Robert Connolly

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Independent investigation into
the death of Mr Robert Connolly
on 29 April 2024,
following his release from
HMP Featherstone
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 Robert Connolly was found hanged at his home on 29 April 2024, following his
release from HMP Featherstone on 18 April 2024. He was 46 years old. We offer
our condolences to those who knew him.
5. Mr Connolly had a history of substance misuse. He completed a detoxification
programme in prison and received appropriate support. Prior to his release he was
referred to the community drug and alcohol team.
6. Mr Connolly had anxiety and depression and was prescribed medication, but he
declined to be referred to the mental health team for additional support. Prison and
probation staff did not identify any concerns relating to his risk of suicide and he
was not monitored under suicide and self-harm prevention procedures (known as
ACCT) during his time at Featherstone.
7. We did not find any issues of concern in the pre or post-release planning. We make
no recommendations.
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The Investigation Process
8. HMPPS notified us of Mr Connolly’s death on 30 April 2024.
9. The PPO investigator obtained copies of relevant extracts from Mr Connolly’s prison
and probation records.
10. We informed HM Coroner for Rochdale of the investigation. She 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 Connolly’s family to explain the investigation
and to ask if they had any matters they wanted us to consider. Mr Connolly’s family
wanted to know what support Mr Connolly received with drug withdrawal in prison
and on release. These concerns have been addressed in this report.
12. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
13. Mr Connolly’s family received a copy of the initial report. They did not make any
comments.
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Background Information
HMP Featherstone
14. HMP Featherstone is a category C prison which holds convicted male prisoners. It
is managed by HMPPS.
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 Featherstone was in May 2022. Inspectors
reported mental health and substance misuse services were well-led, integrated,
co-located and responded effectively to needs.
17. Patients had swift access to mental health services and the waiting times for non-
urgent cases were favourable to what they would expect in the community. The
service offered various interventions for different mental disorders.
18. There was efficient planning of care for substance misuse service patients due to
be released. Their pre-release concerns were identified to ensure continuity with
community agencies.
HM Inspectorate of Probation
19. The most recent inspection of NPS Greater Manchester Division was in May 2023.
Inspectors found that the Probation Delivery Units (PDU) within that division had
developed strong strategic partnerships and had capitalised on the comprehensive
range of services to meet the needs of people on probation.
20. Inspectors stated that it was imperative the region supported all PDU’s within it to
build on their strong foundations by improving work to keep people safe. This
included improving assessment of risk, risk management planning and delivery of
case management.
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Key Events
Background
21. On 18 May 2023, Mr Robert Connolly was remanded to HMP Dovegate, charged
with burglary of a dwelling.
22. On 18 May, a Nurse completed Mr Connolly’s initial health screen. She noted he
presented with clear signs of substance withdrawal. Mr Connolly said that he had
used heroin the previous day and would usually take 75mg of pregabalin and 30mg
of mirtazapine daily. He denied any alcohol use. He tested positive for opiates,
cocaine and cannabinoids. Mr Connolly was placed on a methadone detoxification
programme and was prescribed 10mg of methadone (a substitute medication for
opiate addiction). (Mr Connolly’s methadone was later increased to 25ml, then to
30ml, because he felt that 25ml was not helping him during the night.)
23. On 19 May, a Nurse saw Mr Connolly. Mr Connolly told her that he suffered with
anxiety and depression and was prescribed pregabalin and mirtazapine in the
community. He said that he had never self-harmed or attempted suicide and did not
have any active thoughts to do so. Mr Connolly was prescribed mirtazapine
(antidepressant), he was not prescribed pregabalin. He later declined support from
the mental health team.
24. On 28 June, a substance misuse worker offered Mr Connolly naloxone training (a
medication that can reverse the effects of an opiate overdose). Mr Connolly
declined the offer and said that he would not need it.
25. On 29 June, Mr Connolly was convicted and was sentenced to two years in prison.
He remained at Dovegate.
26. On 14 July, the substance misuse worker saw Mr Connolly to discuss the work the
drug and alcohol service offered. Mr Connolly declined the offer and said that he
had previously completed the work and did not want to do it again.
