Steven Blake

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Independent investigation into
the death of Mr Steven Blake,
a prisoner at HMP Haverigg,
on 28 April 2023
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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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.
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.
Mr Steven Blake died on 28 April 2023, after taking an overdose of propranolol (a
medication which he had been prescribed for anxiety) while a prisoner at HMP Haverigg.
He was 38 years old. I offer my condolences to his family and friends.
Mr Blake had a history of anxiety and had tried to take his own life in March 2022, before
he went to prison. While in custody, Mr Blake felt low, had anxiety, and was under the care
of mental health services.
Mr Blake’s anxiety increased at Haverigg because of his concerns about his life outside
prison, the nature of his offences and a conflict with some prisoners. We are satisfied that
healthcare and prison staff supported him well and treated him fairly. We do not think that
they could reasonably have identified that Mr Blake intended to end his life imminently.
The clinical reviewer concluded that the clinical care extended to Mr Blake was of a good
standard. However, this conclusion did not extend to the prescription of propranolol, which
healthcare staff considered Mr Blake could safely keep in his cell despite a recent history
of attempted suicide.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Adrian Usher
Prisons and Probation Ombudsman July 2025
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 6
Findings ......................................................................................................................... 13
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Summary
Events
1. On 30 May 2022, Mr Steven Blake was sentenced to two years and nine months in
prison for sexual offences. He was sent to HMP Forest Bank.
2. On 22 February 2023, Mr Blake was transferred to HMP Haverigg, an open prison.
During his initial health screen, Mr Blake said that he did not have thoughts of
suicide or self-harm but felt anxious and took medication to help.
3. Mr Blake was referred to the prison’s mental health team. During his initial health
screen, healthcare staff carried out a risk assessment and assessed that Mr Blake
could keep and administer his medications himself.
4. On 1 March, a GP at Haverigg saw Mr Blake as he had complained of stomach
cramps which were thought to be linked to his anxiety. Mr Blake was prescribed
propranolol (a medication used to treat anxiety).
5. On 21 April, Mr Blake told a psychological wellbeing practitioner that he had issues
with some prisoners. Mr Blake was encouraged to speak to the safer custody team.
He denied thoughts of suicide and self-harm.
6. On 28 April, a custodial manager (CM) and senior probation officer spoke to Mr
Blake about letters that he had written to another prisoner. Later that day, the CM
spoke to him about this for a second time.
7. At approximately 6.55pm, a prisoner told an officer that Mr Blake had taken an
overdose of his medications. Prison staff attended immediately and an ambulance
was called.
8. Prison staff cared for Mr Blake until a paramedic arrived at 7.28pm, and took him to
a waiting ambulance. Once in the ambulance, Mr Blake had a cardiac arrest and
prison officers supported the paramedic with life-saving treatment.
9. At 7.55pm, a second ambulance crew arrived and they took over Mr Blake’s care.
The air ambulance arrived at 8.12pm. Paramedics pronounced life extinct at
8.20pm.
Findings
10. When they assessed whether Mr Blake could safely keep his medication in his cell,
healthcare staff did not identify from his medical history that he had attempted an
overdose in the previous twelve months. They also did not undertake a new
assessment when they prescribed him a new drug.
11. The prison acted in a proportionate and reasonable manner in their attempts to deal
with the conflict between Mr Blake and some other prisoners and when carrying out
their investigation into the allegations made.
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12. The officers and prisoner who responded to the emergency situation were
compassionate and did everything they could to help Mr Blake.
Recommendations
The Head of Healthcare at HMP Haverigg should ensure that:
• information relating to incidents of self-harm by overdose reported as part of
the medicines in-possession risk assessment should be checked against the
medical records to ensure accuracy; and
• all prescribers are aware of Spectrum Community Health CIC’s medicines in
possession policy in relation to propranolol.
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The Investigation Process
13. HMPPS notified us of Mr Blake’s death on 29 April 2023.
14. The investigator issued notices to staff and prisoners at HMP Haverigg informing
them of the investigation and asking anyone with relevant information to contact
him. Two prisoners contacted the investigator, and they were subsequently
interviewed on 27 June 2023.
15. The investigator visited Haverigg on 27 and 28 June 2023. He obtained copies of
relevant extracts from Mr Blake’s prison and medical records, body-worn video
camera footage, transcripts of Mr Blake’s telephone conversations and ambulance
records.
