Rhys Willis

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Independent investigation into
the death of Mr Rhys Willis,
on 29 April 2024 following his
release from HMP Cardiff
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. 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 Rhys Willis died from nitrous oxide suffocation on 29 April 2024, following his
release from HMP Cardiff on 23 April. He was 37 years old. We offer our
condolences to those who knew him.
5. Mr Willis had a history of substance misuse. He was appropriately referred and
supported for this while in prison and in the community. We did not identify any
significant learning relating to the pre-release planning or post-release supervision
of Mr Willis.
6. We make no recommendations.
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The Investigation Process
7. HMPPS notified us of Mr Willis’ death on 11 September 2024.
8. The PPO investigator, Ms Hannah Wallis, obtained copies of relevant extracts from
Mr Willis’ prison and probation records.
9. The investigation was suspended between February and May 2025, while we
waited for the cause of death.
10. We informed HM Coroner for South Wales of the investigation. He gave us the
results of the post-mortem examination. We have sent the Coroner a copy of this
report.
11. The Ombudsman’s office contacted Mr Willis’ next of kin to explain the investigation
and to ask if they had any matters they wanted us to consider. Mr Willis’ next of kin
wanted to know if Mr Willis smoked spice (synthetic cannabinoids) in prison and
why he looked so unwell when he was released from prison. They also asked for a
copy of our report. Their questions have been addressed in our report and in
separate correspondence.
12. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
13. Mr Willis’ family received a copy of the initial report. They did not make any
comments.
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Background Information
HMP Cardiff
14. HMP Cardiff is a category B reception and resettlement prison which holds
convicted and remanded adult male prisoners. It is managed by HMPPS. Dyfodol
provides substance misuse treatment and Cardiff & Vale University Health Board
provides physical and mental health.
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
appropriates. 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 Cardiff was in January-February 2024.
Inspectors reported 40% of prisoners said it was easy to access drugs, this was
confirmed by mandatory testing which suggested a quarter of prisoners were active
drug users at the time of the inspection. However, they did report good quality staff-
prisoner relationships, prisoners were treated respectfully, and they trusted staff
because they were reliable. The Governor and her senior team were visible,
approachable and set clear standards.
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Key Events
Background
17. On 20 December 2023, Mr Rhys Willis was convicted of causing affray and was
remanded to HMP Cardiff.
18. That day, a Nurse completed Mr Willis’ initial health screen. He tested positive for
benzodiazepine and cannabinoids. Mr Willis told the Nurse that he was epileptic,
had been hit over the head with a hammer and was run over by a car a few days
prior to his arrest. He said that he hurt his leg, and while in hospital he had a CT
scan (results were normal), but he had since suffered seizures. The Nurse reviewed
the police notes about his seizures and prison staff completed checks on Mr Willis
every half an hour.
19. Mr Willis arrived at Cardiff with other medications including levetiracetam (to treat
epilepsy) diazepam (for anxiety, seizures and alcohol withdrawal) and pregabalin
(for epilepsy and anxiety). A Nurse noted his medication needed to be reviewed.
20. That day, a General Practitioner (GP) at the prison, saw Mr Willis about his recent
seizures. Mr Willis said that prior to his arrest, he was prescribed keppra (anti-
epileptic drug) but had not taken this medication for two days. The GP arranged for
Mr Willis to be given keppra, be observed overnight and for a GP to review him in
the morning. A Nurse tried to give Mr Willis keppra, but he refused to take it. He
was more concerned about not being given his diazepam. The Nurse told Mr Willis
that a GP would review his medication.
21. On 21 December, a Nurse Practitioner from the substance misuse team assessed
Mr Willis. He said that he had used 16mg of buprenorphine every day since he was
released from prison in May 2023. The last time he took buprenorphine was two
days earlier, and his alcohol use had also increased. Mr Willis started a methadone
detoxification programme starting on 20ml and increasing to 40ml and was also
placed on an alcohol detoxification programme.
22. That day, a GP at the prison, reviewed Mr Willis’ medication and she re-prescribed
5mg of diazepam.
23. A Nurse saw Mr Willis and he told her he had no warning signs prior to a seizure,
and they had been managed well by his medication in the past. Mr Willis said he
had a seizure a few years previously and was placed into a coma, developed nerve
damage and was prescribed pregabalin (150mg) to manage this. After his head
injury, this was increased to 300mg. A Doctor informed Mr Willis that prescribing
pregabalin with methadone was not suitable.
24. On 29 January 2024, Mr Willis was sentenced to 36 weeks in prison. He stayed at
Cardiff. He was due to be released in April.
25. On 2 February, a Nurse Practitioner saw Mr Willis after he requested to speak with
someone from the substance misuse team about buvidal (an injection used to treat
opioid dependence). Mr Willis said he wanted to change medication so that he did
not have to collect it every day, however after some discussion, he decided that he
would not cope with changing his medication while in prison and decided to discuss
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this with his recovery worker in the community. Mr Willis asked if his methadone
could be increased to 50ml because he was still experiencing withdrawal
symptoms. This was increased the following day.
26. On 14 March, staff reported Mr Willis was under the influence of drugs. Healthcare
staff were notified and a GP at the prison informed the substance misuse team so
that a member of their team could discuss this with Mr Willis.
27. The following day, a Nurse from the substance misuse team, gave Mr Willis a
verbal warning and told him that he would not receive his methadone until the
following day. Mr Willis admitted to using spice (a synthetic cannabinoid) a few
times per week. They discussed the risks.
