Lee Gilligan

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Independent investigation into
the death of Mr Lee Gilligan on
9 July 2023, following his
release from HMP Forest Bank
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 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 Lee Gilligan died of multiple organ failure caused by cocaine toxicity on 9 July
2023, following his release from HMP Forest Bank on 30 June. He was 43 years
old. We offer our condolences to those who knew him.
5. Mr Gilligan had a history of substance misuse. On his arrival at Forest Bank, Mr
Gilligan denied having any current or historic substance misuse issues. Despite
this, he was told how to access substance misuse services should he need them in
the future. We are satisfied that Mr Gilligan received appropriate support for his
substance misuse issues while he was at Forest Bank.
6. We consider that Mr Gilligan’s community offender manager (COM) appropriately
prepared for his release. She liaised with external support agencies, secured
accommodation, and gave him post-supervision requirements to try to ensure he
addressed his substance misuse issues.
7. We make no recommendations.
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The Investigation Process
8. HMPPS notified us of Mr Lee Gilligan’s death on 26 June 2024.
9. The PPO investigator obtained copies of relevant extracts from Mr Gilligan’s prison
and probation records.
10. We informed HM Coroner for Bolton of the investigation. They gave us the results of
the post-mortem examination. We have sent the Coroner a copy of this report.
11. The Ombudsman’s office contacted Mr Gilligan’s next of kin, to explain the
investigation and to ask if they had any matters they wanted us to consider. They
did not respond.
12. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
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Background Information
HMP Forest Bank
13. Forest Bank is a private reception and resettlement prison which holds men who
have either been convicted or are on remand. It is managed by Sodexo. Healthcare
services, including mental health services, are provided by Spectrum (Greater
Manchester Mental Health NHS Foundation Trust). Change, Grow, Live (CGL)
provides substance misuse services.
Probation Service
14. 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.
HM Inspectorate of Prisons
15. The most recent inspection of HMP Forest Bank was in February 2022. Inspectors
reported a longstanding leadership team who led services well and supported a
team of skilled and motivated staff. Close working was evident with other prison
departments particularly in the delivery of the evolving drug strategy, which was
used to inform practice. Discharge planning started early with practitioners allocated
to local areas in Manchester, enabling close partnerships and networks to be
developed, which facilitated more effective continuity of care.
16. Inspectors reported that the need for resettlement help was high. For sentenced
prisoners, release planning was reasonable and accommodation outcomes on
release had improved since the last inspection. A dedicated housing specialist had
been introduced and they had developed relationships with local authorities and
housing providers in the community. There was also new funding from the Greater
Manchester temporary housing scheme, and about 86% of prisoners left with some
form of accommodation on the day of their release.
HM Inspectorate of Probation
17. The most recent inspection of the Greater Manchester Probation region was in
2023. Inspectors found that leadership teams across the probation delivery units
were impressive and there was positive morale among highly motivated probation
practitioners. However, staff shortages, high workloads, and a predominance of
inexperienced staff hindered delivery of the intended quality of case management.
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Key Events
Background
18. On 1 December 2022, Mr Lee Gilligan was convicted of grievous bodily harm and
sentenced to seven months in prison. He was sent to HMP Doncaster.
19. On 16 March 2023, Mr Gilligan was released from Doncaster. Over the next six
weeks, Mr Gilligan repeatedly breached his licence conditions. These breaches
included missing his curfew and testing positive for drugs and alcohol. As a result,
his community offender manager (COM) initiated his recall to prison. On 28 April,
Mr Gilligan was arrested by police and sent to HMP Forest Bank.
20. On Mr Gilligan’s arrival at Forest Bank, a nurse completed his reception health
screen. Mr Gilligan told the nurse that he did not drink alcohol. Although Mr Gilligan
had a history of substance misuse, when asked he said he had no current problems
with drugs or alcohol and had never taken illicit drugs. Mr Gilligan was not seen by
anyone from the substance misuse team during his time at Forest Bank.
21. On 30 April, an officer completed Mr Gilligan’s induction. The officer told Mr Gilligan
about the support services available at Forest Bank and how to access them. This
included the substance misuse and recovery service. On 2 May, a chaplain
completed Mr Gilligan’s chaplaincy induction. Again, staff told Mr Gilligan about the
support services available to him at Forest Bank.
22. On 11 May, Mr Gilligan saw a nurse and asked for pain relief for sciatica (nerve
pain in the leg that is caused by a problem in the lower back). A GP prescribed
Duloxetine (an antidepressant medication, which is also used to treat nerve pain).
23. Mr Gilligan attended three sessions with his key worker on 19 May, 30 May and 3
June. Mr Gilligan engaged positively. He told his key worker that he was happy on
his wing and did not need any support from any services at Forest Bank. He said he
was looking forward to his upcoming release.
24. On 22 May, Mr Gilligan was allocated a new community offender manager (COM).
On 27 June, she visited him at Forest Bank to discuss his release.
25. On 6 June, Mr Gilligan attended an intervention with the programmes team to
address his offending behaviour issues. Mr Gilligan engaged well.
26. On 30 June, Mr Gilligan was released from Forest Bank. A nurse recorded his
clinical observations (which involves checking body temperature, blood pressure,
pulse rate, and breathing rate) prior to his release. They were all within normal
range. The nurse gave him pain relief medication and a discharge letter for his GP.