16. The investigator interviewed six members of staff and two prisoners at Haverigg on
27 and 28 June. He carried out a further two interviews using Microsoft Teams on
31 July and 2 August.
17. Another investigator took over the investigation in October 2024.
18. NHS England commissioned a clinical reviewer to review Mr Blake’s clinical care at
the prison. She was present at all face-to-face interviews carried out by the first
investigator.
19. We informed HM Coroner for Cumbria of the investigation. The Coroner gave us the
results of the post-mortem examination. We have sent the Coroner a copy of this
report.
20. The Ombudsman’s office contacted Mr Blake’s father to explain the investigation
and to ask if he had any matters he wanted us to consider. He asked why Mr Blake
had been allowed to have his medications in possession and why the prison had
not notified him earlier about his son’s death. He wanted to know what had
happened following his conversation with his son a few hours before his death and
the details of the emergency response. We have addressed these questions in this
report.
21. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
22. Mr Blake’s family received a copy of the draft report. They did not make any
comments.
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Background Information
HMP Haverigg
23. HMP Haverigg is a category D male open prison in West Cumbria. It predominantly
holds men who have been convicted of sexual offences.
24. Spectrum Community Health provide the primary healthcare with medical staff on
duty each day between 7.30am and 6.30pm (Monday to Friday) and 8.15am and
4.15pm (weekend), with on call cover available outside these hours. Tees Esk and
Wear Valleys NHS Foundation Trust provide Mental Health services. Rethink
Mental Illness provide psychological therapy and OUTspoken provides a sexual
trauma service.
HM Inspectorate of Prisons
25. The most recent inspection of HMP Haverigg was an unannounced inspection in
May 2021. Inspectors concluded that outcomes for prisoners were at least
reasonably good against all of the healthy prison tests. They stated that the prison
was very safe and they noted a calm and relaxed atmosphere. They reported that
there was a comprehensive safety policy in place and the weekly safety intervention
meetings were effective, with multidisciplinary attendance.
26. They noted that intelligence reports were collated, analysed and disseminated, and
the number of prisoners returned to closed conditions was comparatively low.
27. They concluded that relationships between staff and prisoners were good, with 86%
of prisoners saying they were treated with respect and 88% said that they had a
member of staff to turn to if there was a problem.
Independent Monitoring Board
28. Each prison has an Independent Monitoring Board (IMB) of unpaid volunteers from
the local community who help to ensure that prisoners are treated fairly and
decently.
29. In its latest annual report for the year to November 2023, the IMB reported that the
population had increased by 50% during the reporting year. They noted that the
introduction of the Link Worker scheme, where prisoners meet with their link worker
every two weeks, had further strengthened relationships between staff and
prisoners.
30. They stated that prisoners felt that they received a good mental health service,
supported by a psychiatric service orderly (a trusted prisoner). They reported that
the opening of the Resettlement Hub was a positive development and there were
positive outcomes in terms of the numbers of prisoners who found employment on
release from Haverigg.
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Previous deaths at HMP Haverigg
31. Mr Blake was the third prisoner to die at Haverigg since April 2020. The two
previous deaths were both as a result of natural causes. Mr Blake’s was the first
self-inflicted death at Haverigg since 2018. There were no similarities between our
investigation findings into the previous deaths and our findings in this investigation.
To the end of March 2025, there have been four further deaths at Haverigg since Mr
Blake’s. Three were from natural causes and one was self-inflicted.
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Key Events
32. On 9 March 2022, Mr Steven Blake took an overdose of multiple medications and
was treated in hospital.
33. On 30 May 2022, Mr Blake was convicted of sexual offences and was sentenced to
two years and nine months in prison. This was his first time in prison.
34. A probation officer at Manchester Crown Court completed a suicide risk form which
noted that Mr Blake would be at risk of suicide and self-harm if he received an
immediate custodial sentence. The probation officer noted that Mr Blake had taken
an overdose in March 2020 and tried to poison himself in December 2020.
35. Later that day, Mr Blake was sent to HMP Forest Bank. An officer noted that when
he arrived Mr Blake said he had no thoughts of suicide or self-harm.
36. On 1 June, a medication review was carried out as part of the reception process.
His medical record noted that Mr Blake had attempted suicide in March 2022. The
nurse completed a medicine in possession risk assessment (MIPRA) and
concluded that Mr Blake should not hold his medications in-possession. (A MIPRA
consists of a number of questions which result in a score which indicates if a person
can be considered for keeping their medications in their cell and being responsible
for taking them as prescribed rather than healthcare staff administering them.)
