custody and Teamwork
28. ACCT is the Prison Service care-planning system used to support prisoners at risk
of suicide or self-harm. The purpose of ACCT is to try to determine the level of
risk, how to reduce the risk and how best to monitor and supervise the prisoner.
After an initial assessment of the prisoner’s main concerns, levels of supervision
and interactions are set according to the perceived risk of harm. Checks should be
irregular to prevent the prisoner anticipating when they will occur. There should be
regular multidisciplinary review meetings involving the prisoner.
29. As part of the process, a caremap (plan of care, support and intervention) is put in
place. The ACCT plan should not be closed until all the actions of the caremap
have been completed. All decisions made as part of the ACCT process and any
relevant observations about the prisoner should be written in the ACCT booklet,
which accompanies the prisoner as they move around the prison. Guidance on
ACCT procedures is set out in Prison Service Instruction (PSI) 64/2011.
Psychoactive substances (PS)
30. The term ‘psychoactive substances’ is a broad term that refers to a drug or other
substance that affects mental process. Synthetic cannabinoids and synthetic
opioids (including nitazene) are substances that mimic the effects of traditional
controlled drugs such as cannabis, cocaine, heroin and amphetamines. Synthetic
cannabinoids and synthetic opioids can be difficult to detect as the compounds
used in their manufacture can vary and use of these substances presents a serious
problem across the prison estate.
31. PS can affect people in a number of ways, including increasing heart rate, raising
blood pressure, reducing blood supply to the heart and vomiting. Prisoners under
the influence of these substances can present with marked levels of disinhibition,
heightened energy levels, a high tolerance of pain and a potential for violence.
Besides emerging evidence of such dangers to physical health, the use of PS is
associated with the deterioration of mental health, suicide and self-harm. Testing for
PS is in place in prisons as part of existing mandatory drug testing arrangements.
Prisons and Probation Ombudsman 5
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Key Events
32. Mr John Robinson had a significant offending history and had been in prison
several times. He had last been released from prison in November 2022.
HMP Forest Bank, 24 February – 30 November 2023
33. On 24 February 2023, Mr Robinson was remanded to custody and taken to HMP
Forest Bank, having been charged with violent offences. Mr Robinson told a nurse
that he had no thoughts of suicide or self-harm. He said that he did not have any
diagnosed mental health conditions, although he had received medication for
depression in the past.
34. The same day, a substance misuse service (SMS) nurse at Forest Bank saw Mr
Robinson to discuss his substance misuse issues. The nurse completed drug tests
which showed that Mr Robinson tested positive for cocaine, buprenorphine (a
synthetic opioid used to treat opioid addiction), and benzodiazepines (sedatives).
The nurse identified that Mr Robinson was withdrawing from alcohol and
benzodiazepines, so she prescribed him a combined detoxification programme and
referred him to the SMS caseload.
35. On 27 February, Mr Robinson told a SMS recovery worker that he had been taking
illicit substances and drinking alcohol since he was 15, and that he would like help
to address these issues whilst at Forest Bank. The recovery worker created a
substance misuse care plan for Mr Robinson. They also told Mr Robinson about the
risks associated with psychoactive substances (PS) and they explored ways to
reduce harm and prevent potential overdose situations.
36. On 1 March, Mr Robinson completed his combined detoxification programme. On 7
March, a nurse suspected that Mr Robinson was under the influence of an illicit
substance. Mr Robinson denied this.
37. On 21 March, Mr Robinson told an SMS recovery worker that he had been taking
PS whilst at Forest Bank. He said that his mum was terminally ill and that he was
using PS to block out the thoughts in his head. Mr Robinson agreed to continue his
recovery care plan and said that he would like to attend substance misuse support
groups.
38. Over the next two months, Mr Robinson attended his substance use recovery
appointments and completed various recovery and relapse prevention workbooks.
39. On the afternoon of 22 May, an officer suspected Mr Robinson to be under the
influence of an illicit substance. The officer alerted healthcare staff but due to
staffing issues, a nurse was not able to assess Mr Robinson until later that evening.
The nurse assessed him as no longer being under the influence and advised him to
contact staff should his condition change.
40. The next day, a nurse completed a welfare check on Mr Robinson. Mr Robinson
told the nurse that he had been smoking PS for a couple of months, and that he
was using daily. He asked for additional substance misuse support, so the nurse
6 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
contacted his recovery worker to advise of this. The recovery worker saw Mr
Robinson later that afternoon and gave him some workbooks to complete.
