Richard Cosgrove

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Independent investigation
into the death of
Mr Richard Cosgrove,
on 18 April 2024, following his
release from HMP Humber
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
This report is licensed under the terms of the Open Government Licence v3.0. To view this licence,
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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 Richard Cosgrove died from multiple drug toxicity on 18 April 2024, following his
release from HMP Humber on 17 April 2024. He was 37 years old. We offer our
condolences to those who knew him.
5. We found an issue of concern relating to information sharing between the prison
and probation staff during the pre-release planning stage.
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The Investigation Process
6. HMPPS notified us of Mr Cosgrove’s death on 7 May 2024.
7. The PPO investigator obtained copies of relevant extracts from Mr Cosgrove’s
prison and probation records.
8. The investigator interviewed Mr Cosgrove’s Community Offender Manager (COM)
and the Senior Probation Officer (SPO) at Leeds probation office.
9. We informed HM Coroner for Yorkshire 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 Mr Cosgrove’s family to explain the
investigation and to ask if they had any matters they wanted us to consider. The
family asked questions about:
• The End of Custody Supervised Licence (ECSL) scheme
• Pre-release accommodation planning
• The care Mr Cosgrove received in prison
• What happened on the day of Mr Cosgrove’s release
• The circumstances of Mr Cosgrove’s’ death
We have addressed their questions in this report.
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.
12. Mr Cosgrove’s family received a copy of the draft report. The solicitor representing
the family wrote to us raising a number of questions that do not impact on the
factual accuracy of this report. We have provided clarification by way of separate
correspondence to the solicitor.
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Background Information
HMP Humber
13. HMP Humber is a category C prison which holds male prisoners who have either
been convicted or are on remand. It is managed by HMPPS.
Probation Service
14. 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
15. On 17 February 2024, Mr Richard Cosgrove was remanded to HMP Leeds charged
with assault of an emergency worker.
16. During his reception health screen, healthcare staff noted that this was Mr
Cosgrove’s first time in prison, and that there were issues around his
accommodation in the community, mental health and substance misuse. Mr
Cosgrove was prescribed methadone (an opiate substitute) and healthcare staff
created a methadone care plan.
17. On 19 February, a recovery worker from the substance misuse team saw Mr
Cosgrove. They discussed low tolerance to drugs after a period of abstinence, signs
and symptoms of overdose, what to do in an emergency and mixing medication with
alcohol. Mr Cosgrove was given in-cell booklets to complete. Mr Cosgrove agreed
to transfer to E wing, a drug recovery unit. He also said he would accept a naloxone
(a medicine that rapidly reverses an opioid overdose) kit on release.
18. The substance misuse team referred Mr Cosgrove to the community team, Forward
Leeds, and to the primary mental health team.
19. On 26 February, the mental health team conducted an initial assessment with Mr
Cosgrove. They discharged him from their service as there was no indication that
he had an acute mental illness.
20. On 29 February, Mr Cosgrove was sentenced to 24 weeks imprisonment.
21. On 6 March, a Probation Officer from Leeds Probation office was allocated as Mr
Cosgrove’s Community Offender Manager (COM).
22. On 6 March, staff at Leeds referred Mr Cosgrove to Ingeus, a service that helps
people improve their employment, skills, health and wellbeing, once released. Staff
from Ingeus arranged an initial appointment with Mr Cosgrove at Leeds on 14
March, however the appointment did not take place as he was transferred to
Humber.
23. On 11 March, Mr Cosgrove was transferred to Humber.
24. During the first reception screen, healthcare staff noted that Mr Cosgrove was
prescribed methadone and reviewed his medications. Mr Cosgrove said that he was
struggling with his mental health. Healthcare staff referred him to the GP.
25. On 12 March, during his second reception health screen, healthcare staff referred
Mr Cosgrove to the substance misuse team for psychosocial intervention and opioid
maintenance. The nurse noted that Mr Cosgrove declined to be referred to the
mental health team and that he would refer himself if he needed support.
26. On 19 March, the GP at the prison saw Mr Cosgrove to discuss his mental health
and prescribed fluoxetine (antidepressant). The GP scheduled an appointment to
see Mr Cosgrove in four weeks’ time.
