Michael Fox

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Independent investigation into
the death of Mr Michael Fox on
15 March 2022, following his
release from HMP Humber
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 a prisoner’s release.
3. We carry out investigations to understand what happened and identify how the
organisations whose actions we oversee can improve their work in the future.
4. Mr Michael Fox died of drug poisoning on 15 March 2022, the day after his release
from HMP Humber. He was 43 years old. I offer my condolences to those who
knew him.
5. Mr Fox had a long history of substance misuse, which was closely linked to his
offending risk. We found that the resettlement team at Humber and probation
services worked together to put appropriate measures in place to support Mr Fox
on release and manage his risks in the community. This included training Mr Fox
how to use naloxone, a medicine that rapidly reverses an opioid overdose and can
significantly reduce or prevent harm or death. We are concerned that despite this,
Mr Fox was not issued with a naloxone kit when he was released. The Head of
Healthcare accepts that this was a serious oversight and Humber has initiated a
review of the local policy, to ensure this does not happen again.
Recommendations
• The Head of Healthcare should ensure that prisoners who are assessed as at
risk of opioid overdose are provided with a naloxone kit when they leave prison
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The Investigation Process
6. The PPO investigator obtained copies of relevant extracts from Mr Fox’s prison
and probation records.
7. The investigator talked to healthcare staff and the service lead for Nacro BASS
(Bail Accommodation and Support Services) North-East as part of her enquiries.
8. We informed HM Coroner for Hull and East Riding of the investigation. He gave us
the results of the post-mortem examination. We have sent the coroner a copy of
this report.
9. Our initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS pointed out a factual inaccuracy and this report has been amended
accordingly.
2 Prisons and Probation Ombudsman
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Background Information
HMP Humber
10. HMP Humber is a category C prison in Yorkshire that holds approximately 1,000
men. During the time that Mr Fox spent at Humber, City Health Care Partnership
Community Interest Company delivered healthcare services, substance misuse
treatment and mental health interventions.
HM Inspectorate of Prisons
11. The most recent inspection of HMP Humber was in November 2020. Inspectors
reported that information sharing between the prison and community-based
offender managers was reasonably good. At the time of the report, 147 prisoners
had been released on Home Detention Curfew (HDC), also known as electronic
tags, over the previous six months. However, 30 had been released late, mainly
due to the shortage of suitable accommodation in the community or late responses
for further referral information from community-based offender managers.
12. The report outlined how pre-release planning for prisoners with substance misuse
needs was effective. Inspectors commended Drug and Alcohol Recovery Team
(DART) workers for giving every prisoner harm reduction advice before release.
However, at the time of the report naloxone, and the related training in its
administration, were not available.
The Probation Service
13. The Probation Service supervises individuals serving community orders, provides
offenders with resettlement services while they are in prison (in preparation for
their release) and supervises all individuals for a minimum of 12 months when they
are released from prison on licence. Supervision in the community is carried out
by a community offender manager.
Home Detention Curfew (HDC)
14. HDC is a scheme that allows for prisoners serving at least 12 weeks but no more
than 4 years to be released from prison early if they wear an electronic tag and
stay at their address between set times.
Naloxone
15. Naloxone is an emergency medication that can reverse the effects of an overdose
of opioids, such as heroin or methadone. Prisoners with a history of opioid use
have a high risk of drug-related death in the first weeks after prison release. Since
2019 some prisons, including HMP Humber, have been issuing training and “take
home” naloxone kits to every prisoner, meeting relevant criteria, on release.
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Key Events
16. On 23 August 2021, Mr Fox was convicted of violent offences and burglary. On 1
December 2021 he was sentenced to 14 months in prison. Mr Fox was transferred
to HMP Humber on 17 December.
17. Mr Fox’s conditional release date was 24 March 2022. However, he was eligible
for HDC from 15 December 2021, subject to appropriate accommodation being
secured.
18. Mr Fox had a long history of substance misuse including alcohol, cannabis,
amphetamines, heroin and crack cocaine. He engaged well with substance
misuse agencies in prison and in the community.
Pre-release planning
19. On 12 January, Mr Fox met his prison offender manager (POM) to discuss
resettlement planning. Mr Fox said that he was keen to find stable accommodation
and stay away from drugs. The POM referred Mr Fox to the Drug and Alcohol
Recovery Team (DART) in the community, who would be able to support his
needs.
