Neil McCarthy

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Independent investigation into
the death of Mr Neil McCarthy,
on 20 March 2024
following his release from
HMP Hollesley Bay
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
This report is licensed under the terms of the Open Government Licence v3.0. To view this licence,
visit nationalarchives.gov.uk/doc/open-government-licence/version/3
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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. 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.
3. Since 6 September 2021, the PPO has investigated post-release deaths that occur
within 14 days of the person’s release from prison.
4. Mr Neil McCarthy died from the respiratory depressive effects of methadone on 20
March 2024 following his release from HMP Hollesley Bay on 7 March 2024. He
was 57 years old. We offer our condolences to those who knew him.
5. Mr McCarthy had a history of substance misuse. He was appropriately supported
for this in prison and on release. We did not identify any significant learning relating
to the pre or post-release planning. We make no recommendations.
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The Investigation Process
6. HMPPS notified us of Mr McCarthy’s death on 6 June 2024.
7. The PPO investigator obtained copies of relevant extracts from Mr McCarthy’s
prison and probation records.
8. We informed HM Coroner for Hammersmith and Fulham of the investigation. She
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 McCarthy’s family to explain the
investigation and to ask if they had any matters they wanted us to consider. Mr
McCarthy’s family had questions about Mr McCarthy’s medication and his release
from prison. These questions have been addressed in this report and in separate
correspondence.
10. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
11. Mr McCarthy’s family received a copy of the initial report. They did not make any
comments.
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Background Information
HMP Hollesley Bay
12. HMP Hollesley Bay is a category D, open, resettlement prison, which holds male
prisoners coming to the end of their sentences. It is managed by HMPPS.
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.
HM Inspectorate of Prisons
14. HMP Hollesley Bay was inspected in 2018, and again, in April 2024, after Mr
McCarthy’s death. Inspectors reported that the substance misuse teams were well
led and enthusiastic, providing an effective service to maintain recovery. They had
good working relationships with the prison and a strong joint commitment to its drug
strategy and action plan. They also reported effective post-release support and
community engagement which was developed 12 weeks before release.
HM Inspectorate of Probation
15. The most recent inspection of NPS Hammersmith, Fulham, Kensington, Chelsea,
and Westminster Division was in October 2022. Inspectors found very poor quality
of work and gave the rate of ‘Inadequate’. They found ineffective monitoring
arrangements to keep the public safe which was a serious concern. They found
there were clear delivery plans and improved relationships with key partner
agencies but the impact of these were yet to be seen in effective delivery of
services. Only 20% of the people on probation that were surveyed said they had
access to the services they needed through the Probation Service.
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Key Events
Background
16. On 19 March 2022, Mr Neil McCarthy was remanded to HMP Wandsworth charged
with burglary.
17. On 10 May, Mr McCarthy was sentenced to 50 months in prison. He was due to be
released on 7 March 2024.
18. On 30 May, Mr McCarthy was transferred to HMP Wayland.
19. On 10 January 2024, Mr McCarthy was transferred to HMP Hollesley Bay.
20. A nurse completed Mr McCarthy’s initial health screen and noted that he had a
history of heroin use and that he was prescribed 50ml of methadone (used to treat
opioid dependence). This prescription was continued at Hollesley Bay, and Mr
McCarthy felt that the prescribed amount was helping him. Mr McCarthy said that
he suffered with depression but felt stable with his mental health at that time
because he was taking mirtazapine (antidepressant).
21. On 25 January, a GP at the prison and a substance misuse recovery worker saw Mr
McCarthy for a review. Mr McCarthy had been on 50ml methadone for two years
and told the GP that he would reduce the dose in the community. Mr McCarthy was
offered naloxone training (a medication that can reverse the effects of an opiate
overdose) but he declined.
22. On 26 January, a nurse saw Mr McCarthy as part of his drug addiction therapy. Mr
McCarthy said that he did not want to reduce his methadone prescription while in
prison. The nurse explained the discharge process and informed him that an
appointment would be arranged for him with the local community drug and alcohol
service on release.
23. On 23 February, a nurse saw Mr McCarthy again as part of his drug addiction
therapy, and he reported he was still happy on his current dose of methadone and
felt stable. Mr McCarthy told the nurse that he would arrange his own GP
appointment on release because he was going to be living in the same area he had
been living before. During this meeting, they discussed risk factors around his
reduced tolerance to illicit drugs and Mr McCarthy said that he understood.
Pre-release planning
24. The pre-release team at Hollesley Bay completed a duty to refer (DTR) form (the
Homelessness Reduction Act 2017 requires prisons and probation services to refer
anyone who is homeless or at risk of becoming homeless within 56 days to a local
housing authority) and sent it to Hammersmith and Fulham council, the area where
Mr McCarthy would be returning to on release, on 9 January.
25. A housing advisor at Hollesley Bay continued to chase the outcome of the DTR,
and, on 2 February, he was informed that Mr McCarthy would be discussed at the
Hammersmith and Fulham council housing panel the following day, and that the
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housing options team at the council would be liaising with other agencies and
completing an assessment with Mr McCarthy.
26. On 13 February, the housing advisor chased the outcome of the housing panel
meeting because no one from the housing options team had been in touch to
complete an assessment with Mr McCarthy. He did not receive a response.