41. On 30 May, Mr Robinson received the results from a recent random drug test. He
tested positive for PS. There is no evidence that Mr Robinson was seen by the SMS
after this date, nor is there any reason documented as to why his contact with them
stopped.
42. On 20 August, Mr Robinson requested to speak with the mental health team at
Forest Bank as he was feeling anxious and low in mood. Staff referred him to the
mental health team. On 29 August, a mental health nurse assessed Mr Robinson.
They discussed Mr Robinson’s concerns and possible treatment options. They
agreed that Mr Robinson would benefit from the intuitive thinking skills service,
specifically the intuitive recovery course. The nurse completed the relevant referral
to the Psychological Wellbeing Practitioner (PWP) Service.
43. On 15 September, Mr Robinson attended court and was sentenced to two years
imprisonment. He returned to Forest Bank.
44. On 26 September, a nurse from the PWP team discussed treatment options with Mr
Robinson. They agreed to work on his low mood management. Over the next two
months, Mr Robinson attended most of his PWP intervention sessions, although he
did not always fully engage and appeared disinterested in the sessions.
45. On 8 November, Mr Robinson saw a GP after he reported having digestive
problems. The GP concluded that his symptoms were likely to be caused by his low
mood and anxiety and prescribed him mirtazapine to treat this.
HMP Lancaster farms
46. On 30 November, Mr Robinson moved to HMP Lancaster Farms. During his initial
health screening, Mr Robinson told a nurse that he did not have substance misuse
issues and that he did not want to be referred to the prison’s substance misuse
service. She undertook the Alcohol Use Disorders identification test known as
AUDIT PC (a screening tool used by health and social care professionals to assess
a person’s level of risk of alcohol harm). Mr Robinson scored 0, which indicated
there were no issues regarding alcohol use. When asked, Mr Robinson said he had
mental health problems and had been treated by the mental health team in Forest
Bank. He denied any thoughts of suicide and self-harm. Staff continued his
prescription of mirtazapine. They also referred Mr Robinson to the mental health
team on his request.
47. On 1 December, a senior drug and alcohol practitioner saw Mr Robinson to
complete an initial assessment as part of his induction process. Mr Robinson again
said that he did not want any support from the SMS at Lancaster Farms. The
practitioner gave Mr Robinson a leaflet on harm reduction and told him about
different substance misuse referral pathways, should he change his mind in the
future.
48. The same day, Mr Robinson moved from the induction wing to a single cell on a
standard wing.
Prisons and Probation Ombudsman 7
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
49. On 2 December, a nurse reviewed Mr Robinson’s referral to the mental health team
(for anxiety, depression and thoughts of violence), and completed a desk top triage.
She noted that he had no recorded history of self-harm and was currently
prescribed mirtazapine. She added Mr Robinson to the talking therapies triage
waiting list and sent him a letter explaining this.
Events of 11 December 2023
50. On 11 December at around 9.00am, a prisoner told Officer A that he was concerned
about Mr Robinson. When the officer went to Mr Robinson’s cell and looked through
the observation panel, it looked like Mr Robinson was having a seizure. He went
into the cell while simultaneously radioing a code blue (used when a prisoner has
stopped or is having difficulty breathing). Mr Robinson was initially unable to speak,
but quickly became alert and conscious. Mr Robinson presented as confused as to
why staff were in his cell. Staff noted that there was a smell in the cell associated
with smoking PS.
51. A few moments later, a Custodial Manager (CM) and a nurse responded to the
code blue and arrived at Mr Robinson’s cell. The nurse agreed that the ambulance
could be cancelled and instructed wing staff to monitor Mr Robinson. The CM told
us that wing staff searched Mr Robinson’s cell for drug paraphernalia and removed
some suspicious pieces of paper. These were tested and came back positive for PS
after Mr Robinson had died.
52. Shortly afterwards, the CM and nurse returned to Mr Robinson’s cell so that the
nurse could complete some medical observations. As they approached his cell
door, Mr Robinson appeared to be ringing someone from his in-cell phone. The CM
unlocked and opened the cell door and tried to engage in conversation with Mr
Robinson. Mr Robinson ignored staff despite repeated requests to speak to them.
As Mr Robinson’s speech was coherent and he appeared to be angry, staff left the
cell and asked wing staff to monitor him.
53. At around 9:30am, Officer A went to Mr Robinson’s cell to complete a welfare
check. At interview, he said that he found Mr Robinson with a telephone cord
wrapped around his neck. He told Mr Robinson to remove the cord from around his
neck and asked him if he was okay, but his response did not make much sense.
