Melissa Ridley

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Independent investigation into
the death of Ms Melissa Ridley
on 27 February 2025,
following her release from
HMP Low Newton
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. Ms Melissa Ridley died from mixed drug toxicity on 27 February 2025, the day after
her release from HMP Low Newton. She was 39 years old. We offer our
condolences to those who knew her.
5. Prior to Ms Ridley’s release, the prison’s substance misuse service (SMS) arranged
a community SMS appointment for her in Carlisle for the afternoon of her release,
where she would collect her methadone prescription (used to treat heroin
addiction). However, the day before her release, Ms Ridley’s community offender
manager (COM) was told that Ms Ridley had been given temporary accommodation
in Cleator Moor, so she changed her community SMS appointment to the following
afternoon in Whitehaven, which was much closer than Carlisle. When she told Ms
Ridley this on the day of her release, Ms Ridley was distressed that she would have
to wait until the afternoon to get her methadone when she normally took it in the
morning. She said she would not cope and would have to seek methadone, or an
alternative drug, elsewhere to prevent her suffering withdrawal symptoms.
6. We accept that the location of the CAS3 accommodation was outside the COM’s
control and that she did her best to change the community SMS appointment to a
more convenient location at short notice. However, it was unfortunate that an earlier
appointment could not have been made as the timing of the new appointment had a
detrimental impact on Ms Ridley. While we make no recommendation, we highlight
this issue as it is possible that if attempts had been made to move the appointment
to an earlier time, Ms Ridley may not have sought illicit drugs elsewhere.
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The Investigation Process
7. HMPPS notified us of Ms Ridley’s death on 27 February 2025.
8. The PPO investigator obtained copies of relevant extracts from Ms Ridley’s prison
and probation records.
9. We informed HM Coroner for Cumbria of the investigation. She gave us the results
of the post-mortem examination. We have sent the Coroner a copy of this report.
10. The Ombudsman’s office contacted Ms Ridley’s mother to explain the investigation
and to ask if she had any matters she wanted us to consider. She did not respond
to our letter.
11. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS pointed out some factual inaccuracies and this report has been amended
accordingly.
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Background Information
HMP Low Newton
12. HMP Low Newton is located near Durham. It holds women on remand and serving
short and long sentences including some high security prisoners. Spectrum
Community Healthcare CIC provides physical healthcare services and Tees, Esk &
Wear Valleys NHS Foundation Trust provides mental health services. The prison
has 24 hour a day nursing cover.
Probation Service
13. 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
appropriates. Post-release, the Probation Service supervises people throughout
their licence period and post-sentence supervision.
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Key Events
Background
14. On 21 December 2023, Ms Melissa Ridley was sentenced to 16 months in prison
for shoplifting. She was taken to HMP Low Newton. She was released on licence on
10 July 2024.
15. On 19 July, police arrested Ms Ridley for shoplifting, and she was recalled to Low
Newton for the rest of her sentence. On 9 August, she received an additional one-
month sentence for the offence.
16. Ms Ridley had a history of drug use. Before her initial release, she was on an opioid
maintenance plan and was prescribed Espranor (buprenorphine, a synthetic opioid
medication used to treat withdrawal from opiates such as heroin).
Pre-release planning
Substance misuse
17. When Ms Ridley was recalled to Low Newton, she appeared to be under the
influence of drugs. A substance misuse service (SMS) worker assessed her for
withdrawal symptoms.
18. The next day, Ms Ridley told a SMS worker that she had stopped taking her opioid
substitution treatment (OST) while in the community. The day before her arrest she
had visited the community SMS, who gave her a dose of Espranor.
19. On 21 July, Ms Ridley restarted OST with a methadone (another synthetic opioid)
prescription.
20. On 24 July, a nurse reviewed Ms Ridley five days into treatment. She asked the
nurse to increase her dose of methadone from 30ml to 40ml as she had withdrawal
symptoms. The nurse requested for her prescription to be increased.
21. On 3 August, Ms Ridley told the SMS team she wanted to reduce her methadone
by 2ml every two weeks until she reached 20ml.
