Lee Walker

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Lee Walker,
a resident at Clarks House
Approved Premises,
on 13 March 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
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© Crown copyright, 2024
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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 Lee Walker died from multiple injuries after being hit by a vehicle on 13 March 2023,
while a resident at Clarks House Approved Premises (AP). He was 35 years old. I offer my
condolences to Mr Walker’s family and friends.
Although Mr Walker had some risk factors for suicide and self-harm, my investigation
found no evidence that he intended to die that night. Toxicology showed that he had
consumed a significant amount of alcohol before he died. The Coroner’s inquest in
September 2023 also found insufficient evidence that Mr Walker intended to die.
A local initiative to investigate and learn lessons from Mr Walker’s death at an early stage
was comprehensive and robust. I recommend that this approach is adopted nationally.
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 June 2024
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 5
Findings ........................................................................................................................... 9
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Summary
Events
1. Mr Walker had a history of childhood trauma, self-harm by cutting, alcohol and
substance misuse. He was in prison almost continuously from May 2011 until March
2023 interspersed with brief periods in the community totalling seven months.
2. In November 2017, Mr Walker was convicted of grievous bodily harm. The victim
was his partner. He was sentenced to an extended determinate sentence of 64
months in prison and an extended licence period of 36 months.
3. On 10 March 2023, Mr Walker was released on licence from HMP Swaleside. He
arrived later than expected at Clarks House AP the same day. Mr Walker admitted
to having drunk alcohol before his arrival and a breathalyser test showed a level
below the drink/drive limit.
4. Over the next three days, Mr Walker was pleasant to staff and residents and said
he was looking forward to a fresh start. He complied with all the rules at Clarks
House, signing in when required, completing his induction, attending appointments
and obeying the curfew.
5. On 13 March, Mr Walker attended the job centre in the morning and seemed fine to
staff during the day. At about 6.45pm, he returned to the AP to collect his wallet and
then went out again. Just before he left, his probation officer gave him a licence
compliance letter which reminded him that abstinence from alcohol was a condition
of his licence.
6. Mr Walker did not return to the AP for the 7.00pm sign in or the 11.00pm curfew.
Shortly after 1.00am on 14 March, police informed Clarks House staff that Mr
Walker had been involved in a fatal road traffic incident at about 11.15pm.
Subsequent tests showed Mr Walker had drunk a significant amount of alcohol
before he died.
Findings
7. Mr Walker had some risk factors that indicated he might be at risk of suicide and
self-harm, but we found no evidence that his risk was raised during his period at
Clarks House AP and we cannot say whether he intended to die on 13 March.
8. Mr Walker was handed a licence compliance letter as he left the AP for the last time
before his death. We do not know whether Mr Walker read the licence compliance
letter before he died, or, if he did, if it had any impact on his actions. However, best
practice would have been for staff to give Mr Walker the letter at a time when they
could go through the contents with him. This, and other issues, were identified in a
local investigation after Mr Walker’s death. Further staff training occurred alongside
improved quality assurance processes. We welcome such timely intervention and
recommend that a similar approach is adopted nationally.
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Recommendation
• The Head of the National Approved Premises Team should ensure that every death
in an AP is subject to a local investigation and report similar to the process adopted
in Southwest and South Central Region.
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The Investigation Process
9. The National Approved Premises Team notified us of Mr Walker’s death on 14
March 2023.
10. The investigator issued notices to staff and residents at Clarks House Approved
Premises (AP) informing them of the investigation and asking anyone with relevant
information to contact her. No one responded.
11. The investigator visited Clarks House on 22 March 2023. She obtained copies of
relevant extracts from Mr Walker’s records and interviewed five members of staff
and one resident. She interviewed Mr Walker’s community offender manager (COM
– probation officer) on 24 March and another member of staff on 27 March 2023.
She obtained further information from the police investigator.