Staff started Prison Service suicide and self-harm monitoring and support
procedures, known as ACCT. They set ACCT observations at one every two hours,
and the CM arranged Mr Robinson’s initial ACCT review for the following morning.
Staff submitted an intelligence report.
54. At approximately 10.00am, wing staff completed a welfare check on Mr Robinson
and noted that he still appeared under the influence (he was slurring his words and
having muscle spasms) and was throwing things around his cell. Staff radioed
another code blue. Moments later, both healthcare staff and additional wing staff
attended the cell. A Senior Officer (SO) noticed that Mr Robinson had a vape in his
hand, which he suspected contained illicit drugs. He told Mr Robinson to give the
vape to staff. However, Mr Robinson became aggressive and refused. As a result,
staff had to use force to take the vape. They left the cell and waited for healthcare
staff to arrive.
8 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
55. When a nurse arrived at Mr Robinson’s cell, he was still being aggressive and was
shouting and kicking his cell door. As a result, she did not go into his cell but noted
that Mr Robinson appeared orientated and alert. Mr Robinson became angry when
she suggested he had taken illicit substances and he refused to allow her to take
his physical observations. She noted that his movements and presentation now
appeared normal. She advised the wing staff to conduct 15-minute welfare checks
for the next hour and to report any concerns to healthcare staff. Staff removed Mr
Robinson from the cell to search for any illicit items. They found some more
suspicious pieces of paper which they put in evidence bags. Staff returned Mr
Robinson back into his cell. They charged Mr Robinson with being found under the
influence and for disobeying a lawful order and scheduled his adjudication
(disciplinary hearing) for the next day. Both Mr Robinson’s vape, and the additional
pieces of paper, tested positive for PS after Mr Robinson died.
56. At 2.04pm, an officer saw Mr Robinson and attempted to complete an ACCT
assessment with him. Mr Robinson refused to engage and stated that “he doesn’t
need to be on an ACCT”. When asked how he felt after the morning’s incident, Mr
Robinson said that he was completely fine, that he could not recall much about the
incident and did not want to talk about it anymore. Mr Robinson said that he had no
thoughts of suicide or self-harm. The officer assessed that Mr Robinson was not
suicidal or depressed, and given that he was due to be released in two months’
time, had a sense of hope for the near future.
57. That afternoon and evening, staff recorded that Mr Robinson appeared to be in a
good mood and watched television in his cell. He was issued with his adjudication
hearing paperwork.
Events of 12 and 13 December 2023
58. On 12 December at 9.00am, the CM, SO and an Officer went to Mr Robinson’s cell
to complete his first ACCT case review. No mental health staff were available to
attend the review that morning due to staffing constraints. Mr Robinson declined to
leave his cell for the ACCT review, and said he was embarrassed by his actions
and had been just messing about with the phone line. The CM asked him if he had
any thoughts of suicide or self-harm to which he replied “no, can you close the
ACCT, I do not need it”. Mr Robinson went on to say that he had never been
monitored under ACCT procedures before and would never kill himself. He said that
he had plans for the future which were to get out of prison in a few weeks’ time and
help look after his terminally ill mother.
59. The CM, officer and SO agreed that the ACCT would be put into post-closure. The
CM advised Mr Robinson that he would still be monitored daily and to inform staff if
he felt low. Mr Robinson appeared happy with this and thanked staff. A post-closure
review was scheduled for 19 December.
60. The next day, Mr Robinson attended his adjudication hearing for disobeying a lawful
order. Due to his positive presentation at the hearing and positive conduct report, a
senior prison manager gave him a suspended sentence, which Mr Robinson
appeared happy with. The adjudication for being suspected to be under the
influence of illicit substances was adjourned pending legal advice and for tests to be
carried out on the illicit items seized from Mr Robinson’s cell.
Prisons and Probation Ombudsman 9
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
61. A few hours later, Mr Robinson also attended an appointment with his Prison
Offender Manager (POM). They discussed Mr Robinson’s offence, sentence plan,
and what was expected of him whilst at Lancaster Farms. The POM advised Mr
Robinson to refer himself to the substance misuse service and to engage with them
to address his substance misuse issues.
62. Overall, staff recorded that Mr Robinson had a good day, ate food, and mixed with
his peers. Staff recorded no concerns about Mr Robinson.
Events of 14 December 2023
63. The investigator watched CCTV footage, body worn video camera (BWVC) footage
and listened to prison radio transmissions from 14 December. She also obtained
information from the Northwest Ambulance Service. The following account has
been taken from all sources.