27. On 28 July, Mr Connolly was transferred to Featherstone.
28. A Nurse completed Mr Connolly’s initial health screen. Mr Connolly denied any
thoughts of suicide and self-harm. He continued his methadone detoxification
programme and was prescribed 30ml of methadone.
29. On 30 July, a nurse completed Mr Connolly’s secondary health screen. Mr Connolly
said that he suffered with anxiety, depression and post-traumatic stress disorder
(PTSD) but declined to be referred to the mental health team. He said that he was
happy taking his mirtazapine and did not need additional support, but he was aware
of how to access the service if he needed too.
30. On 3 August, a member of the substance misuse team completed an initial
assessment with Mr Connolly. He became upset during the assessment and said
that he could not think straight. He described his head as being all over the place.
He rated himself a seven on a scale of one to ten, (ten being severely depressed),
however he would not expand on his feelings. She advised on the counsellors
available within the prison, but Mr Connolly did not appear interested in the support.
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Mr Connolly said that he did not have anyone in the community to support him and
that he did not want to complete any interventions, he just wanted to get a job and
to settle into prison. Following this assessment, Mr Connolly was allocated a
psychosocial worker to discuss and complete a care plan in preparation for his
release in May 2024.
31. On 12 January 2024, a GP at the prison uploaded a letter from the prescribing team
to Mr Connolly’s medical records. The letter stated that mirtazapine was not
recommended for insomnia or normally prescribed to those with significant
addiction problems. They had decided it was in Mr Connolly’s best interest to
reduce and stop his prescription and a GP appointment would be requested to
assess his wellbeing.
32. On 22 January, another GP at the prison saw Mr Connolly. Mr Connolly said that he
had no thoughts of suicide or self-harm, but he felt that his mirtazapine helped him
and that it would not have been stopped in the community. The GP prescribed Mr
Connolly sertraline (antidepressant), alongside his mirtazapine as an alternative to
support him with his mood. However, Mr Connolly refused to take the sertraline,
even after his mirtazapine stopped.
33. On 3 February, an Associate Practitioner Nurse saw Mr Connolly to discuss why he
was not collecting his sertraline, and he said he did not want to take it.
34. Mr Connolly’s mirtazapine was reduced to 15mg for one month, then reduced to
every other day until the prescription stopped on 21 March.
Pre-release planning
35. On 26 March, Mr Connolly’s allocated Community Offender Manager (COM)
completed a CAS3 referral (provides temporary accommodation for up to 84 nights
for those being released homeless from prison).
36. On the 10 April, Mr Connolly was approved for End of Custody Supervised Licence
Scheme (ECSL) which allowed prisoners to be released up to 70 days early to ease
overcrowding in prisons. This meant that Mr Connolly would be released on 12 April
instead of in May. Mr Connolly said that he felt overwhelmed knowing that he was
going to be released so quickly.
37. Mr Connolly was referred to Rochdale Turning Point (community drug and alcohol
service) who gave him an appointment for 12 April.
38. On 11 April, the Offender Management Unit (OMU) at Featherstone was told that
additional days were to be added to Mr Connolly’s sentence because he had tested
positive for synthetic cannabinoids (spice) the previous month, and therefore his
release date had been changed to 18 April. Turning Point arranged another
appointment for 19 April at 11.00am.
39. On 11 April, a member of the substance misuse team, met with Mr Connolly and
gave him advice on harm reduction. Mr Connolly said that when he was released,
he wanted to get the keys to his flat, engage with Turning Point, work with
probation, stay away from others and remain drug free.
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40. Mr Connolly was approved for CAS3 accommodation. He was given a self-
contained flat and would be given the keys at his initial probation appointment, on
the day of his release. Mr Connolly called his COM, as he was worried about losing
his accommodation because additional days had been added to his sentence. She
reassured him that his accommodation would still be available.
Release from HMP Featherstone
41. On 18 April, Mr Connolly was released from Featherstone under ECSL. Mr Connolly
declined a supply of naloxone kits.
42. Mr Connolly attended his initial probation appointment with the duty COM (his
allocated COM was not available that day). No concerns were identified during the
meeting.