22. On 24 September, a nurse reviewed Ms Ridley after she had asked to stop
reducing her methadone dose. Ms Ridley said she did not feel stable and had
withdrawal symptoms. The nurse completed a Clinical Opiate Withdrawal Scale
(COWS) assessment and calculated a score of 2 (very mild or minimal opioid
withdrawal). She added Ms Ridley to the waiting list for an appointment to increase
her dose.
23. On 4 October, Ms Ridley asked to increase her methadone to 40ml, saying she had
reduced it too quickly and was struggling. The SMS team approved the increase.
24. On 6 November, Ms Ridley asked to start reducing her dose again, by 1ml each
week until she reached 30mls.
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25. On 1 January 2025, Ms Ridley asked for an appointment with the SMS team to stop
reducing her methadone. The next day, a nurse saw her for a review. Ms Ridley
decided to continue reducing her methadone until she reached 30mls. This was so
she could be changed back to Espranor when released.
26. On 17 January, a SMS worker saw Ms Ridley on the wing. Ms Ridley told her that
she had used gabapentin (a medication used to treat nerve pain and reduce anxiety
and sleep problems but also widely abused – it was not prescribed to Ms Ridley)
and had a positive drug test. She said she had taken the medication because she
was unable to sleep and had requested an increase in her methadone which had
not been actioned. The recovery coordinator said that she was on the waiting list to
be seen by the clinical SMS team.
27. On 25 January, a nurse saw Ms Ridley for a 13-week review of her OST. During the
appointment, Ms Ridley told the nurse that she wanted to increase her methadone
dose from 30ml to 35ml to better manage symptoms and for stability upon her
release.
28. On 27 January, a nurse was unable to complete Ms Ridley’s methadone increase
as the necessary forms had not been completed. The nurse added her back to the
waiting list to have the required forms completed.
29. On 4 February, a SMS worker referred Ms Ridley to the community SMS in Carlisle
and requested to increase her methadone prescription to 35mls. She arranged an
appointment with the community SMS for Ms Ridley’s methadone script on the day
of her release after 3.00pm, as requested by Ms Ridley.
30. On 13 February, a SMS worker met with Ms Ridley for a one-to-one session. Ms
Ridley said that if her methadone was not increased in the next week, she would
stay on 30mls until release and change to Espranor in the community. Ms Ridley
did not want to change to Espranor while in prison, as she said she found it easier
to manage in the community. Ms Ridley’s keyworker discussed harm reduction on
release, including reduced tolerance levels, avoiding using alone, and not mixing
substances.
31. On 21 February, a SMS worker saw Ms Ridley on the wing. Ms Ridley said her
CAS3 accommodation had been confirmed, though she did not know the address.
She did not want to change her script appointment as all her appointments were
close together. They agreed that if her accommodation was confirmed for another
part of Carlisle, then Ms Ridley would transfer her appointment to the nearest drug
and alcohol team.
Housing
32. Before entering custody, Ms Ridley was homeless. During her reception at Low
Newton, she told staff that she would have nowhere to live when released.
33. On 21 January, Ms Ridley’s prison offender manager (POM) told her community
offender manager (COM) that Ms Ridley did not want to be released to an approved
premises. She said she wanted to return to west Cumbria.
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34. On 28 January, Ms Ridley’s COM referred her to the local council for housing
support under the Duty to Refer policy (for individuals who are at risk of
homelessness).
35. On 10 February, Ms Ridley’s COM referred her for CAS3 accommodation (a type of
temporary, supported housing for people leaving prison homeless, which provides
up to 84 nights of accommodation).
36. On 24 February, the local authority told the COM that Ms Ridley did not meet the
priority need criteria and would not be offered housing through the council.
37. The same day, the COM confirmed that CAS3 accommodation in Cleator Moor
(about five miles from Whitehaven and 40 miles from Carlisle), had been reserved
for Ms Ridley’s release.