64. On the afternoon of 14 December, Mr Robinson asked Officer C about his eligibility
for category D status. The officer referred his query to the offender management
unit (OMU) and was informed that Mr Robinson would not be assessed for category
D status because there was insufficient time to evidence a reduction in his risk
factors. Instead, Mr Robinson would be released on his conditional release date of
22 February 2024 and would probably have to live at an approved premises. The
OMU had informed Mr Robinson’s community offender manager of this so that they
could start the appropriate assessments. When the officer told Mr Robinson, he
said he took the news in “good spirits”.
65. Some prisoners on the wing were let out of their cells for association from 5.45pm.
As Mr Robinson was not due to have association that evening, he remained locked
in his cell. Several prisoners spoke to Mr Robinson through his observation panel.
66. At approximately 6.56pm, a prisoner went to the wing office and told Officer C that
something was wrong with Mr Robinson, and that he was lying on the floor of his
cell. The officer went to check on Mr Robinson, looked through his observation
panel and found him slumped at the back of his cell, unresponsive. He immediately
unlocked his cell, opened the door, and radioed a code blue. Control room staff
immediately telephoned for an ambulance. He checked Mr Robinson for signs of life
and found none, so he started cardiopulmonary resuscitation (CPR).
67. A nurse and a Healthcare Assistant (HCA) arrived at Mr Robinson’s cell at 7.01pm.
Mr Robinson was laid on the floor at the back of his cell under the window. The
nurse checked Mr Robinson for signs of life. He was not breathing, he was cold,
and he had no pulse. She told the staff to move Mr Robinson onto the wing landing,
so they had more space to treat him.
68. Once on the landing, staff attached a defibrillator which did not initiate a shock but
advised the officers to continue giving CPR. Due to Mr Robinson’s suspected
intoxication, the nurse administered naloxone at 7.04pm, and repeated this dose
every two minutes. (Naloxone is a drug that is used to rapidly reverse opioid
overdose.)
69. At 7.14pm, paramedics arrived at Lancaster Farms. At 7.18pm, the paramedics
arrived at Mr Robinson’s cell and took over his medical care, assisted by the nurse.
10 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
At around 8.00pm, paramedics took Mr Robinson to hospital by ambulance. At
8.10pm, hospital doctors pronounced that Mr Robinson had died.
Contact with Mr Robinson’s family
70. The prison assigned two family liaison officers (FLOs). At 10.50pm, they arrived at
Mr Robinson’s mother’s address, informed her of the death of her son and offered
their condolences. The prison contributed to Mr Robinson’s funeral costs in line with
national policy.
Support for prisoners and staff
71. After Mr Robinson’s death, the Drugs Strategy Lead debriefed the staff involved in
the emergency response to ensure they had the opportunity to discuss any issues
arising, and to offer support. The staff care team also offered support.
72. The Head of Healthcare provided a debrief to primary healthcare staff on duty on
the evening of Mr Robinson’s death. Another debrief was provided the next
morning.
Post-mortem report
73. The post-mortem and toxicology examinations did not establish Mr Robinson’s
cause of death. The toxicology results showed the presence of synthetic
cannabinoids, but no other unprescribed substances. Severe toxic effects of
synthetic cannabinoids include chest pains, stroke and psychosis and death has
been known to occur due to arrhythmia, convulsion and multi-organ failure. The
pathologist concluded that the circumstances surrounding Mr Robinson’s death
suggested that it was likely to be drug related.
74. At an inquest held in March 2025, the coroner concluded that Mr Robinson died of
aspiration of gastric contents as a result of synthetic cannabinoid toxicity.
Prisons and Probation Ombudsman 11
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Findings
75. The pathologist did not establish Mr Robinson’s cause of death but noted PS in Mr
Robinson’s system. They concluded that the circumstances surrounding his death
suggested that it was drug related. We have therefore focused our findings on Mr
Robinson’s drug misuse.
Substance misuse support
76. Mr Robinson said he had a history of drug and alcohol misuse dating back to when
he was 15. Mr Robinson initially engaged with SMS at Forest Bank although there
is nothing documented as to why he did not have contact with the SMS between
June and November 2023.
77. On his arrival at Lancaster Farms, Mr Robinson told a nurse that he did not have
substance misuse issues, and that he did not want to be referred to the prison’s
substance misuse service. The next day, Mr Robinson again said that he did not
want any support from the SMS team at Lancaster Farms. Staff gave Mr Robinson
a leaflet on harm reduction and told him about substance misuse referral pathways,
should he change his mind in the future.
