Kirsten Hocking

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Independent investigation into the
A report by the Prisons and Probation Ombudsman
death of Ms Kirsten Hocking
on 24 May 2023, following her
release from HMP Downview
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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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 detained people in immigration centres.
2. 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.
3. Since 6 September 2021, the PPO has been investigating post-release deaths that
occur within 14 days of the person’s release from prison.
4. Ms Kirsten Hocking died in hospital on 24 May 2023, after a drugs overdose,
following her release from HMP Downview on 19 May. Ms Hocking was 31 years
old. We offer our condolences to those who knew her.
5. The lack of suitable accommodation has been a significant factor with many post-
release deaths we have investigated and is again in this case. A report by the
Probation Service, written in April 2022, identified rehabilitation accommodation for
Ms Hocking on leaving prison as being essential to prevent an immediate relapse
into substance misuse. At Downview, staff arranged a rehabilitation placement for
her on release in May 2023. Unfortunately, with escalating self-harm towards the
end of her sentence, this accommodation was no longer viable for Ms Hocking and
was withdrawn. There was insufficient time to arrange an alternative rehabilitation
placement before release, and temporary stop-gap accommodation was only
finalised by her community offender manager (COM) the day before release. The
accommodation provided did not offer the support that Ms Hocking required. This
was due to a very difficult housing situation and not the fault of individuals trying to
assist Ms Hocking.
6. Ms Hocking was also released on a Friday, which is a known risk factor for
vulnerable prisoners. It would appear that she relapsed almost immediately. The
day after her release, Ms Hocking travelled back to an area of previous offending
and substance misuse, where she took the drugs that killed her. It is not known
what her intentions were, but her risk of overdose was raised by a period of
abstinence from drugs in prison.
7. Ms Hocking had complex mental health and substance misuse needs, and she
received a lot of input and support from staff at Downview. For months they worked
towards preparing her for her release. Unfortunately, the release arrangements
changed very close to her release from Downview, and Ms Hocking went from a
very supportive environment into one which was extremely challenging for her.
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The Investigation Process
8. HMPPS notified us of Ms Hocking’s death on 25 May 2023.
9. The PPO investigator obtained copies of relevant extracts from Ms Hocking’s prison
and probation records. As part of his investigation, the investigator interviewed Ms
Hocking’s COM.
10. We informed HM Coroner for West Sussex of the investigation. She gave us the
cause of death and toxicology report. We have sent the Coroner a copy of this
report.
11. The Ombudsman’s family liaison officer contacted Ms Hocking’s mother to explain
the investigation and to ask if she had any matters she wanted us to consider. She
asked for a copy of the report and had questions around her daughter’s housing on
release from prison, which are answered in this report.
12. The initial report was shared with Ms Hocking’s mother. She did not make any
comments.
13. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS found no factual inaccuracies.
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Background Information
HMP Downview
14. HMP Downview is a women’s prison which holds up to 356 women. Healthcare is
provided by Central and Northwest London NHS Foundation Trust between 7.15am
and 6.15pm Monday – Friday and between 8.00am and 5.30pm at weekends.
Psychological and clinical substance misuse services at Downview are provided by
the Forward Trust.
HM Inspectorate of Prisons
15. The most recent inspection of Downview was in July 2021. Inspectors said that
safety was reasonably good, and that healthcare provision was generally very good.
They reported good follow up on PPO investigations.
16. Inspectors said that a good standard of care was provided by the substance misuse
services and that there was good release planning in relation to this, including the
appropriate issue of naloxone (a medicine that rapidly reverses an opioid overdose)
on departure from Downview. They also said that there was a well-staffed
resettlement team providing a good service, and that practical release
arrangements were sound.
Independent Monitoring Board
17. 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 to April 2023, the IMB reported that
between a third and a half of prisoners were released on a Friday with a resulting
difficulty in getting support over the weekend for issues like mental health. They
also said that often there was insufficient communication from COMs with the
prison.