12. We informed HM Coroner for Oxfordshire of the investigation. The Coroner gave us
the results of the post-mortem examination, toxicology report and inquest verdict.
We have sent the Coroner a copy of this report.
13. The Ombudsman’s family liaison officer contacted Mr Walker’s adoptive father and
stepmother to explain the investigation and to ask if they had any matters they
wanted us to consider. They asked for a copy of our report but did not ask any
specific questions.
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Background Information
Clarks House AP
14. Prisoners are released to Approved Premises in order to resettle into the
community. They live within a supportive and structured environment whilst they
look for work and permanent accommodation. The residents have to abide by a
number of rules and conditions. Each resident is allocated a key worker, with whom
the resident discusses their progress and well-being. The key worker also ensures
that residents adhere to their individual licence conditions and the rules of the
approved premises.
15. Clarks House is managed by HMPPS. A maximum of 18 men can live in the AP. At
least two members of staff are on duty 24 hours a day. The building is locked up for
the night at 11.00pm.
Previous deaths at Clarks House
16. In 2011, a resident of Clarks House died in a road traffic accident while on home
leave with his family. We did not identify any learning for Clarks House in that
investigation and made no recommendations.
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Key Events
17. Mr Lee Walker had a history of childhood trauma, alcohol and substance misuse.
His prison record showed he self-harmed by cutting as a coping strategy.
18. Mr Walker was in prison almost continuously between May 2011 and March 2023,
interspersed with brief periods in the community totalling seven months. In
November 2017, Mr Walker was convicted of grievous bodily harm. The victim was
his partner. He was sentenced to an extended determinate sentence of 64 months
in prison and an extended licence period of 36 months.
19. Mr Walker had brewed fermenting liquid (known as hooch) several times in prison,
most recently in 2022. The last reference to self-harm in his prison record was in
November 2021 when he said he would harm himself after the death of his partner
(who was also the victim of his offence). Mr Walker transferred to HMP Swaleside
on 28 June 2022.
20. On 7 March 2023, the community offender manager (COM – probation officer) held
a video conference call with Mr Walker and the prison offender manager (POM), to
discuss Mr Walker’s forthcoming release on licence to Clarks House AP. He said Mr
Walker appeared reasonably happy about his release to Oxford and had
commented that there were “worse places to be”. He went through the terms of Mr
Walker’s licence with him, including that he should not consume alcohol, and he did
not indicate he had any issues with the conditions.
Clarks House AP, Friday 10 March – Sunday 12 March 2023
21. On 10 March 2023, Mr Walker was released on licence to Clarks House AP. A
residential worker said Mr Walker was due to arrive by 2.00pm but did not. At
3.00pm, he telephoned the COM and they agreed to give Mr Walker until 7.00pm
because he had been in prison a long time and might have had difficulty negotiating
the journey from Swaleside on public transport.
22. Mr Walker arrived at about 4.50pm. The residential worker asked him why he was
late, and he said he had been for a drink. Mr Walker agreed to take a breathalyser
test and the result showed that he had consumed alcohol below the drink driving
limit..
23. A probation service officer said she met Mr Walker briefly when he arrived at the
AP. She introduced herself as his keyworker and said she would see him early the
following week for a formal session to see how he was settling in. She said Mr
Walker seemed tired and naturally a bit nervous about being in a new place but
responded well to her questions. She said she kept their conversation brief as she
did not want to overwhelm him and left him to complete his induction.
24. Two residential workers completed Mr Walker’s induction, including his Support and
Safety Plan (SaSP), which addressed his risk of self-harm. Mr Walker denied any
thoughts of harming himself and said he felt optimistic for his future.
25. A residential worker told the investigator that Mr Walker seemed very open in his
responses. Mr Walker described his mood as nine out of ten, with ten being the
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best. He acknowledged to the investigator that people often did not want to admit to
feeling too low as they knew it meant more welfare checks. Nevertheless, Mr
Walker seemed very positive about staying at Clarks House and referred to having
a new start in a new place. He said he would speak to staff if he felt low or had any
issues. He said Mr Walker seemed positive after the assessment and went out to
the local shops.