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27. Later that day, a recovery worker from the substance misuse team saw Mr
Cosgrove. They discussed the dangers of using drugs on top of his methadone
prescription, reduced tolerance and increase risk of overdose associated with poly-
drug use while in prison and following release. Mr Cosgrove said that he had
support from his family, including his sister, but he was worried about being
released. Mr Cosgrove’s methadone prescription was increased to 25 ml.
28. On 15 March, Mr Cosgrove told the substance misuse team that he had now
changed his mind about taking a naloxone kit home following his release. He said
he would not be around opiate users when released, and therefore would not need
the kit. The benefits of taking the kit were outlined to him.
Pre-release planning
29. On 21 March, the resettlement team at the prison completed a Community
Accommodation Service 2 referral for Mr Cosgrove. (CAS2 is a service, provided by
Nacro, which provides short-term accommodation for those who have no suitable
accommodation and may otherwise be held in prison.) They requested
accommodation to allow Mr Cosgrove to be released under Home Detention Curfew
(HDC - a scheme which allows some prisoners to be released early if they have
suitable accommodation) on 30 March. The resettlement team noted that Mr
Cosgrove had proposed a release address and sent this to his COM for
consideration.
30. The COM called the occupant of Mr Cosgrove’s proposed HDC address. She
deemed this address to be unsuitable and did not continue with the checks. (On 28
March, the resettlement team confirmed that Mr Cosgrove was now on the waiting
list for CAS2 accommodation in Leeds).
31. On 26 March, the prison’s Offender Management Unit (OMU) emailed the COM to
notify her that Mr Cosgrove was eligible for release from 5 April under the End of
Custody Supervised Licence (ECSL) scheme. (The ECSL scheme was introduced
in October 2023 and allowed certain determinate sentenced prisoners to be
released prior to their Conditional Release Date (CRD), to ease overcrowding in
prisons. When it was initially introduced, prisoners could be released a maximum of
18 days prior to their CRD. This increased to a maximum of 35 days on 8 March
2024, and then further increased to a maximum of 70 days on 23 May 2024). On 5
April, she returned the ECSL checklist to the prison.
32. On 11 April, the OMU notified Mr Cosgrove’s Prison Offender Manager (POM) and
his COM by email that his confirmed ECSL release date was 17 April.
33. Mr Cosgrove’s recovery worker informed Forward Leeds, who confirmed that his
first appointment in the community would be at 11.00am on 18 April.
34. On 15 April, Mr Cosgrove was offered CAS2 accommodation for his release on
HDC. The following day, the prison notified Nacro that Mr Cosgrove was now
eligible for release under the ECSL scheme. Nacro withdrew the offer of
accommodation because CAS2 accommodation was not available for prisoners
being released under ECSL.
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35. On 16 April, the recovery keyworker from the substance misuse team saw Mr
Cosgrove. He was given his Forward Leeds appointment and he confirmed that he
would attend. Mr Cosgrove told his recovery worker that he was likely to smoke
cannabis upon his release. His recovery worker spoke to him about how his
tolerance would have reduced while in prison. Mr Cosgrove said that his tolerance
was really high. His recovery worker advised him that if he intended on using any
substances he should do so with caution and assume that his tolerance had
reduced. Mr Cosgrove maintained that he did not want to take a naloxone kit on
release and said that he would not be using opiates or associating with any opiate
users. The benefits of taking the kit were explained to him, but he still declined.
36. Later that day, a duty POM saw Mr Cosgrove to go through his licence. Mr
Cosgrove said that he would be homeless upon release. He said he was not happy
and felt like he was being left and he had no support in the community.
37. Also on 16 April, the GP at the prison was due to have an appointment with Mr
Cosgrove for a review of his mental health and medication, but Mr Cosgrove did not
attend. The appointment was not rescheduled as Mr Cosgrove was due to be
released the following day.
Post-release management
38. On 17 April, Mr Cosgrove was released from Humber under the ECSL scheme.
Prior to his release he was seen by healthcare staff in reception, but he refused to
have his observations taken. Mr Cosgrove said that he was happy he was being
released and did not report any concerns. There is no record of what clothing Mr
Cosgrove wore on his day of release, or what documents he left the prison with.