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. Ms Kirsten Hocking had a difficult background. She was in the care of social
services for much of her childhood. At the age of 18, she moved into supported
accommodation (which aims to support young people to develop their
independence and prepare for adult life) until the age of 21. Ms Hocking had a
chaotic lifestyle characterised by substance misuse and prolific offending, much of it
to support her drug misuse.
20. On 17 June 2021, Ms Hocking was sentenced to 20 months imprisonment for
breach of criminal behaviour orders, threatening behaviour, fear or provocation of
violence, and shoplifting.
21. On 18 March 2022, Ms Hocking was released from prison into supported housing.
However, she failed to engage with support services and following non-compliance
with her accommodation conditions and the discovery of drug paraphernalia in her
room, her accommodation was withdrawn on 23 March.
22. On 21 April, police arrested Ms Hocking for numerous offences. She had also
breached her licence conditions and was recalled to prison. The next day, she was
taken to HMP Bronzefield. In an assessment written the same day, her COM wrote,
“Ms Hocking states she is not ready to give up drugs and will return to her chaotic
lifestyle unless her thought process dramatically changes with the right
interventions and release plan to a rehab.”
23. On 20 May, Ms Hocking was sentenced to a further 24 months imprisonment for
five thefts from shops and six breaches of her criminal behaviour order.
24. Ms Hocking moved to Downview on 30 June. She had been on a methadone
treatment programme since returning to prison and engaged with the substance
misuse service (SMS) at Downview. However, in October she admitted that she had
been using Psychoactive Substances (PS).
25. Ms Hocking had a long history of mental health difficulties and self-harming, and as
with previous sentences, she spent much of her time at Downview on an ACCT (a
process to manage and support people at risk of suicide and self-harm). This meant
that she had very intensive input from staff while she was at Downview.
26. On 27 March 2023, Ms Hocking’s Forward Trust substance misuse case manager
told her that Steps 2 Recovery had accepted her onto their rehab programme. She
also told Ms Hocking that the offer was conditional on her self-harming not
becoming too high for them to be able to manage. One of the conditions set by
Steps 2 Recovery, was that Ms Hocking detoxed from methadone before she took
up her rehab placement. She began this on 29 March.
27. Between 11 April and 21 April, Ms Hocking made cuts to her arm on four occasions,
and the episode on 11 April resulted in significant blood loss. Ms Hocking said she
did it because she was struggling with the effects of coming off methadone. She
also said on 21 April that she was worried that she would not be able to cope on
release without the support she was getting in the prison.
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28. On 25 April, Ms Hocking received a Letterbox communication from her son’s
adoptive parents. (Letterbox is a confidential letter exchange service set up by the
child's social worker, which allows information to be sent between the adoptive
parents and birth relatives.) She had been looking forward to this but was slightly
overwhelmed by it as it was the first contact she had had since her son’s adoption
eight years previously.
29. On the same day, Steps 2 Recovery also withdrew their offer of a rehab placement
due to Ms Hocking’s level of self-harming. They said that they did not have 24-hour
medical care and the risks would be too high. Prison staff decided not to tell Ms
Hocking at that point while they attempted to find an alternative placement. They
were concerned that she might make a serious attempt on her own life if she knew
the placement had been withdrawn. After all the options were explored and Steps 2
Recovery declined to reconsider, staff informed Ms Hocking on 9 May.
Pre-release planning
30. Following the collapse of all the previous pre-release plans which had been in
preparation for several months, both staff at Downview and Ms Hocking’s COM had
a short time to make alternative arrangements. Forward Trust staff arranged a new
rehab placement with the Nelson Trust for the following month but Ms Hocking still
needed interim accommodation until then.