26. The duty manager reviewed Mr Walker’s induction paperwork and SaSP at 7.30pm.
He noted Mr Walker’s history of substance misuse and self-harm and concluded
that staff should have one meaningful conversation with him a day for his first seven
days and two extra welfare checks during the night. (AP residents are normally
subject to at least one routine welfare check overnight.) He directed that Mr Walker
should be drug tested the next day and every four weeks thereafter. His room was
to be searched fortnightly and more often if staff noticed any low mood or if Mr
Walker reported thoughts of self-harm.
27. The next day, 11 March, a residential worker completed Mr Walker’s second stage
induction. He said he had slept well and took his planned drug test which was
negative for amphetamines, cannabis, cocaine and opiates. Mr Walker spent the
day either in his room or out in Oxford. She said she asked Mr Walker how he was
when he came back at about 3.00pm. He said he was fine and asked for the kitchen
to be opened so he could make some food. She said Mr Walker was pleasant and
did not give her any cause for concern. He said he was looking forward to a fresh
start.
28. The residential worker said Mr Walker followed the same pattern of behaviour on 12
March. He spent some time in Oxford getting to know the city and spoke about
wanting to live there. Again, he talked about having a fresh start. Mr Walker
complied with the required sign-in times and AP rules and was back in the AP well
before the 11.00pm curfew.
29. Another resident at the AP said he had known Mr Walker to say hello to when they
were both in HMP Erlestoke and recognised him when he came to the AP. He said
he spent about 30 minutes talking to Mr Walker over the weekend of 11/12 March.
Mr Walker seemed OK and was optimistic about making a fresh start in Oxford. He
said he had not noticed any signs Mr Walker was struggling and had no concerns
about him.
Events of Monday 13 March
30. On 13 March, Mr Walker left Clarks House to attend the local Job Centre between
8.24am and 9.37am.
31. Due to Mr Walker’s positive breathalyser test on 10 March, the COM emailed a
licence compliance letter to a probation service officer at the AP, at 10.13am that
morning. This is a standard letter sent if someone breaches a condition of their
licence. He said in the letter that the breathalyser result did not indicate heavy use
and he did not consider that it was necessary to initiate the recall process to return
Mr Walker to prison. He reminded Mr Walker that he must comply with the
conditions of his licence and that he should abstain from alcohol until 10 September
unless he told Mr Walker before then that he could drink alcohol.
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32. In his email to the probation service officer, the COM said he was happy to discuss
the contents of the letter with Mr Walker if she thought it was appropriate to hand it
to him the next day. He told the investigator that he had a video call booked with Mr
Walker for the following afternoon and intended to go through the letter with him
then.
33. The probation service officer said she and a colleague spoke to Mr Walker at about
12.00pm. She said Mr Walker was in the smallest room in the AP and they told him
that a bigger room was available. Mr Walker said he was happy with the room he
had and did not want to move. They laughed with him about this as he was the first
person to be happy with that room and people usually moaned about having it. Mr
Walker said he liked small rooms.
34. A residential worker said Mr Walker spent most of the time he was in the AP that
day in his room. He went out in the afternoon between 4.30pm and 6.45pm. When
he came back, he said he was just collecting his wallet and then left again. He said
he was fine. She said Mr Walker’s emergency payment for universal credit may
have come through for him to collect since he had been at the job centre in the
morning, and it usually came through the same day. As he was leaving, she handed
Mr Walker the compliance letter from the COM. She said she did not know whether
Mr Walker read the letter, but he took it with him. She said she just told him it was a
letter that the COM had asked her to give to him.
35. Mr Walker did not sign back in and out before he left and did not return to the AP for
the 7.00pm sign in or for the 11.00pm curfew. After consultation between AP night
staff and the out of hours duty manager, they decided to issue an emergency recall
for Mr Walker to be returned to prison.