HMP Risley
37. On 15 July, Mr Blake was transferred to HMP Risley. A MIPRA was completed and
the decision was made that Mr Blake should not have his medications in-
possession.
38. On 26 August, staff started suicide and self-harm prevention procedures, known as
ACCT. Mr Blake told officers that he felt low, had problems sleeping and anxiety. At
the time, a psychological well-being practitioner (PWP) supported Mr Blake.
39. On 30 August, the ACCT was closed.
40. On 3 November, a GP at Risley saw Mr Blake and changed his medication
prescription for depression and anxiety to trazadone. He assessed that Mr Blake’s
risk of suicide was low, so he changed his medication status to weekly in-
possession.
HMP Haverigg
41. On 22 February 2023, Mr Blake was transferred to HMP Haverigg.
42. When he arrived, healthcare staff saw Mr Blake in reception for his initial health
screen. They noted that Mr Blake was taking trazadone daily and had a seven-day
supply which he administered himself.
43. On 23 February, the clinical team manager carried out a full healthcare assessment
and completed the MIPRA. Mr Blake told him that he had not harmed himself or
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taken an overdose in the preceding twelve months. Based on his MIPRA score, Mr
Blake was permitted to hold his medications (now increased to a 28 day supply) in-
possession, with a review to take place in six months.
44. Mr Blake was referred to the mental health team and discussed at the Mental
Health Integrated Management Panel later that day. They referred Mr Blake to
Rethink (an organisation providing psychological therapy).
45. On 1 March, a GP saw Mr Blake after he complained of stomach cramps. She
prescribed him propranolol (a medication to treat anxiety), in addition to trazadone,
as she thought his anxiety could be causing the cramps. A new MIPRA was not
completed as it should have been.
46. On 3 March, an officer spoke to Mr Blake. He told her he felt safe in prison but was
very anxious about being released due to his conviction for sex offences and fears
of how he would be treated outside prison. She recorded that she offered him
reassurance.
47. On 4 March, an officer carried out a key work session with Mr Blake. (Key work is
one-to-one support provided to a prisoner.) He noted that Mr Blake was quiet and
appeared to get on well with other prisoners.
48. On 7 March, Mr Blake had his first Rethink session with a psychological wellbeing
practitioner. Mr Blake said he was uncertain of the prison rules and what behaviour
could lead to being sent back to closed conditions. She encouraged him to speak to
officers and she referred him to the Improving Access to Psychological Therapies
team (IAPT - which offers talking therapies for people with anxiety, depression or
low-level mental health problems) and to the weekly mood and mindfulness group.
49. On 9 March, Mr Blake attended the mood and mindfulness group.
50. On 12 March, an officer conducted an early days check with Mr Blake. He noted
that Mr Blake was enjoying his time at Haverigg, that he had no concerns and knew
to tell wing staff if he had any.
51. On 18 March, an officer met Mr Blake for a key work session. He said that Mr Blake
was settling in well and had grown in confidence.
52. On 22 March, a mental health nurse consultant met Mr Blake and carried out a
comprehensive assessment. She increased Mr Blake’s trazodone dosage.
53. On 23 March, the psychological wellbeing practitioner met Mr Blake for his
scheduled therapy appointment. He said he was worried about life outside prison
and was still uncertain about prison rules.
54. On 1 April, an officer met Mr Blake for a key work session. He noted that Mr Blake
was doing well and was mixing well with prisoners.
55. On 16 April, Mr Blake called a friend and told her that he had had an argument with
another prisoner and had spent the day in bed “pissed off”.
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56. On 18 April, Mr Blake called his father and said there had been some drama the
week before because people got on each other’s nerves as they spent so much
time together.
57. On 21 April, Mr Blake attended a Rethink drop-in session and psychological
wellbeing practitioner saw him. She said he was upset and told her that someone
he had trusted had manipulated his words and it appeared to other people that he
was saying unkind things about them. She noted that she told Mr Blake that he
should report this to the safer custody team and that they had gone through some
thought-challenging techniques to help him manage his worry.
58. Later that day, Mr Blake called his father and told him there had been more drama
and he was fed up. He said he was looking forward to seeing him on Sunday.
59. A Senior Probation Officer (SPO) told the investigator that she first heard about Mr
Blake on 23 April when she saw some intelligence reports which included his name.