Release from HMP Low Newton
38. On 26 February, Ms Ridley was released from Low Newton. A member of the
healthcare team offered her naloxone (a medication that can reverse an opioid
overdose) to take with her, but she declined.
39. Ms Ridley’s POM took her to her CAS3 accommodation, then to her first probation
appointment.
40. At the appointment, Ms Ridley’s COM told her that her Recovery Steps Cumbria
(community substance misuse service) appointment which she was due to attend
that day had been arranged for the Carlisle office. Since it was too far away for Ms
Ridley to attend, the COM rearranged the appointment at the Whitehaven office.
This meant the appointment would now take place the following day at 1.30pm.
41. Ms Ridley became upset and told her COM that she would not manage until the
afternoon, as she usually had her methadone in the morning. She said that she
would need to buy methadone or another substance to manage and could not see
any other way of coping. Ms Ridley said that she planned to attend Recovery Steps
after her appointment to ‘kick off’. Her COM advised her not to do this. The
manager of Recovery Steps Whitehaven confirmed that she did not attend the
service.
42. Later that day, Ms Ridley went to the bank and tried to withdraw money without a
card. Staff at the bank phoned the police, as they were concerned that she was
under the influence and was withdrawing the money for someone else. When
officers arrived, Ms Ridley said her card had been stolen or possibly lost. The bank
allowed her to withdraw £50 and stopped her card. They advised her to come back
when she was sober.
Circumstances of Ms Ridley’s death
43. On 27 February, at around 11.15am, a member of staff at Ms Ridley’s
accommodation found her unconscious and not breathing. She phoned for an
ambulance and started CPR.
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44. At 11.32am, the paramedics arrived and took over CPR. However, despite their
efforts, they were not successful. At 12.06pm, they pronounced life extinct.
Post-mortem report
45. The post-mortem report concluded that Ms Ridley died from combined drug toxicity.
The toxicology report found evidence of methadone, bromazolam (a synthetic
benzodiazepine) and pregabalin (medication not prescribed to Ms Ridley).
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Findings
Substance misuse services
46. Ms Ridley’s appointment with the community substance misuse service (SMS) in
Carlisle needed to be rearranged, due to it being too far away from her release
address. The earliest appointment Ms Ridley was able to get was the day after her
release at 1.30pm. This meant she would not be able to take her methadone in the
morning as she usually did.
47. The investigator spoke with Ms Ridley’s COM, who explained that the initial
appointment in Carlisle was made by Low Newton prior to Ms Ridley’s release
address being confirmed. When the release address was confirmed on 25
February, the COM changed the appointment at the earliest opportunity.
48. The investigator spoke with the area manager for the SMS at Low Newton who said
that they were unaware of the change to Ms Ridley’s appointment, however, they
would not have been able to issue a script directly to a pharmacy. In exceptional
circumstances, where a community appointment is not able to be arranged for the
day after a prisoner’s release, they may be able to issue an FP10 (a prescription
that can be taken to a chemist for methadone before the community appointment).
However, this was unlikely to have been appropriate in Ms Ridley’s case as she had
an appointment arranged for the day after her release. The area manager said that
if they become aware of changes to appointments prior to a prisoner’s release, they
can contact the community services to see if they have any earlier appointments or
walk in times. However, once a prisoner has been released, they are unable to
help.
49. The area manager for Recovery Steps Cumbria told the investigator that to improve
communication, the Recovery Steps Cumbria criminal justice lead now attends the
pre-release meetings for Low Newton.
50. We understand that Ms Ridley’s appointment had to be changed because her
accommodation was confirmed late and there were time limits with the community
drug service. We acknowledge too the efforts both her COM and POM went to to
ensure that Ms Ridley had somewhere to live and an appointment with Recovery
Steps. However, the delay in collecting her methadone had a big impact on her. On
the day she was released, she found out she would have to go longer than usual
without her methadone, which was very difficult for her. We consider it important to
highlight this.
Adrian Usher
Prisons and Probation Ombudsman September 2025
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Inquest
At an inquest held on 7 October 2025, the Coroner concluded that Ms Ridleys death was
drug related.
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