Liam Darby

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Independent investigation into
the death of Mr Liam Darby,
on 21 July 2023, following his
release from HMP Erlestoke
A report by the Prisons and Probation Ombudsman
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
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© Crown copyright, 2025
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Summary
1. The Prisons and Probation Ombudsman aims to make a significant contribution to
safer, fairer custody and community supervision. One of the most important ways in
which we work towards that aim is by carrying out independent investigations into
deaths, due to any cause, of prisoners, young people in detention, residents of
approved premises and detainees in immigration centres.
2. Since 6 September 2021, the PPO has investigated post-release deaths that occur
within 14 days of the person’s release from prison.
3. If my office is to best assist His Majesty’s Prison and Probation Service (HMPPS) in
ensuring the standard of care received by those within service remit is appropriate,
our recommendations should be focused, evidenced and viable. This is especially
the case if there is evidence of systemic failure.
4. Mr Liam Darby died from respiratory depression on 21 July 2023, following his
release from HMP Erlestoke on 18 July 2023. This was caused by central nervous
system depression, which was in turn caused by the combined use of heroin,
codeine, methadone, pregabalin and alcohol. He was 31 years old. We offer our
condolences to those who knew him.
5. Although Erlestoke told us that the substance misuse service at the prison saw Mr
Darby frequently for clinical and psychosocial care in the two months he spent
there, we found that record-keeping was poor and did not document the treatment
he received. We make the following recommendation:
The Head of Healthcare should ensure that all contact and interventions with
prisoners under the care of the substance misuse service are properly
recorded.
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The Investigation Process
6. HMPPS notified us of Mr Darby’s death on 26 June 2024.
7. The PPO investigator obtained copies of relevant extracts from Mr Darby’s prison
and probation records.
8. We informed HM Coroner for Winchester of the investigation. They gave us the
results of the post-mortem examination. We have sent the Coroner a copy of this
report.
9. The Ombudsman’s office contacted Mr Darby’s mother to explain the investigation
and to ask if she had any matters she wanted us to consider. She did not respond.
10. 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 Erlestoke
11. HMP Erlestoke is a category C prison which holds men who have been convicted or
remanded into custody. Oxleas NHS Foundation Trust provides healthcare,
including mental health services, at the prison. Change Grow Live provides
substance misuse services.
Probation Service
12. The Probation Service works with all individuals subject to custodial and community
sentences. During a person’s imprisonment, they oversee their sentence plan to
assist in rehabilitation, prepare reports to advise the Parole Board and have links
with local partnerships to which they refer people for resettlement services, where
appropriate. Post-release, the Probation Service supervises people throughout their
licence period and post-sentence supervision.
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Key Events
Background
13. On 4 November 2022, Mr Liam Darby was convicted of robbery and sentenced to
two years and ten months in prison. He was sent to HMP Winchester.
14. During his initial health screen, it was noted that he was withdrawing from drug use
and had a stoma bag due to his intravenous drug use. Winchester’s substance
misuse service saw Mr Darby regularly, including for psychosocial intervention. He
was given harm minimisation advice and therapy.
15. On 15 May 2023, Mr Darby was transferred to HMP Erlestoke, where he was
referred to the mental health service and substance misuse service. Erlestoke told
the investigator that Mr Darby had no direct contact with the mental health service
as there were no indications it was needed.
16. On 16 May, the substance misuse service booked an initial appointment with Mr
Darby for 25 May. Although Erlestoke told us that they saw him that day, there is no
record of this interaction or any subsequent contact with him. He was prescribed
methadone.
17. On 30 May, Mr Darby’s community offender manager (COM) completed an
Offender Assessment System (OASys) assessment which identifies a prisoner’s
risks and needs. This noted that Mr Darby’s offending behaviour was significantly
linked to his substance misuse, and he would benefit from addressing this.
Pre-release planning
18. On 7 June, Mr Darby’s prison offender manager (POM) handed over Mr Darby’s
care to his COM in preparation for his release the following month. Mr Darby
attended the handover. The probation records system noted that they were in the
process of completing a referral to the Community Accommodation Service (CAS2,
for people who do not have suitable accommodation for the term of their licence) for
post-release accommodation and had discussed Mr Darby’s mental health needs
with him. He was advised to register with a GP immediately on release. It was
agreed that he also needed to be referred to NHS Inclusion, a community service,
for his prescriptions and support on release.
19. On 19 June, Mr Darby was trained on how to use naloxone (a medicine that
reverses an opioid overdose) and was to be released with it.
20. On 14 July, the substance misuse service referred Mr Darby to NHS Inclusion.
21. Erlestoke’s substance misuse service referred Mr Darby to NHS Inclusion for
clinical treatment for his substance misuse, and he was given a bridging
prescription of methadone. Mr Darby’s COM told us that NHS Inclusion also
provided psychosocial interventions for substance misuse.