She said that she was part of a group of officers who reviewed intelligence reports
with the security team and decided what should happen next. The intelligence
reports suggested that there had been a relationship breakdown among a group of
prisoners. She said the intelligence report was passed to the wing custodial
manager (CM) to consider if any action was needed.
60. At 9.16pm on 23 April, Mr Blake called his father and said he was worried that
someone was “making stuff up” about him and telling other prisoners. He told his
father that he felt really “shite” and was not sleeping. He said he had an
appointment with the mental health team the next day and his father encouraged Mr
Blake to tell them how the situation was making him ill.
61. On 24 April, Mr Blake spoke to an instructor from Fusion 21 (an organisation
contracted by HMPPS to deliver construction courses ). He told her that he had got
into a situation on the wing and did not know who to talk to. He said someone had
befriended him on the wing and Mr Blake had ended up sharing information about
other prisoners with him. He said that this prisoner was now sharing this information
with others and this had led to Mr Blake being alienated by some. Mr Blake said he
was hoping to speak to his prison offender manager (POM) later that day. She
submitted an intelligence report about this the following day.
62. Later that day, Prisoner A attended an Offender Management drop-in session. He
told a POM that Mr Blake was trying to cause trouble by saying he was “anti-gay”
and he was bringing illegal items into the prison. The POM created an intelligence
report.
63. At 9.11pm, Mr Blake phoned his brother and talked about the issues he had with
another prisoner and that it was having a significant impact on his anxiety. He told
his brother that he had told an instructor about it.
64. On 25 April, an intelligence report was created which stated that Mr Blake was
causing friction between prisoners on A Wing and B Wing and that there were
rumours about a Prisoner A intimidating Mr Blake.
65. That day, a Prison Offender Manager (POM) met Mr Blake to find out how he was
getting on at Haverigg. There is no further information about their discussion.
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66. A second intelligence report was created later that day which stated that Prisoner A
might be bullying Mr Blake. It also noted that Mr Blake used to be friends with
Prisoner B, but this was no longer the case, perhaps because of Prisoner A.
67. On 26 April, an intelligence report was created. It stated that information had been
received that Mr Blake was causing issues on the wing by accusing prisoners,
particularly Prisoner A, of being homophobic.
68. At 2.00pm on 26 April, the mental health nurse consultant saw Mr Blake for a
scheduled review of his medications. He told her that his anxiety had increased due
to issues on the wing with a fellow prisoner. He said that he had reported it to OMU
and the safer custody team (there is no record of him having done so) and they
were dealing with it. He denied thoughts of suicide and self-harm.
69. On 27 April, an intelligence report was created. It stated that Mr Blake was causing
problems with other prisoners by accusing prisoners of doing things that they had
not done.
70. That day, an SPO organised a case conference with two POMs, as there had been
further intelligence about Mr Blake and Prisoner A. The SPO said it was agreed that
both POMs would speak to the prisoners separately to try to understand what was
going on.
71. At 11.15am, a therapist from OUTSpoken (a sexual trauma service) met Mr Blake
to assess him for their service. She said that Mr Blake appeared to be in a neutral
to fair mood and denied thoughts of suicide or self-harm.
72. Later that day, a POM and Mr Blake’s community offender manager (COM) met Mr
Blake. They discussed Mr Blake’s release, including his likely licence conditions.
The POM noted that after the meeting, she had a discussion with Mr Blake about
his current concerns. Following this, she submitted an intelligence report in which
she recorded that she had asked Mr Blake about the information he gave Prisoner
A and why he thought the prisoner was behaving this way. She also noted that she
had asked Mr Blake if he wanted to move to a different wing but he declined.
73. That evening, Prisoner B told a CM that he had received letters from Mr Blake
about his feelings towards him and that some of the content was sexually graphic
and violent. He said he was nervous to speak to anyone but asked if he could
speak to another CM. The CM told him the other CM would be on duty the following
day and he would let her know.
74. At 10.10pm, Mr Blake spoke to his father on the phone. He told him about meeting
with the COM and said he was worried that life outside would be difficult because of
the restrictions that would be placed on him. He said that the prison was trying to
move him to a different wing because of the trouble but he did not want to go.
28 April 2023
75. The CM told the investigator that in the morning, she was handed letters that
Prisoner B had given an officer. She said that she was alarmed by the content of
the letters, so she sought advice from a SPO and the duty governor. She said it was
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agreed that she and the SPO would speak to both prisoners before deciding what to
do.