43. On 19 April, Mr Connolly attended his appointment with Turning Point for his initial
assessment and to collect his methadone. Mr Connolly said that he was suffering
with PTSD but had no suicidal thoughts. He did not go into any more detail about
this. Mr Connolly was given his methadone prescription for 19 to 24 April, and a
medical review appointment was scheduled for 24 April.
44. The COM had an appointment with Mr Connolly on 22 April. She said Mr Connolly
did not express any suicidal ideations during this meeting, or during any contact she
had with him. Mr Connolly told her that he felt overwhelmed by the rush of his
release. They discussed his mental health, but Mr Connolly said that he was doing
okay and planned to book an appointment with his GP. Mr Connolly said that he
was previously involved with the community mental health team before he went to
prison, but he was unsure as to what degree, and he could not confirm his
diagnosis. It was agreed that she could investigate this further if Mr Connolly felt he
needed additional support, but the first step was for Mr Connolly to book an
appointment with his GP. She did not know if Mr Connolly had booked an
appointment with his GP.
45. On 22 April, Turning Point was informed that Mr Connolly had not taken his
prescription to the pharmacy and was therefore out of treatment.
46. On 24 April, Mr Connolly attended Turning Point for his medical review and was
restarted on a methadone script. He did not express any thoughts of suicide or self -
harm. That day, Mr Connolly collected his methadone from the pharmacy.
Circumstances of Mr Connolly’s death
47. On 29 April, the COM spoke to a CAS3 support worker, and told her she had not
had any recent contact with Mr Connolly. The support worker went to Mr Connolly’s
address and found him hanging from the stairs with a ligature around his neck. She
left the property and called the COM immediately.
48. The COM said that the support worker sounded extremely stressed by what she
had seen, so the COM called the emergency services.
49. The police and paramedics arrived promptly, and Mr Connolly was pronounced
dead.
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Inquest
50. At the inquest held on the 5 August 2024, the Coroner concluded that Mr Connolly
died of suicide.
51. The toxicology results showed low levels of alcohol, nicotine, cannabis and
methadone in Mr Connolly’s system at the time of his death. While these drugs did
not directly contribute to his death, the toxicologist said that it was not possible to
determine whether the use of cannabis had an effect on Mr Connolly’s state of mind
at the time of his death.
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Findings
Mental health
52. Mr Connolly said that he suffered with anxiety, depression and PTSD. While he was
initially prescribed antidepressants, he declined any further support from the mental
health team.
53. Mr Connolly’s antidepressant prescription was changed while he was at
Featherstone after the prescribing team advised mirtazapine was not suitable for
people with a history of addiction. Mr Connolly was prescribed an alternative but
refused to take it. Healthcare staff explored his reason for refusing the prescription.
54. Mr Connolly did not have a history of suicide attempts or self-harm. He was not
subject to suicide and self-harm monitoring (ACCT) while serving his most recent
sentence. Prison staff had no concerns about his risk of suicide and his COM had
no concerns about his risk after his release. Because Mr Connolly declined to be
referred to the mental health team, he was not referred to any community mental
health services.
55. We are satisfied that neither prison nor probation staff had any reason to consider
Mr Connolly at imminent risk of suicide and that they took appropriate steps to
support his mental health.
Substance misuse
56. Mr Connolly had a history of substance misuse. While he was in prison, Mr
Connolly was promptly referred to the substance misuse team who saw him and
warned him about the risks and dangers of taking drugs. He declined to complete
any interventions, but he was placed on a methadone programme and was also
allocated a psychosocial worker to complete a discharge plan with him. He was
trained in the use of naloxone but declined a supply of this on release.
57. Although Mr Connolly did not complete any interventions with the SMS at
Featherstone, he was appropriately referred to the community drug and alcohol
service, and Mr Connolly engaged with them on release. He was provided with
ongoing support in the community.
58. We are satisfied that both the prison and probation services did all they could to
manage the risks associated with Mr Connolly’s substance misuse.
Adrian Usher
Prisons and Probation Ombudsman December 2024
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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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