Paul Skinner

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Independent investigation into
the death of Mr Paul Skinner,
on 21 February 2025,
following his release from
HMP Forest Bank
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 Paul Skinner died from multiple drug toxicity on 21 February 2025 following his
release from HMP Forest Bank the previous day. He was 51 years old. We offer our
condolences to those who knew him.
5. Mr Skinner was a persistent offender and he had a significant history of alcohol and
drug use in the community. As a result, he frequently returned to prison, which
disrupted any progress he made during his release. His short stays in prison
prevented him from benefiting fully from the available interventions.
6. We understand that short-term custodial sentences create challenges for staff
working with prisoners, especially in terms of rehabilitation and release preparation.
The Independent Sentencing Review, commissioned by the Justice Secretary, has
identified this issue, and we support any changes aimed at addressing the problems
linked to short custodial sentences.
7. Mr Skinner left prison without suitable accommodation in place. Staff made an error
while processing his referral for CAS3 accommodation. However, even if they had
processed the referral correctly, we cannot know whether a suitable placement
would have been available.
8. We did not identify any significant learning and make no recommendations.
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The Investigation Process
9. HMPPS notified us of Mr Skinner’s death on 21 February 2025.
10. The PPO investigator obtained copies of relevant extracts from Mr Skinner’s prison
and probation records.
11. We informed HM Coroner for Bolton of the investigation. He gave us the results of
the post-mortem examination. We have sent the Coroner a copy of this report.
12. The Ombudsman’s office contacted Mr Skinner’s father to explain the investigation
and to ask if he had any matters he wanted us to consider. He did not respond.
13. 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 Forest Bank
14. HMP Forest Bank in Salford holds adult men both on remand and sentenced. The
prison serves the courts of Greater Manchester. The prison is managed and run by
Sodexo Limited.
Probation Service
15. 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.
HM Inspectorate of Prisons
16. The most recent inspection of HMP Forest Bank was in December 2024. At the
time, inspectors reported that the support and treatment for prisoners with
addictions was good for both clinical care and psychosocial interventions.
Inspectors concluded that the prison’s discharge planning was effective.
17. They said that staff contacted community mental health teams and GPs to support
the transfer of care, although most patient stays were short due to a rapid turnover
of prisoners coming in and out of Forest Bank.
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Key Events
Background
18. Mr Paul Skinner was a prolific offender and had a significant custodial history. His
offences, which included theft and being threatening and abusive, were
predominantly linked to his alcohol addiction.
19. Mr Skinner had a history of poor mental health, alcoholism and taking drugs,
including heroin and cocaine.
20. On 7 May 2024, Mr Skinner was sentenced to six months in prison for theft, threats
and assault and he was sent to HMP Preston. During his initial health screen, Mr
Skinner said that he had been taking alcohol and drugs but denied having any
mental health concerns.
21. On 22 May, Mr Skinner was transferred to HMP Lancaster Farms.
22. On 14 June, Mr Skinner told healthcare staff that he had anxiety, depression and
trauma. Following a mental health review, Mr Skinner was referred to talking
therapies (where the patient works with a health practitioner to understand and
overcome problems). Because there was a waiting list, Mr Skinner was not seen
before he was released.
23. On 3 July, Mr Skinner was released on licence. He attended his initial probation
appointment but he later missed his meeting with the housing provider and his
community offender manager, was unable to reach him by phone. This breach of
licence led probation to recall him to prison.
24. On 8 July, Mr Skinner was sent to HMP Berwyn.
25. On 9 July, a resettlement officer saw Mr Skinner and recorded that he was due to
be released on 18 July and that accommodation had been arranged for him. He
said Mr Skinner had told him that he was keen to address his alcohol and mental
health issues.
26. Later that day, a mental health nurse reviewed Mr Skinner. It was recorded that Mr
Skinner had said that he had post-traumatic stress disorder (PTSD) and he had
taken part in a one-to-one and group substance misuse session earlier.
27. On 16 July, a substance misuse worker met Mr Skinner. They discussed harm
minimisation and she told Mr Skinner that referrals to community services had been
made. Mr Skinner told her that he was fed up being recalled for short periods as all
it did was create more community issues. Mr Skinner was given naloxone (a
medication to reverse the effects of opiate overdose) to take with him ahead of his
release.
28. On 18 July, Mr Skinner was released from prison on licence.
29. On 21 October, Mr Skinner was arrested and charged with robbery and theft. His
licence was revoked and he was sent to HMP Preston.
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30. During his initial health screen, it was noted that Mr Skinner needed to see the
mental health team because he was taking antipsychotic medication. Mr Skinner
said that he did not want to be referred to the alcohol treatment service.