31. On 10 May, Ms Hocking’s COM submitted the “homelessness duty to refer form” to
Brighton and Hove Council. However, Ms Hocking had an offending history with the
area, but not a residential history that she could evidence. She did have a
residential history in Worthing but exclusion orders and associations with drug users
there, made Worthing unsuitable for Ms Hocking. The COM asked the prison to
liaise with Ms Hocking to obtain relevant information, but this was problematic as
some of the required information was simply not available because of her previous
residential history. Therefore, there was a delay with the completion of the process,
and with the follow up CAS3 application. (CAS3 accommodation provides
temporary accommodation for up to 84 nights for homeless prison leavers.)
32. CAS3 was a last resort for Ms Hocking as there is minimal support for residents. It
is not a guaranteed provision and the Forward Trust staff at Downview contacted
Change Grow Live. (CGL, a national charity specialising in substance misuse and
criminal justice interventions and associated homelessness.) CGL said they were
not an emergency service and, with the timescales available, could not arrange
accommodation for Ms Hocking. However, they arranged standby appointments
with the Brighton team and West Sussex team, just in case Ms Hocking was
released homeless. They also contacted Sussex Pathways, a local charity that
provides support for prison leavers. The COM also made a standby referral to
Turning Tides, a charity providing homeless support in West Sussex.
33. Because of Ms Hocking’s fragile mental health and concerns about the
arrangements for her on release, Downview arranged for two Approved Mental
Health Professionals (AMHP) to assess her on 18 May to see if she could be
transferred from prison to a hospital on mental health grounds. However, the
AMHPs determined that Ms Hocking was not detainable under the Mental Health
Act.
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34. Although the fallback arrangements were with organisations in Sussex, the COM
tried to get out of area accommodation for Ms Hocking to keep her away from her
home environment where she would be more likely to be triggered into relapsing.
On the afternoon of 18 May, the COM received confirmation of a CAS3 placement
for her in Chertsey, Surrey.
35. The Forward Trust staff at Downview made an appointment with I-Access drug
services in Chertsey for Ms Hocking to give her the opportunity to engage with them
if she wished. They also referred her to Catalyst who support people with substance
misuse and mental health issues in Surrey. The COM made arrangements with the
local probation office for them to supervise Ms Hocking.
Events of 19-20 May
36. Before Ms Hocking was released on 19 May, prison and healthcare staff completed
an ACCT review. Staff were concerned that she may not have been ready for the
rapid detoxification from methadone that she had undertaken for her rehab
placement and asked her ahead of her release if she wanted to return to opioid
substitution prescription. Ms Hocking said she did not want to go back on the
progress that she made. Her SMS support worker discussed harm minimisation
with her and the risk of overdose following her period of drug abstinence in prison.
Ms Hocking was issued with naloxone by the prison on departure.
37. When she left the prison, Downview gave Ms Hocking a release pack which
included contact details for information and help. She was taken to her CAS3
accommodation by a prison officer to reduce her anxiety about getting there.
Probation also decided not to enforce the normal requirement to report to them on
the day of release. It was more important to get Ms Hocking settled in her
accommodation without the stress of getting to a probation office in an area she did
not know.
38. Her COM communicated with Ms Hocking over the telephone. The first call was
from the telephone of the prison officer with her on the way to her accommodation
around 11.00am. Although the COM asked the housing officer to call her when Ms
Hocking was having her induction at 1.00pm, this did not happen. Instead, Ms
Hocking phoned her COM after the induction at around 1.30pm, using the
telephone of another resident in her housing block. It was not a very productive call
as Ms Hocking was in the company of another person and said she was drinking
alcohol. The COM limited her discussion to the licence conditions and the reporting
arrangements that she had put in place, so that Ms Hocking did not have to go to
Brighton.