78. Mr Robinson was only at Lancaster Farms for two weeks before he died. Three
days before he died, he was suspected to be under the influence of an illicit
substance. Prison and healthcare staff assessed him and regularly observed him.
However, he was not referred to the substance misuse team. We spoke to a
practitioner about referral pathways at Lancaster Farms. He explained that every
prisoner entering Lancaster Farms is seen by a member of the substance misuse
team and is offered support from their service. He explained that as a referral
requires a prisoner’s consent, when a prisoner is suspected to be under the
influence, they are not automatically referred to the SMS. If the prisoner is
repeatedly found under the influence however, a member of the SMS team would
speak to them to offer further support. He said that ultimately, a prisoner’s
engagement with the SMS service is voluntary, and that the prisoner needs to want
to stop taking drugs and actively engage to benefit from their services.
79. The practitioner said that if every prisoner who was suspected to be under the
influence was referred to their service, they would be inundated and would not be
able to undertake psychosocial interventions. He said that there were typically more
than ten prisoners each day suspected to be under the influence. However, he also
said that there was heightened awareness around PS and prisoners were often
suspected to be under the influence when they were not.
80. Mr Robinson also attended an adjudication hearing the day after he was found
under the influence. A prison manager told us that if he had admitted his guilt
(which he did not) he could have had a ‘Chance to Change’ adjudication. This offers
the prisoner a chance to receive a supportive, more rehabilitative outcome, rather
than a punitive one. In the adjudication, the prisoner is able to explore the reasons
for their substance misuse and discuss recovery treatments. With the prisoner’s
consent, referrals can then be made to any additional support services. Mr
Robinson’s adjudication was adjourned while items taken from his cell were tested.
12 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
81. Overall, we are satisfied that Mr Robinson was offered appropriate substance
misuse support at Lancaster Farms. The clinical reviewer concurs with this view.
Monitoring prisoners under the influence of illicit substances
82. When Mr Robinson was found under the influence of illicit substances on 11
December, a nurse attended to take clinical observations twice. Staff also tried to
ensure that Mr Robinson had no further access to illicit substances on his person or
in his cell. After the first code blue, staff searched his cell and removed some
suspicious pieces of paper. After the second code blue, Mr Robinson became
aggressive and refused to hand over his vape to staff. Staff used force to ensure
they retrieved the vape that they suspected contained illicit substances. They also
searched his cell and found some more suspicious paper. Both the vape and the
paper tested positive for PS.
83. The drug strategy team also tried to identify the source of the drugs and as a result,
moved three prisoners to the segregation unit before transferring one out of the
establishment.
84. We are satisfied that when Mr Robinson was suspected to be under the influence,
staff appropriately monitored him, as well as taking steps to reasonably mitigate the
potential of him accessing any further illicit substances.
Drug Supply at Lancaster Farms
85. Between December 2023 and April 2024, Lancaster Farms had between 30 and 67
positive drugs finds per month, of which between two to 15 related to PS. In April
2024, the prison introduced a local dedicated search team which increased the
amount of drugs found. Drugs were found across the prison but with the majority
generally being on D wing.
86. A prison manager told us that she is responsible for the prison’s drug strategy which
covers joint working with security and operations to reduce the supply and demand
of illicit substances. She said that the prison has taken steps to reduce the supply of
drugs into Lancaster Farms including the use of enhanced gate security measures,
X-ray machines, body scanners, stringent monitoring of visits, and anti-drone
netting. She said that although the population and drug culture is constantly
evolving, these measures had had a positive impact in the reduction of the supply of
drugs at Lancaster Farms.
87. We acknowledge that Mr Robinson’s death was the first likely drug-related death at
Lancaster Farms since 2017. The prison has made considerable efforts to combat
drug supply and demand, both before and since Mr Robinson’s death. We therefore
make no recommendation.
Clinical care
88. The clinical reviewer found that the care Mr Robinson received at Lancaster Farms
was not of a satisfactory standard and was not equivalent to that which he could
have expected to receive in the community. The clinical reviewer found that Mr
Robinson was not seen by the mental health team within five days of referral, which
Prisons and Probation Ombudsman 13
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
is not compliant with the NHS standard. He made one recommendation around this
issue as well as one other issue unrelated to Mr Robinson’s death, which the Head
of Healthcare will wish to address.
14 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
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
OFFICIAL - FOR PUBLIC RELEASE