36. At 1.00am, the residential worker who was on night duty, received a call from
Thames Valley Police to say that Mr Walker had been involved in a fatal incident on
the A34. Officers attended the AP the same night and tried to find details of his next
of kin in his room. Staff later noticed a bag of letters from Mr Walker’s deceased
partner on his bed.
37. The police told the investigator that they had received an anonymous call from a
driver on the A34 at about 11.15pm saying they thought they had hit a pedestrian.
There was no evidence that Mr Walker had deliberately stepped in front of the
vehicle and the police did not know what he had done in the five hours since he had
left the AP.
38. The police confirmed to the investigator that they did not remove anything from Mr
Walker’s room and did not find a suicide note.
Contact with Mr Walker’s family
39. Mr Walker was estranged from his significant family members and gave the name
of a friend from his local church as his next of kin when he arrived at Clarks House.
As he died away from AP, Thames Valley Police initially assumed responsibility for
informing Mr Walker’s next of kin of his death. They eventually identified that Mr
Walker’s adoptive father and stepmother were living abroad and told them that Mr
Walker had died. The AP appointed a family liaison officer who contacted Mr
Walker’s father and stepmother in the week beginning 27 March.
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Support for prisoners and staff
40. After Mr Walker’s death, the AP manager spoke to all the staff who had met Mr
Walker during his brief time at Clarks House. Staff spoke to all residents and offered
support in case they had been affected by Mr Walker’s death.
Post-mortem report
41. The pathologist gave the cause of death as multiple injuries. Toxicology showed Mr
Walker had 350mg/dL of blood ethanol indicating he had consumed a considerable
amount of alcohol. (Toxic concentration is dependent on individual tolerance and
usage although levels greater than 300-400 mg/dL can be fatal due to respiratory
depression.)
42. On 27 September 2023, the Coroner gave a narrative verdict at an inquest into Mr
Walker’s death. He said that Mr Walker was heavily intoxicated with alcohol when
he died and found insufficient evidence that his death was an intentional act.
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Findings
Assessment of risk
43. In common with the police investigation and Coroner’s inquest into Mr Walker’s
death, we cannot say whether he intended to die on 13 March. Mr Walker had some
risk factors that indicated he was at risk suicide and self-harm, including a history of
substance misuse, a traumatic childhood and history of self-harm. However, we
have not seen any evidence that his risk was raised during his period at Clarks
House AP. He was pleasant to staff, said he was looking forward to a fresh start
and, until he failed sign in at 7.00pm or return for the 11.00pm curfew on the night
he died, was compliant with the rules.
Action taken by the AP following Mr Walker’s death
44. After Mr Walker died, the Southwest and South Central Approved Premises region
commissioned a local investigation to identify whether there was any learning from
his death. This was a thorough investigation with practical recommendations.
Among other issues, it identified that staff could have had more professional
curiosity when dealing with Mr Walker, for example when he tested positive for
alcohol on the day of his release. It also found that when staff gave Mr Walker his
licence compliance letter, they should have ensured he read it, understood its
meaning and asked him how he felt about it. Instead, we do not know whether Mr
Walker read it before he died, and we cannot say whether it had any impact on his
later actions.
45. The local investigation made several recommendations and, as a result, staff have
received further training and quality assurance processes were improved. We
therefore make no further recommendations.
Local investigation
46. The local introduction of an early investigation to identify lessons learned following a
death in an AP is good practice. This was the first time that the region had adopted
this approach. We found the investigation was useful and comprehensive, resulting
in quick learning. This is not a national initiative but instigated by the local area on
their own initiative.
47. The National Approved Premises Team told us that although they review every
death informally in an AP, that this is not recorded, nor do they produce a report.
We make the following recommendation:
The Head of the National Approved Premises Team should ensure that every
death in an AP is subject to a local investigation and report similar to the
process adopted in Southwest and South Central Region.
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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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