76. At approximately 1.15pm, the CM and SPO spoke to Mr Blake. The CM said that he
confirmed that he had written the letters to Prisoner B and explained why. Mr Blake
said that writing letters to each other was common on the wing. The CM said that
they shared their concerns about the content of the letters with Mr Blake and said
that they intended to speak to Prisoner B about it, and, in the meantime, they told
Mr Blake he should not discuss their conversation with anyone else.
77. In an intelligence report submitted at 12.33am on 29 April, the SPO noted that Mr
Blake was preoccupied with how this issue would affect his risk profile and if it
would result in him having to leave Haverigg. She said that they told Mr Blake that
he needed to be open and honest with his POM about his sexual thoughts. Mr
Blake declined to move wings as he had support where he was.
78. At 12.53pm, an officer carried out a key work session with Mr Blake. He noted that
Mr Blake was a quiet prisoner who seemed to get on well with prisoners on A Wing
and B Wing and made no reference to the recent issues.
79. Prisoner C told the investigator that he had spoken to Mr Blake after the meeting
with the CM and SPO. Mr Blake had told him they had discussed a move to a
different wing and he wondered if they would send him back to closed conditions (a
category C prison). Mr Blake told him that he was worried that the content of the
letter would affect his risk level which would then affect his licence conditions.
80. The CM told the investigator that she and the SPO then spoke to Prisoner B. He
told them that he had received the letters three weeks earlier. He explained why he
had kept them and what had prompted him to hand them in.
81. In the intelligence report, the SPO noted that Prisoner B was nervous and scared.
He told them that Mr Blake had told other prisoners on the wing that he had been
spoken to about the letters and that they too were going to be “hauled in”. The SPO
asked Prisoner B if he wanted to move wings, and he said he did not want to move.
She noted that following the meeting with him, they agreed to speak to Mr Blake
again and he would be moved.
82. At 2.24pm, Mr Blake phoned his father. He told him that he had been called into the
office about his letters to Prisoner B. He said, “they don’t know whether to ship me
out”. He said he did not know what was going on and that nothing might happen
until after the weekend.
83. At 2.27pm, Mr Blake called his father again because he had not been able to make
contact with his brother. Mr Blake’s father told him that his brother was on holiday
and would not return until the next week. Mr Blake said that he would talk to him
when he was back. This was Mr Blake’s last conversation with his family.
84. The CM told the investigator that after the meeting with Prisoner B, she looked for
Mr Blake, but he was not around, so she asked staff to let her know when he
returned. Another prisoner told officers on 29 April that he had spoken to Mr Blake
that afternoon and he had seemed a bit down.
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85. At approximately 4.00pm, an officer from OMU spoke to Prisoner A to find out what
was happening on the wing. The prisoner said he was aware of the letters Prisoner
B had received. He made allegations that an associate of Mr Blake was upsetting
people on the wing.
86. At around 5.00pm, the CM spoke to Mr Blake in the staff room. She told him that
she was unhappy that he had spoken to other prisoners about their meeting as she
had told him not to and this had led to issues on the wing. She told Mr Blake that
they would speak again the next day and she would decide what to do.
87. At around 6.00pm, an officer went to Mr Blake’s cell to find out if he wanted his
evening meal. He told the investigator that when he arrived, Mr Blake was on his
bed, writing in a notebook. He said that Mr Blake had refused his meal but
appeared calm and not in distress.
88. A prisoner told the investigator that at around 6.00pm, he went to Mr Blake’s cell
and found him on his bed, writing in a note pad. Mr Blake told him he was writing
notes from his meeting. He invited Mr Blake for a cup of tea and a chat in his cell.
Mr Blake accepted.
89. The prisoner said that in his cell, Mr Blake told him that he thought he would be sent
back to closed conditions and that he had ruined his life.
90. The prisoner said a short while later, they visited another prisoner who was Mr
Blake’s friend, in his cell. Mr Blake told them that he had taken an overdose. The
prisoner said he immediately went to Mr Blake’s cell to see what medication he had
taken, and he was joined a few moments later by Mr Blake, who sat down on his
bed.
91. At approximately 6.47pm, the prisoner went to the wing office with lots of empty
medication packets and told an officer that Mr Blake had taken an overdose. In her
statement, she said she called a medical emergency code blue (which triggers the
control room to call an emergency ambulance and for staff to provide assistance).