31. On 22 October, a mental health nurse met Mr Skinner. An entry was made in his
medical record that there was no record of Mr Skinner being prescribed
antipsychotic medication in his Summary Care Record (the national database that
holds patient information, including current medications).
32. On 23 October, one of the nurses contacted the community mental health team who
told them that Mr Skinner had been discharged from their service (the previous day)
due to a lack of engagement. She said that Mr Skinner had significant issues with
substance misuse and he had not been prescribed any medications for his mental
health.
33. On 28 October, Mr Skinner saw a psychosocial practitioner. He agreed to engage
with the substance misuse service.
34. On 1 and 7 November, the psychosocial practitioner saw Mr Skinner. She told him
that she was referring him to be considered for abstinence supported housing.
35. On 21 November, the psychosocial practitioner saw Mr Skinner. He told her that he
had been offered a bed space by an abstinence housing provider which would be
available for him on release.
36. On 2 January 2025, Mr Skinner was released from prison, and he moved to
Redwood House (a supported abstinence housing scheme).
37. On 4 February, a community offender manager (COM) was notified that Mr Skinner
had been taken to hospital after being found by the side of a canal, heavily
intoxicated and having had a seizure. Because Mr Skinner had started to drink
again, he was evicted from Redwood House.
38. On 5 February, Mr Skinner left hospital. However, he returned to hospital later that
day, having been found unresponsive in a public area. The COM made repeated
attempts to contact him by phone, but he did not respond. She also spoke to
paramedics to share her concerns about the potential impact of detoxification.
39. On 6 February, Mr Skinner left hospital. The COM sent a message to Mr Skinner to
ask him to come to the probation office, but he did not respond. The decision was
made to issue him with a 14-day fixed term recall to prison.
40. On 7 February, the police told the COM that Mr Skinner had been arrested the day
before for a breach of the peace and that it had been related to alcohol.
41. On 11 February, Mr Skinner was sent to HMP Forest Bank. A GP operating at the
prison, reviewed Mr Skinner as part of his initial health screen. He recorded that Mr
Skinner needed methadone stabilisation and to undergo an alcohol detoxification.
Mr Skinner declined sertraline (an antidepressant) and they agreed that he would
request a GP appointment to consider an alternative once he had stabilised.
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42. On 12 February, a substance misuse support worker saw Mr Skinner and a
substance misuse management plan was agreed. The SMS team saw Mr Skinner
each day up to the day before he was released.
43. That day, the COM emailed the Northwest Homeless Prevention Team (NWHPT)
asking for guidance on referring Mr Skinner for CAS3 accommodation as he was
due to be released in eight days. The NWHPT responded the next day and told the
COM to proceed with a referral which would be treated as an emergency. (CAS3
accommodation is a government scheme which provides housing for people who
are leaving prison homeless). The COM told the investigator that she should have
referred Mr Skinner to the local council for accommodation at the same time under
the statutory duty to refer those at risk of homelessness but she did not.
44. On 13 February, an officer from the resettlement team saw Mr Skinner. She
recorded that Mr Skinner had no fixed abode and wanted to live in Preston. She
emailed the COM a summary of what they discussed and explained that she was
not able to link him with the housing team at Forest Bank as he wanted to move
outside of the area that they covered.
45. On 14 February, the COM submitted the CAS3 referral using the digital portal. She
stated that his release date was 20 February.
46. Later that day, the COM emailed the NWHPT and the Offender Management Unit
(OMU) to advise that Mr Skinner’s release date of 20 February was incorrect, she
referenced that he had been returned to custody on 11th February on a fixed term
recall. She advised the OMU that his release date should be 25 February and, in
the email, informed NWHPT to be aware of this. The OMU replied to the email
(including to the NWHPT) the same day and confirmed that Mr Skinner’s release
date was 20 February. A Senior Operational Support Manager (SOSM) for NWHPT,
told the investigator that they had received the email from the OMU but the
administrative team had missed it and therefore not passed it on to the person
dealing with the referral.
47. The SOSM told the investigator that the person managing the inbox at that time was
not fully aware of the protocols in place and since then, they have strengthened
their processes to reduce the likelihood of such an error occurring again.
48. On 17 February, the application for CAS3 was allocated to a probation services
officer, to process. At the time, the officer was not aware of the revised release date
of 20th February and therefore proceeded with planning for a release date of 25
February 2025.
49. On 18 February, Mr Skinner told a prison officer that probation staff were trying to
arrange for him to be placed in CAS3 accommodation.
20 February 2025
50. A substance misuse worker met Mr Skinner before his release. They recorded that
Mr Skinner was anxious as all he could think about was alcohol. They wrote that
they had an in-depth discussion about harm minimisation, and they gave him
naloxone. Before leaving, Mr Skinner spoke to his community sponsor and an
appointment was made for him to see the community services team later that day.