39. Mr Cosgrove was released homeless.
40. At 2.00pm, Mr Cosgrove attended Leeds probation office for his induction
appointment with his COM. She was unable to complete the induction paperwork
because Mr Cosgrove’s mood was not sufficiently stable. He said that he was
frustrated about the lack of accommodation and his early release. She instructed Mr
Cosgrove to attend the local housing association for accommodation support, the
Job Centre for financial support and reminded him of his appointment with Forward
Leeds the following day. She gave Mr Cosgrove an appointment to see her again at
12.00pm on 22 April.
41. On 22 April, Mr Cosgrove failed to attend his appointment at Leeds probation office.
The COM did not record this absence. At interview, she said that she would usually
give people 24 hours to contact her before taking any action.
Circumstances of Mr Cosgrove’s death
42. At 7.30pm on 18 April, a member of the public found Mr Cosgrove dead in a park in
Barnsley. Mr Cosgrove was found with a bag full of clothing, two full-sized bottles of
alcohol, and a small plastic bag with the remnants of cannabis in it.
43. On 23 April, the police notified the COM of Mr Cosgrove’s death. She checked to
see if he had attended the local housing association following his induction
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appointment and his appointment with Forward Leeds on 18 April. Mr Cosgrove did
not attend either appointment.
Post-mortem report
44. The post-mortem report concluded that Mr Cosgrove died from multiple drug
toxicity.
45. Toxicology tests found that there was a moderate concentration of methadone in Mr
Cosgrove’s system, which although within a normal therapeutic range, could have
been fatal if the user was not on a regular prescription. There was also a
moderately high blood concentration of benzoylecgonine, a cocaine metabolite.
This would have caused more physiological strain on top of the respiratory
depression caused by methadone.
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Findings
Substance misuse services
46. During his time in prison, Mr Cosgrove engaged with the substance misuse teams.
While at Leeds he agreed to accept a naloxone kit on release. However, when he
transferred to Humber, he changed his mind but he continued to attend regular
appointments with his recovery worker. Mr Cosgrove was released from prison
without a naloxone kit.
47. Mr Cosgrove’s recovery worker had referred him to the community substance
misuse team, Forward Leeds, for an appointment upon his release. The
appointment was scheduled for 18 April. The keyworker gave this appointment to
Mr Cosgrove before he was released from prison and Mr Cosgrove confirmed that
he would attend. On 17 April, the COM reiterated the appointment details. She told
the investigator during interview that she only found out that Mr Cosgrove failed to
attend this appointment after she had been notified of his death and she checked
with Forward Leeds directly. We consider that prison and probation staff provided
Mr Cosgrove with appropriate substance misuse support.
ECSL scheme
48. Mr Cosgrove left prison homeless which increased his vulnerability and the risks of
harm. Sadly, his release under ECSL made sourcing appropriate accommodation
for him more difficult. Had he been released under HDC, he would most likely have
had CAS2 accommodation.
49. On 21 March, Mr Cosgrove became eligible for release on HDC and was
appropriately referred for CAS2 accommodation. On 26 March, he became eligible
for ECSL, and a new release date of 17 April was calculated. People released
under ECSL were not eligible for CAS2 accommodation, so Nacro withdrew the
accommodation offer. The COM was not made aware and only discovered this by
chance when looking at Mr Cosgrove’s record. She had not made any other
accommodation referrals because she assumed he would have CAS2
accommodation.
50. While we recognise that the scheme was introduced to alleviate untenable prison
population pressures, Mr Cosgrove’s release planning was undoubtedly rushed and
negatively impacted by the ECSL. Information sharing between all relevant
agencies is key to release planning and the Governor and Head of Leeds Probation
Delivery Unit may want to reflect on the learning from this case.
51. ECSL is no longer in place, but HMPPS will also want to be aware of the issues
raised by Mr Cosgrove’s death.
Adrian Usher
Prisons and Probation Ombudsman March 2025
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Inquest
At the inquest held on 25 September 2025, the Coroner concluded that Mr Cosgrove’s
death was drug-related.
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