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Pre-release planning for Mr Gilligan
27. On 18 May, Mr Gilligan’s COM submitted a CAS3 referral (an accommodation
service for prison leavers). He was accepted by CAS3 and allocated a bed in a
shared property on 12 June. Prison staff informed him on the same day.
28. On 19 June, a GP prescribed a week’s worth of Duloxetine to be given to him on 29
June to prepare for his release.
29. On 27 June, the COM visited Mr Gilligan at Forest Bank to discuss his upcoming
release. She told Mr Gilligan that she had secured him accommodation for his
release, and they discussed employment opportunities. Mr Gilligan agreed to
continue to work with the local community substance misuse service, Achieve, who
were also helping him to gain his scaffolding certificates. She explained the
requirements of his post-sentence supervision which included regular drug testing.
Mr Gilligan asked what would happen if he tested positive for cocaine, and she
explained that this would be a breach of his requirements and would risk him
returning to custody. She warned Mr Gilligan about the risks associated with taking
illicit drugs and drinking alcohol, including the damage this could do to his body,
specifically the risk of a heart attack and overdose. She noted that Mr Gilligan did
not appear to take this information seriously.
30. The next day, a pre-release team worker at Forest Bank saw Mr Gilligan to advise
him of the support available to him after his release from prison. Mr Gilligan asked
the worker if he could contact Achieve regarding his scaffolding certificate. The
worker agreed and told Mr Gilligan he would contact him one week after his release
to see how he was progressing in the community.
Post-release management from HMP Forest Bank
31. On the day of his release, Mr Gilligan attended Salford Probation Office as required.
His COM completed his induction and again, warned Mr Gilligan of the risks
associated with drinking alcohol and taking cocaine. Mr Gilligan said he would likely
be working with a scaffolding company the following week, so she scheduled his
next probation appointment for 5 July at 5.30pm.
32. Mr Gilligan was released from prison on his sentence expiry date. However, he was
still subject to a period of post-sentence supervision (PSS). This applies to all
offenders who receive a custodial sentence shorter than two years. This enforces a
supervision period to help with the offender's rehabilitation after they leave prison.
PSS has different, less stringent guidelines regarding supervision contact. Licence
conditions are no longer applicable, and individuals can be supervised with more
flexibility.
33. Later that day, Mr Gilligan collected the keys for his new accommodation and
attended an appointment at the job centre.
34. On 5 July, Mr Gilligan did not attend his scheduled probation appointment. His COM
attempted to contact Mr Gilligan, but his phone was switched off. She issued Mr
Gilligan a breach warning letter.
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35. On 6 July, the police emailed Salford Probation to inform them that Mr Gilligan had
been arrested and was currently in hospital.
Circumstances of Mr Gilligan’s death
36. On 6 July, police attended an address in Salford after Mr Gilligan had entered a
stranger’s address and barricaded himself in the utility room. Police suspected him
to be under the influence of illicit substances and experiencing a drug induced
psychotic episode. He was arrested and taken to Salford Royal Critical Care Unit.
He remained in the hospital’s intensive care unit for the next few days where his
condition continued to deteriorate. On 9 July, Mr Gilligan died. Greater Manchester
Police informed HMPPS.
Post-mortem report
37. The post-mortem report concluded that Mr Gilligan died of multiple organ failure. Mr
Gilligan developed heart, liver and kidney failure while in hospital, which was
caused by cocaine toxicity.
38. Toxicology tests also identified the presence of ketamine (an anaesthetic that can
cause hallucinations) and midazolam (a sedative medication used before surgery
and medical procedures).
Inquest
39. At the inquest held on 3 June and 4 June 2025, the Coroner concluded that Mr
Gilligan’s death was drug-related.
Findings
Substance misuse services
Pre-release
40. Mr Gilligan had a history of substance misuse. However, on his arrival at Forest
Bank, Mr Gilligan told a nurse that he did not have any current or historic problems
with substance misuse. As a result, he was not initially offered any support from or
seen by a representative from the substance misuse service. Over the next few
days, Mr Gilligan was told about the substance misuse services available at Forest
Bank (and how to access them) on two occasions. We are therefore satisfied that
Mr Gilligan was fully aware of how to access their services, should he have wished
to do so.
41. During his short period in custody at Forest Bank, Mr Gilligan denied any history of
substance misuse and gave no indication to staff that he had ongoing substance
misuse issues. Therefore, we consider it reasonable that he received no
intervention from the SMS service whilst at Forest Bank.
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Post-release
42. Prior to his release, Mr Gilligan’s COM identified that his offending behaviour was
linked to his substance misuse. She therefore included drug testing and
engagement with community drug and alcohol services as requirements of his post-
sentence supervision. The COM arranged for Mr Gilligan to be supported by
Achieve throughout his period of PSS, and she warned him about the risks
associated with taking illicit substances.
43. The COM also identified that for Mr Gilligan, homelessness was a risk factor to
offending and substance misuse, and employment was a protective factor. As a
result, she ensured he had accommodation arranged for the day of his release and
supported him to gain employment in scaffolding. We are satisfied that Mr Gilligan’s
COM put appropriate measures in place to address his substance misuse issues
when he was released from prison.
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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