27. On 27 February, Mr McCarthy’s Community Offender Manager (COM) completed a
CAS3 accommodation referral (temporary accommodation for those leaving prison
homeless). The referral was accepted on 29 February, and Mr McCarthy was
offered an 84-night placement with Housing Action Management (HAM) within a
shared unit.
28. On 5 March, the housing advisor informed the COM that the homeless application
to Hammersmith and Fulham council was still outstanding, because alternative
accommodation had been found for him. However, when Mr McCarthy attended the
CAS3 accommodation, HAM would be able to pass his application to the Single
Homeless Project (SHP) team, who would then support him with move on
accommodation.
29. Turning Point (a service supporting individuals with complex needs) provided Mr
McCarthy with two post-release appointments, the first on 8 March to complete a
medication review, take observations and arrange prescriptions, and the second
appointment was arranged for 13 March to discuss the different treatment options
available to Mr McCarthy.
Release from HMP Hollesley Bay
30. On 7 March, Mr McCarthy was released from Hollesley Bay on his conditional
release date. He was released with a 2-week supply of his current medication
(including his antidepressant) until he was able to see his community GP.
31. Mr McCarthy did not attend his initial appointment with probation on the day of his
release, due to the time it took him to travel from Hollesley Bay, but he was given
another appointment to attend the following day. A duty probation officer emailed
the CAS3 accommodation to let them know that Mr McCarthy was unlikely to attend
his induction because he had not yet arrived at the probation office to receive his
accommodation address. (Mr McCarthy did not have a phone. It appears that he
stayed with a friend on release from Hollesley Bay.)
32. On Friday 8 March, Mr McCarthy attended his initial appointment with Turning
Point. He was given a six-day prescription of methadone and a follow up
appointment for 14 March to collect his next prescription. However, the Deputy
Operations Manager confirmed that Mr McCarthy did not attend any further
appointments after his initial appointment on 8 March.
33. That day, Mr McCarthy attended the probation office for his initial appointment, and
he was seen by the duty probation officer. She noted that Mr McCarthy looked
unkempt and was very frustrated that he had missed his induction at the CAS3
accommodation. She gave Mr McCarthy his next probation appointment for 11
March (which he did not attend).
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34. Following the initial appointment, the duty officer completed another DTR to
Hammersmith and Fulham Council.
35. Mr McCarthy was told to attend his CAS3 accommodation induction on 8 March, but
he did not attend. As a result, HAM withdrew the offer of accommodation and
informed his COM.
36. Mr McCarthy was homeless, but he was staying with his friend until he could find
alternative accommodation. Because he did not engage with the CAS3
accommodation provider, they did not refer him to the SHP for ongoing
accommodation support.
37. The COM told the investigator Mr McCarthy attended the probation office on 12
March, wanting to know what was happening about his accommodation. As he did
not have an appointment booked, she was only able to speak to him briefly, but she
told him another DTR had been submitted for him. She also advised him to present
as homeless to the council. There is no evidence to suggest Mr McCarthy
presented himself as homeless to the council.
38. Mr McCarthy was given another appointment to attend the probation office on 18
March, but he did not attend.
Circumstances of Mr McCarthy’s death
39. At 2.00pm on 20 March, Mr McCarthy’s friend called the emergency services when
he found him unresponsive on the floor. Mr McCarthy had been sleeping on an
airbed in his friend’s flat. Rigor mortis (recognisable signs of death characterised by
stiffening of the body) had set in and Mr McCarthy was cold to the touch.
40. The paramedics found drug paraphernalia in the flat. Mr McCarthy’s friend told the
paramedics that Mr McCarthy had been using heroin and crack cocaine.
Post-mortem report
41. The post-mortem report concluded that Mr McCarthy died from the respiratory
depressive effect of methadone, exacerbated by the use of pregabalin and
bromazolam (a synthetic benzodiazepine).
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Findings
Substance misuse
42. Mr McCarthy had a history of substance misuse. While he was in prison, he was
seen regularly by the Substance Misuse Service and warned about the risks and
dangers of taking drugs. He was also offered training in the use of naloxone, but he
declined. He was offered a naloxone kit on release, but again declined.
43. Mr McCarthy was promptly referred to the community drug and alcohol service to
ensure he was provided with the support he needed on release, and he continued
his methadone prescription in the community.
44. We are satisfied that both the prison and probation services did all they could to
manage the risks associated with his substance misuse.
Accommodation
45. We consider that the COM appropriately prepared for Mr McCarthy’s release. She
secured CAS3 accommodation on release, however he did not attend his induction,
and the bedspace was withdrawn.
46. A DTR was completed, and Mr McCarthy was advised to present as homeless to
the local council as they also have a duty of care to support those without
accommodation, however there is no evidence to suggest Mr McCarthy presented
himself as homeless. We consider that prison and probation staff took the
appropriate steps to find suitable accommodation for Mr McCarthy on release. It
seems that initially missing the induction at the CAS3 accommodation on his day of
release was sufficient to discourage him from attending the necessary
appointments to secure accommodation.
Adrian Usher
Prisons and Probation Ombudsman January 2025
At the inquest held on 9 June 2025, the coroner concluded Mr Neil McCarthy died from a
drug related death.
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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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