39. At the end of the afternoon, Ms Hocking texted her COM. Her COM told the
investigator that the text message exchanges were quite pleasant, and that Ms
Hocking was apologetic about the earlier call, saying that she was constrained by
being in the presence of another woman. Ms Hocking said that she was concerned
about her proximity to that person because of her substance misuse. However,
overall Ms Hocking gave a positive impression to her COM and said she just
wanted to get into rehab as soon as possible. More concerning was that Ms
Hocking had contacted her COM on her own phone which had been returned to her
by Downview on leaving prison. Previously she had said that she wanted to avoid
using it as it had contacts on it for obtaining drugs.
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40. At around 8.00pm, Ms Hocking made the first of several calls to Downview, asking
to speak to a Custodial Manager (CM) who had been closely involved in her support
at the prison. The CM said that the subject matter of the calls was fairly consistent:
Ms Hocking said that she had been drinking, that she was struggling outside prison
and did not think that she could cope. She repeated her concerns about other
occupants of the property.
41. The final call from Ms Hocking was at around midnight. Again, she said she was
struggling and mentioned that she had 14 days-worth of medication with her. As
there was an implication that she might take too much medication given the tone of
the call, the CM called the police and asked them to do a welfare check, and the
police visited Ms Hocking. There was no further contact from her.
Circumstances of Ms Hocking’s death
42. Ms Hocking spent the night in her CAS3 accommodation, and the following day
travelled to Worthing. At 5.10pm, Ms Hocking was found unresponsive in a public
place. There was evidence of drug paraphernalia nearby. Paramedics attended and
took Ms Hocking to hospital. She died there on 24 May.
Cause of death
43. The Coroner told us that Ms Hocking had died from a hypoxic brain injury (the lack
of oxygen to the brain resulting in the death of brain cells), following a cardiac arrest
(when the heart suddenly stops pumping blood around the body as a result of an
abnormal heart rhythm), which was caused by a drugs overdose. The Coroner
accepted the cause of death given by hospital doctors and there was no post-
mortem examination.
44. The toxicology report concluded that Ms Hocking had taken several different drugs
before her death, including heroin and cocaine. They also included antihistamine,
antipsychotic and antidepressant medications that she had been prescribed, which
in combination with heroin may enhance sedative effects. Other significant factors
are the unknown effects of combining prescription medications manufactured to
exacting specifications and illegal drugs, as well as the unpredictable effects of
combining heroin with cocaine. Ms Hocking’s tolerance for heroin would have been
lower after she stopped taking methadone the month before she died and following
her abstinence from drugs in prison.
Support for staff
45. The COM told the investigator that she felt well supported following the death of Ms
Hocking. While some staff at Downview felt they had received the support they
needed, not everyone said this was the case. This is discussed further below.
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Findings
46. Following Ms Hocking’s return to prison in April 2022, her post recall risk
assessment report noted that, “The speed at which Ms Hocking relapsed on
release, despite being met by [the] Forward Trust and being placed straight into
Turning Tides accommodation is concerning.” The report identified the need for her
to go straight into rehab on release to reduce the likelihood of immediate relapse.
Ms Hocking agreed this was necessary and a rehab place was allocated in March
2023.
47. Unfortunately, possibly as a result of the emotional load of reconnecting with her
son for the first time since his adoption, and the effects of coming off methadone,
Ms Hocking’s self-harm escalated in the lead up to her release from prison. The
provider, Steps 2 Recovery, felt that her risk had become too high for them to
manage and withdrew her rehab offer. Rehabilitation placements are scarce and
rarely available at short notice. There was insufficient time for an alternative rehab
placement to be found for Ms Hocking, although one was provisionally available
three to four weeks later.
48. Between the withdrawal of her placement and her release, staff at Downview made
intensive efforts to find alternative supported accommodation for Ms Hocking, and
urgently messaged her COM. The situation for the COM was complicated by the
need to keep Ms Hocking away from Brighton and especially Worthing (both to
maximise her chances of remaining drug free and because of exclusion zones), the
barriers to making a council accommodation referral to any area that Ms Hocking
did not have a residential history, and that although Ms Hocking was a high risk to
herself, she was only a medium risk to the public, which is an important factor in
sourcing the limited release accommodation available.