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Post-release management
22. On 18 July, Mr Darby was released from Erlestoke on a Home Detention Curfew.
His licence conditions required him to be tested for Class A and B drugs and to
address his substance misuse offending behaviour.
23. The prison told the investigator that Mr Darby was given harm minimisation advice
on release but there is no record of this. Mr Darby was released with naloxone,
quetiapine (an antipsychotic medication prescribed to Mr Darby for his personality
disorder) and fluoxetine (an antidepressant).
24. Mr Darby reported to his CAS2 accommodation, a shared house in Hampshire,
where his support worker saw him. She noted that he was “high in mood” and
grateful to be out of prison. He talked about improving his life and focusing on
himself. She saw Mr Darby twice that day. He did not raise any concerns and said
he had no intention of harming himself.
25. That day, Mr Darby had his first appointment with Probation. His usual COM was on
annual leave, so another COM saw him instead. They discussed some of his
licence conditions. Mr Darby told her that he had difficulties with his mental health
but that mental health services would not help him due to his substance misuse.
26. The COM noted that Mr Darby had been released from prison without his
prescriptions. She contacted NHS Inclusion who gave them to Mr Darby. The
substance misuse clinical lead at Erlestoke told the investigator that the substance
misuse service had realised the day after Mr Darby’s release that he had not been
given his prescriptions and contacted NHS Inclusion about it.
Circumstances of Mr Darby’s death
27. At approximately 9.00pm on 19 July, Mr Darby’s housemate saw him going to the
bathroom to change his stoma bag. This was the last time he saw him. It was noted
in the police’s sudden death report for the Coroner that Mr Darby had voiced no
intentions of suicide or self-harm and had not raised any other concerns.
28. At approximately 8.44am on 21 July, a support worker knocked on Mr Darby’s door,
but he did not respond. She knocked a further two times before she went into his
room and found him on the bedroom floor. She called the ambulance service
immediately. Paramedics arrived at 8.47am and pronounced Mr Darby dead at
8.48am.
29. Drug paraphernalia was found in Mr Darby’s room, including small cooking spoons
and syringes, one of which appeared to be used.
Post-mortem report
30. The post-mortem report concluded that Mr Darby died of respiratory depression,
caused by central nervous system depression. This was in turn caused by the
combined use of heroin, codeine, methadone, pregabalin and alcohol.
31. Post-mortem toxicology results identified in Mr Darby’s system morphine (at a level
associated with fatalities), alcohol (at a level over the drink-drive limit), methadone
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and pregabalin (which had been prescribed) and a number of other drugs at a
therapeutic level.
Inquest
32. At an inquest held on 10 December 2024, the Coroner concluded that Mr Darby
died of misadventure.
Support for staff
33. After Mr Darby’s death, his COM felt that he was well supported by his then
manager. During our investigation, his current manager also offered support,
including signposting him to relevant support services.
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Findings
Substance misuse services
Medications on release
34. Mr Darby was not released with his bridging medication prescriptions as he should
have been. The substance misuse clinical lead told the investigator that this was an
error, and the substance misuse service had since implemented a new process
which requires a CGL staff member to check at reception if the prison leaver is
being discharged with all their medication and prescriptions. As the service has
identified the learning and addressed the issue, we do not make a recommendation.
Substance misuse support in prison and pre-release
35. Mr Darby had a significant history of substance misuse that was linked to his
offending behaviour. While at Winchester, the substance misuse service saw him
regularly and gave him psychosocial intervention, including therapy, weekly. This
was good practice.
36. Mr Darby was also referred to Erlestoke’s substance misuse service and was
appropriately prescribed methadone. Erlestoke also trained him in the use of
naloxone and appropriately gave it to him on release.
37. The Quality and Governance Lead at Erlestoke identified that the substance misuse
service saw Mr Darby frequently but that not all their contact with him was
documented. The CGL Team Lead at Erlestoke also told the investigator that they
had seen Mr Darby but were concerned about their poor record-keeping. The
investigator saw little evidence in either the prison or healthcare records to establish
what substance misuse care Mr Darby received. Although the Lead told us that she
expected that Mr Darby received psychosocial intervention at Erlestoke, we saw no
records to confirm this. As a result, we are unable to comment on the
appropriateness of the substance misuse support Mr Darby received at Erlestoke or
how well it equipped him for his release. We make the following recommendation:
The Head of Healthcare should ensure that all contact and interventions with
prisoners under the care of the substance misuse service are properly
recorded.
Adrian Usher
Prisons and Probation Ombudsman February 2025
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Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
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