Sonia Little

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Ms Sonia Little,
on 1 August 2024 following her
release from HMP Low Newton
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. Ms Sonia Little died from the effects of a combination of heroin, methadone,
alcohol, bromazolam, pregabalin and cocaine on 1 August 2024, following her
release from HMP Low Newton on 25 July 2024. She was 46 years old. We offer
our condolences to those who knew her.
5. We did not identify any significant learning relating to the pre-release planning or
post-release supervision of Ms Little.
6. We make no recommendations.
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The Investigation Process
7. HM Coroner for Newcastle and North Tyneside notified us of Ms Little’s death on 26
September 2024.
8. The PPO investigator obtained copies of relevant extracts from Ms Little’s prison
and probation records.
9. The Coroner 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 Ms Little’s family to explain the investigation
and to ask if they had any matters they wanted us to consider. They did not
respond.
.
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Background Information
HMP Low Newton
11. HMP and YOI Low Newton is a woman’s local and resettlement prison that services
the courts across northern England. It is managed by HMPPS. Spectrum
Community Health CIC provides physical healthcare services and Tees, Esk and
Wear Valley NHS foundation trust provides mental health care services.
Probation Service
12. 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
13. The most recent inspection of HMP Low Newton was in June 2021. Inspectors
reported that they were concerned about the ease of illicit drug supply in the prison.
In their survey, they found that far fewer women than in 2018 said it was easy to get
illicit drugs in the prison. Despite this, drugs supply remained a significant risk. In
the absence of a body scanner to identify women arriving at the prison who were
secreting drugs internally, a new monitoring unit, the safety and support unit (SSU)
had been opened. There was a clear vision and a credible action plan for the unit in
the longer term, but at the time of the inspection, the daily regime amounted to
segregation.
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Key Events
Background
14. On 10 June 2024, Ms Sonia Little was sentenced to 14 weeks imprisonment for
theft from a shop. She was sent to HMP Low Newton. Ms Little was due to be
released on 25 July.
15. A nurse carried out Ms Little’s initial health screen. Ms Little said that she was an
illicit drug user, and was taking methadone in the community, illicit pregabalin (a
medication used to treat epilepsy and nerve pain but frequently used illicitly) three
times per day and smoked heroin and crack cocaine.
16. On 12 June, Ms Little was referred to and triaged by the primary care mental health
team (Rethink), to find out whether she was suitable to engage in low intensity
cognitive behavioural therapy (a form of self-guided help for those experiencing mild
to moderate symptoms of depression and or anxiety). It was decided that she would
be offered an assessment once she had finished her detoxification programme.
17. On 13 June, the substance misuse team saw Ms Little. She reported that she was
experiencing withdrawal symptoms, however she stated that the medication was
helping her to manage the symptoms and that she was gradually feeling better each
day.
18. On 14 June, Ms Little approached the healthcare unit and asked to speak to the
nurse. Ms Little told the nurse that she had been using subutex and cocaine on the
wing for the past two and a half days as she was struggling with opiate withdrawal.
Ms Little was added to the illicit pathway which provides more intensive support for
prisoners who take medications not prescribed to them.
19. On 3 July, health professional spoke with Ms Little over the phone about her
inability to sleep and continued withdrawal symptoms. Ms Little said that she had
been on methadone for 20 years and was struggling. Ms Little was advised about
harm reduction around illicit use of substances. Ms Little said she did not want to
use illicit substances and wanted a higher dose of methadone or buvidal (another
opiate substitute).
20. On 12 July, the substance misuse team saw Ms Little to discuss opiate substitute
therapy. Staff noted that Ms Little looked well and was coherent. Ms Little
expressed concern about remaining drug free once released into the community.
The substance misuse worker advised her not to use illicit substances in addition to
her prescribed medication. Ms Little was advised to attend her community drug and
alcohol services appointment and the pharmacy for her prescribed methadone after
her release. Ms Little was trained on how to use a naloxone (a medication that can
reverse the effects of an opiate overdose) kit.
21. On 13 July, Ms Little began her methadone prescription, with an initial dose of 3ml.
She told the healthcare assistant that she was prescribed 90ml in the community
and her current dose was not sufficient. Ms Little was advised that her dosage
would be increased, but this would be done in a controlled way.
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Pre-release planning
22. On 16 July, Ms Little attended her pre-release board (a meeting facilitated by the
community offender manager with the prisoner to prepare for release into the
community). She confirmed that she had accommodation following release and
planned to live with her daughter.
23. That day, Ms Little had a five-day review since starting methadone. It was decided
that her dosage would increase to 15mls on 17 July, 20mls on 18 July and 25mls on
21 July. After that, the substance misuse team would review her again.
24. On 17 July, Ms Little received a release appointment from North Tyneside Recovery
Partnership, a community drug support service, for 11.30am on 26 July.
25. On 18 July, a nurse from the substance misuse team saw Ms Little. Ms Little said
that she was now on 20mls of methadone, and it was not holding her.
26. On 23 July, Ms Little had another review and was asked if she felt stable now that
her dosage had been increased to 25mls. Ms Little asked if her dosage could be
increased before her release on 25 July. A nurse said that her request had been
discussed with the clinical lead and that the dosage would be increased to 30mls
over the following two days.
Release from Low Newton
27. On 25 July, Ms Little was released from Low Newton.
28. Ms Little’s post sentence supervision conditions were explained to her, and she
signed the licence to confirm this. She was handed a seven day supply of her
medications. She was also issued with a naloxone kit and provided with training
information.
29. Ms Little did not attend her initial appointment with her local probation office or the
scheduled appointments with the drug and alcohol support agencies. The plan was
that once released she would have been introduced to Changing Lives, a local
support group for women to provide her with additional support regarding her drug
habits.
Circumstances of Ms Little’s death
30. At 1.30pm on 1 August, Ms Little was found unresponsive in a public toilet. The
police and paramedics were called, and she was found with drug paraphernalia
around her. At 1.46pm, paramedics pronounced life extinct.
Post-mortem report
31. The post-mortem report concluded that Ms Little died from the effects of a
combination of heroin, methadone, alcohol, bromazolam (a synthetic
benzodiazepine), pregabalin and cocaine.
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Findings
32. Ms Little had a history of substance misuse. While it is noted that she participated in
the release planning process and actively engaged with the substance misuse team
in prison, the plan was that once released she would have been introduced to
Changing Lives, a local support group for women, that would have provided her
with additional support. We are satisfied that both the prison and probation services
did all they could to support Ms Little.
33. We make no recommendations.
Inquest
34. At the inquest held on 21 October 2024, the Coroner concluded that Ms Little’s
death was drug and alcohol related.
35. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
Adrian Usher
Prisons and Probation Ombudsman May 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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