49. Ms Hocking’s anxiety was increased by the uncertainty of where she was going to
be released to, and the CAS3 accommodation was only confirmed on the afternoon
before her release. Then, on Friday 19 May, Ms Hocking was released from the
very supportive environment she had at Downview, into a vacuum of support. Ms
Hocking had asked if she could stay in Downview at the end of her custodial period,
until the rehab accommodation became available. This was, of course, not possible.
50. After initially concerning telephone contact with her COM soon after arrival at her
CAS3 accommodation, her COM was reassured by more positive messages later in
the afternoon. However, that evening, Ms Hocking made several calls to Downview
stating she was struggling to cope. Several hours after her last call, she returned to
Worthing where she overdosed on drugs.
51. Significant factors in Ms Hocking’s death were the withdrawal of her rehab
placement, and her detoxification from methadone in preparation for her rehab
residency, which increased her risk of overdose, especially as it had been a long
time since she had been free of opioids. Although Ms Hocking may not have
succeeded with her rehabilitation placement, and on a previous release had
withdrawn from a rehabilitation residence before completion, both the withdrawal of
the Steps 2 Recovery rehab offer, and her overdose vulnerability were significant to
the situation Ms Hocking found herself in immediately after her release.
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Friday releases from prison
52. Although it is probable that the biggest factor was that identified by Probation a year
earlier, the lack of rehab accommodation for Ms Hocking on her release, there is a
well-established link between Friday releases and the consequent lack of support
over weekends, and poor outcomes for vulnerable prisoners. Legislation passed on
29 June (Offenders (Day of Release from Detention) Act 2023), seeks to address
this. It was first implemented by HMPPS with releases in December 2023.
53. Although we make no recommendation in connection with this, it is appropriate that
we note that it is likely that Ms Hocking’s release on a Friday may have been a
compounding factor in the outcome the next day.
Governor and Regional Probation Director to note
Communication between Downview and Probation
54. From the end of March to the end of April, it seemed that Ms Hocking’s release
arrangements were in place and so there was not a great deal to be done during
this time. After these fell apart, Downview staff were concerned with the level of
contact and information sharing they were able to achieve with her COM about
alternative housing arrangements. The COM explained to the investigator that
pressures of other work as well as the need to prioritise sourcing release
accommodation for Ms Hocking, meant that with multiple parties contacting her
about Ms Hocking, she had to be selective with her external communications. We
bring this to the attention of the Governor of Downview and Regional Probation
Director to consider whether any improvements could be made to how staff
communicate and share information.
Support for prison staff following a death of a released prisoner
55. Many staff at Downview had been very closely involved in supporting Ms Hocking,
and for a long time in some cases. Some staff told the investigator that they felt they
received the support they needed following the death of Ms Hocking. However, this
was not true in every case. Downview has protocols for support following deaths in
custody, but there do not appear to be formalised procedures for deaths following
release. Deaths shortly after release are not frequent and so the situation may not
have arisen previously, but the Governor may wish to follow this up.
Good practice
56. It is very unusual to see arrangements for prison staff to provide follow up support
following release, but to help Ms Hocking with her transition to the community, two
prison managers had arranged to visit her on 30 May. Ms Hocking said this gave
her something to look forward to. Unfortunately, Ms Hocking was dead by that date.
Also notable, were the CM’s actions on the evening of 19 May, culminating in her
request to the police to carry out a welfare check on Ms Hocking. Despite the
outcome, many people at Downview made considerable efforts to help Ms Hocking,
and the joined up working between clinical, mental health, substance misuse, and
prison staff was both professional and compassionate. It is appropriate that this is
recognised.
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Adrian Usher
Prisons and Probation Ombudsman January 2024
Inquest
57. The inquest into Ms Hocking’s death concluded in November 2024. It found that Ms
Hocking died following a drug overdose which was most likely accidental.
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