28. Mr Willis’ methadone was reduced from 50ml to 40ml due to him testing positive for
buprenorphine and synthetic cannabinoids.
Pre-release planning
29. On 22 March, a Community Offender Manager (COM) was allocated to Mr Willis
and on the 26 February, a Senior Probation Officer noted in his probation record
that she had discussed Mr Willis with his COM and they were both aware he was
medicated for his epilepsy, had a history of mental health linked to substance
misuse, and that he had previously reported he self-medicated. An initial plan was
made for the COM to monitor his mental health, keep interventions focused on his
risk factors (thinking skills) and support him to maintain abstinence in the
community and refer him to Dyfodol in the community if necessary.
30. On the 9 April, the substance misuse team referred Mr Willis to the community
Dyfodol team. Mr Willis was given an appointment at 11am on 23 April.
31. On 18 April, the COM had booked a video conference meeting with Mr Willis,
however she was running late, and Mr Willis did not want to wait, so he returned to
his cell. The COM was not able to re-book another video conference meeting prior
to his release. The COM wanted to use the meeting to discuss Mr Willis’ release
plans.
32. On 22 April, a resettlement worker at Cardiff completed a pre-release catch up with
Mr Willis. He said that he had no concerns with his release. He was returning to his
own accommodation that he had lived in prior to custody, and he had an
appointment arranged with Dyfodol and the job centre.
33. Mr Willis was subject to additional licence conditions including to attend
appointments and comply with requirements set by his probation officer to address
his substance misuse.
Post-release management
34. On 23 April, Mr Willis was released from Cardiff with a naloxone kit (to reverse the
effects of an opioid overdose). Mr Willis was given his methadone that morning, and
his methadone script was sent directly to the community pharmacy.
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35. That day, Mr Willis attended his initial appointment with a Probation Practitioner
(covering the appointment for the COM). Mr Willis completed his induction
paperwork and he did not raise any concerns. The Probation Practitioner gave Mr
Willis his next appointment for 26 April.
36. Later that day, Mr Willis attended Dyfodol, even though his appointment was for the
following day. Mr Willis’ recovery worker was not available to see him, so a
colleague completed the appointment instead. Mr Willis said that he had taken three
illicit benzodiazepine tablets earlier that day. They discussed harm minimisation,
overdose and reduced tolerance and the risks of contaminated street valium and
heroin. Mr Willis said that he would like to speak to the doctor to discuss his clinical
treatment because he wanted to change from methadone to buprenorphine. He was
given another appointment for the following day to discuss this with a Doctor.
37. On 24 April, Mr Willis did not attend his appointment at Dyfodol, however Dyfodol
received a call from the pharmacy who said Mr Willis was not happy that his
methadone script had not been sent yet. He was advised it would be there later that
afternoon and he should come back then.
38. Mr Willis called the recovery worker, and she noted he sounded intoxicated. He told
her that he was going to get ‘those dodgy valiums and take loads.’ She advised him
not to do that and made him aware of the risks associated with illicit substances
(particularly that they could have traces of very strong synthetic opioids – nitazene –
in) and the risk of overdose.
39. On 26 April, Mr Willis attended his probation appointment with his COM. However,
he was an hour and a half late and appeared under the influence of substances
when he arrived. The COM noted his pupils were dilated and his speech was
slurred so he was asked to leave the office and was given another appointment for
29 April.
40. That day, the COM spoke to the recovery worker about Mr Willis’ presentation.
They agreed to see Mr Willis together at his next appointment on 29 April. Mr Willis
did not attend his probation appointment on 29 April.
Circumstances of Mr Willis’ death
41. At 5.23am on 29 April, paramedics arrived at an address occupied by Mr Willis’
friend. His friend told the police and paramedics that they had both been inhaling
nitrous oxide and his friend then went to sleep. When he woke up around two hours
later, he said that Mr Willis had a plastic bag over his head and inside the plastic
bag was a canister of nitrous oxide. Mr Willis was unresponsive so his friend began
CPR. When the paramedics arrived, Mr Willis was cold to touch, had visible pale
skin and there was evidence of hypostasis (pooling of the blood after death). At
5.31am, the paramedics pronounced life extinct.
Post-mortem report
42. The post-mortem report gave Mr Willis’ cause of death as nitrous oxide suffocation.
The toxicology report showed the presence of a large number of other illicit drugs in
his system, including amphetamine, benzodiazepine, cocaine and opiates.
However, these were at levels below the range associated with fatal outcomes.
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Inquest
43. At the inquest held on 16 June 2025 the coroner concluded Mr Willis died from
misadventure.
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Findings
Substance misuse
44. Mr Willis had a history of substance misuse. While he was in prison, he was
promptly referred to substance misuse services and was appropriately supported to
manage his substance misuse issues. The substance misuse team saw him
regularly and he was warned about the risks and dangers of taking drugs.
45. The substance misuse service at Cardiff is responsible for identifying prisoners at
risk from opiate overdose. These prisoners should be offered a supply of naloxone
upon their release from prison, and they should be trained in its use. Mr Willis was
correctly identified and trained in the use of naloxone. He was released with a
supply of this.
46. The substance misuse team ensured Mr Willis would receive support upon release
and appropriately referred him to the community drug and alcohol team. An
appointment was arranged for him, and his methadone prescription was sent to the
community pharmacy in preparation for his release. There was evidence of good
collaboration between Mr Willis’ probation officer and substance misuse worker.
47. We are satisfied that both the prison and probation services did all they could to
manage the risks associated with his substance misuse.
48. We make no recommendations.
Adrian Usher
Prisons and Probation Ombudsman August 2025
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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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