20. On 1 February, a DART practitioner trained Mr Fox on naloxone administration.
This was a standard provision offered to those with opioid misuse issues and who
were due to be released. She offered Mr Fox an optional appointment with the
community DART on the day of his release, but he declined. Mr Fox said that he
was comfortable with self-referring to the service if he needed it, as he had
engaged with DART in the past.
21. On 10 February, an accommodation referral was made to Nacro BASS (a charity
providing low level support and accommodation to people released from prison).
This was made on the basis that Mr Fox needed suitable accommodation in the
community in order to be considered for release on HDC.
22. On 28 February, the POM and Mr Fox’s community offender manager (COM)
discussed his plan for release. The COM confirmed that Mr Fox was on the
waiting list for accommodation and could be released on HDC as soon as a space
was available.
23. On 11 March, Mr Fox was informed that a room in hostel-type shared
accommodation had been secured from 14 March. Mr Fox was allocated a new
COM. He received a full handover from the first COM on 11 March.
24. On 14 March, the morning of his release, Mr Fox was given a copy of his licence
containing the conditions he was expected to comply with in the community. Mr
Fox’s licence conditions included wearing an electronic tag, residing at his
authorised address and remaining in the property between 7pm and 7am every
night, and to comply with any instruction to address his alcohol or substance use
with the community DART.
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25. Before leaving the prison, Mr Fox was seen by a clinical manager in the prison
healthcare team for a pre-release screening. She confirmed that Mr Fox was
registered with a GP in the community. He was given the appropriate supply of his
medication but was not given a naloxone kit as planned.
Post-release
26. Mr Fox reported to Hull probation office at 11.00am, as required. The COM
explained his licence conditions and helped Mr Fox to set up his universal credit
account. Mr Fox said he was feeling positive about staying away from drugs and
engaging with the community DART.
27. The COM instructed Mr Fox to arrive at his accommodation at 3pm and told him he
was required to attend his next probation supervision appointment on 21 March.
He reminded Mr Fox to call the probation office if he had any concerns before then.
Circumstances of Mr Fox’s death
28. Mr Fox arrived at his accommodation on time. He was met by the service lead,
who carried out his induction. She said that he presented well on arrival. He told
her that he had consumed three cans of lager but reported no use of drugs. Mr
Fox told her that he had been drug free for seven months.
29. Following his induction, Mr Fox was required to remain in the property until 7am
the following morning for his electronic tag to be fitted. At 7.30pm and 10.08pm,
two Electronic Monitoring Service Officers came to the property and knocked at his
room door. They recorded that Mr Fox did not respond to either of their visits. The
officers reported that they could hear loud snoring at 7.30pm but that they heard
nothing during the second visit. Another resident told them he believed that Mr
Fox was still in his room. No staff were on duty in the property overnight.
30. At 7.12am on 15 March, a notification of Mr Fox’s failure to comply with his tag
fitting was submitted to Probation. Later that morning, a support worker went to
the property to complete Mr Fox’s follow up induction session. He got no response
when knocking on Mr Fox’s door. Another resident confirmed that Mr Fox was
seen going into his room the previous evening but had not been seen since. The
support worker followed the Nacro BASS welfare procedure and entered the room
to find Mr Fox face down, deceased on the bed. They alerted the emergency
services and did not start CPR as it was clear that Mr Fox had died.
31. Staff called the senior probation officer at Hull and informed her of Mr Fox’s death.
Post-mortem report
32. The post-mortem report concluded that Mr Fox died of drug poisoning. Tests
showed the presence of heroin, cocaine and some prescribed medications.
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Findings
Substance misuse
33. Although Mr Fox was given training on how to use naloxone, staff at Humber failed
to issue a naloxone kit when he was released from prison on 14 March. He died
from drug poisoning (including heroin) one day after he was released.
34. Mr Fox was released early on HDC and at short notice. We found that the process
for issuing naloxone did not capture those released in this way. The release data
report used to issue packs was run around twice weekly and therefore did not
capture HDC releases that fell outside of the period. This is being investigated as
a serious incident by the healthcare providers City health Care partnership
(CHCP). In response to the learning from Mr Fox’s death, Humber are also
undertaking a review of the naloxone policy. In the interim, they run updated
release information twice a day, to capture any short notice discharges. We make
the following recommendation:
The Head of Healthcare should ensure that prisoners who are assessed as at
risk of opioid overdose are provided with a naloxone kit when they leave
prison.
Inquest
35. The inquest into Mr Fox’s death concluded on 25 March 2024, and concluded that
his death was drug related.
Susannah Eagle
Deputy Prisons and Probation Ombudsman July 2023
6 Prisons and Probation Ombudsman
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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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