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51. The COM told the investigator that she spent the morning trying to find out where
Mr Skinner was and she completed a housing referral to Preston Council under the
duty to refer those at risk of homelessness. She said that she had completed a
referral the previous year but it had been rejected on the basis that the supported
housing which Mr Skinner had previously lived in was not considered to be settled
housing.
52. At 12.30pm, Mr Skinner was due to attend the probation office. He did not turn up
for this appointment. She told the investigator that she made a number of attempts
to call Mr Skinner but his phone was switched off.
53. At 1.37pm, the probation services officer emailed the COM to say that she noticed
that Mr Skinner had been released but that they had been processing a referral
based on a release date of 25 February. Emails had also been also received by
NWHPT to this effect. In line with CAS3 Operational Guidance version 4.2 dated
December 2023 the referral was closed by NWHPT at 1:39pm.
54. The SOSM told the investigator that a CAS3 referral could not be processed on the
day of release as the NWHPT had to give their suppliers 12 hours’ notice of a
booking to ensure everything was ready to receive the person and that they had
identified a resident welfare officer.
55. At 3.16pm, a worker from Red Rose Recovery (a charity that supports people with
alcohol and substance misuse issues) called the COM. He told her that Mr Skinner
had been to see them and he had described being at the end of his tether and did
not know what to do. He said that he told Mr Skinner to go to probation.
56. A community worker at Inspire (a community drug and alcohol service) had also
contacted the COM to tell her that Mr Skinner had visited them, heavily intoxicated.
They told her that he declined to have a meeting and did not want any support.
However, they booked an appointment for him to see them the next day.
57. At 4.43pm, the COM received a response from Preston Council. The council said
that they would not provide housing assistance to Mr Skinner and he should make
an application to the council where he had previously lived in settled
accommodation.
58. The COM spoke to her manager about her concerns for Mr Skinner. They decided
that if Mr Skinner did not attend the probation office by lunchtime the next day, they
would arrange for him to be recalled.
Circumstances of Mr Skinner’s death
59. On 21 February, two homeless outreach workers found Mr Skinner on a public
bench, unresponsive and not breathing. They called the emergency services and
the police and paramedics attended. The paramedic pronounced life extinct at
9.44am.
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Post-mortem report/Cause of death
60. The post-mortem report concluded that Mr Skinner died from multiple drug toxicity.
The toxicology report identified evidence of potentially fatal alcohol poisoning, and
that Mr Skinner had also used methadone and cocaine.
Inquest into Mr Skinners death
61. The inquest into Mr Skinner’s death was held on 15 December 2025 and a verdict
of alcohol and drugs was recorded. The coroner concluded that Mr Skinner’s death
was due to multiple drug and alcohol toxicity. Alcoholic liver disease was listed as a
contributory factor.
Support for staff
62. The COM told the investigator that she had been well supported by her manager
and colleagues following Mr Skinner’s death and she was appropriately signposted
to the nominated support provider.
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Findings
63. Mr Skinner had a history of alcohol and drug misuse which was directly linked to his
criminal behaviour. He also had episodes of poor mental health.
64. When he arrived in prison, Mr Skinner’s mental health was assessed and he was
encouraged to engage in psychosocial interventions and talking therapies.
However, this was not always possible due to the brief duration of his sentence.
65. While in prison, Mr Skinner underwent detoxification and he was supported by the
prison’s substance misuse services. When leaving prison, appropriate
arrangements were made with community services to support him with his
abstinence. This included referrals to abstinence supported housing and linking him
with community support groups. Sadly, Mr Skinner was not able to maintain his
sobriety which resulted in him becoming homeless.
66. It is evident that his community offender manager liaised with several different
agencies to ensure that his needs were met. She told the investigator that this
became increasingly difficult because his behaviour meant that some of the
supported housing providers were not willing to offer him another place.
67. During his last spell in prison, the pre-release team saw Mr Skinner and identified
his needs. While there was a delay in referring him to the local authority under the
statutory duty to refer those at risk of homelessness, we note that his request for
assistance was refused so this delay did not change the outcome for him.
68. Mr Skinner’s community offender manager referred him to CAS3 as soon as she
was aware that he had been sent to prison. However, the subsequent emails about
his release date resulted in confusion about when he was due to be released and
the email confirming his release date was then missed by the NWHPT. Given that
the availability of CAS3 accommodation is dynamic, there is no guarantee that a
place would have been available for Mr Skinner if there had not been a mix up with
his release date. We note the actions taken by the NWHPT to reduce the likelihood
for error and we therefore make no recommendation.
Adrian Usher
Prisons and Probation Ombudsman November 2025
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