Her colleague immediately went to Mr Blake’s cell.
92. The control room log shows that an ambulance was called at 6.49pm and staff were
told that the estimated wait time was one hour and 30 minutes.
93. Body-worn video camera footage showed that a CM arrived at Mr Blake’s cell at
6.54pm. Mr Blake was sitting on his bed, and another CM, an officer and the
prisoner were providing physical and emotional support.
94. Officers and the prisoner remained with Mr Blake as his condition deteriorated. The
control room relayed information from the Ambulance Service to the officers and
officers took advice from the healthcare team’s out-of-hours doctor. A defibrillator
was attached to Mr Blake but advised no shock.
95. At 7.28pm, the first paramedic arrived. He confirmed that Mr Blake was still
breathing and Mr Blake was moved from his cell to the ambulance by stretcher.
Both CMs and the officer continued to provide assistance.
96. At 7.44pm, officers began cardiopulmonary resuscitation at the paramedic’s
instruction.
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97. At 7.55pm, a second ambulance arrived and the paramedics took over the
emergency treatment.
98. At 8.12pm, the air ambulance arrived and the air ambulance staff pronounced life
extinct at 8.20pm.
99. Officers who attended to secure Mr Blake’s cell found a letter written to Mr Blake’s
father and brothers on an A4 note pad. Mr Blake wrote about his conflict with
another prisoner and how prison staff had questioned him earlier that day. He wrote
about his fear that his life would not be worth living outside prison due to the
restrictions that he would be subject to. He stated that the day’s events had
increased this fear.
Contact with Mr Blake’s family
100. The prison appointed a family liaison officer (FLO) and Mr Blake’s father was
identified as the next of kin. Following a discussion with the Head of Safety and
Reception, and in recognition that the prison was in night state and Mr Blake’s
father lived far from the prison, the FLO asked the police to visit Mr Blake’s father
and break the news of his son’s death.
101. At 9.15am on 29 April, the police confirmed that they had been to Mr Blake’s
father’s home and notified him of the death. Later that day, the FLO spoke to Mr
Blake’s father and brother.
Support for prisoners and staff
102. After Mr Blake’s death, a CM met all the staff involved in the emergency response
to ensure they had the opportunity to discuss any issues arising, and to offer
support. The staff were notified of the different support options available to them.
103. The prison posted notices informing other prisoners of Mr Blake’s death and
offering support. Staff reviewed all prisoners assessed as at risk of suicide or self-
harm in case they had been adversely affected by Mr Blake’s death. As part of the
prison’s postvention procedures, they arranged for Listeners (prisoners who had
been briefed by Samaritans) to be deployed onto the wing to support other
prisoners and offer additional support to those with known links to Mr Blake.
Post-mortem report
104. The post-mortem toxicology report identified a level of propranolol in Mr Blake’s
system that was in excess of a lethal range. The post-mortem examination
established that Mr Blake died of a propranolol overdose.
Inquest into Mr Blake’s death
105. The inquest into Mr Blake’s death was held on 20-22 October 2025 and a verdict of
suicide was recorded.
106. The coroner concluded that Mr Blakes’s death was due to a propranolol overdose.
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Findings
Assessment of risk
107. It is evident that Mr Blake had anxiety and depression for a number of years. We
are satisfied that when Mr Blake arrived at Haverigg, he was immediately and
appropriately referred to the mental health team who referred him to a number of
agencies that could support him.
108. Mr Blake had attempted suicide before being sent to prison. However, during his
appointments with health professionals, he was repeatedly asked if he had thoughts
of suicide and self-harm and always stated no. His sessions with his key worker
also identified no concerns. He generally appeared to have settled well at the
prison. He had not self-harmed at Haverigg and had not been subject to ACCT
monitoring since August 2022.
109. During the last few weeks of his life, it is clear that Mr Blake was involved in conflict
with some other prisoners and that this left him feeling vulnerable and isolated. As a
result, he became increasingly anxious. However, he appeared to have a core
group of friends who gave him support and advice. We are satisfied that once
prison staff became aware of the issues between Mr Blake and other prisoners,
they acted on the information from the intelligence reports and sought to speak to
the people involved to resolve the situation. It was proportionate and reasonable for
officers to have interviewed Mr Blake about the allegations made and he accepted
his part in them. We did not find any evidence to suggest that staff should have
begun ACCT procedures at that time.
110. Given the testimony of his friends and the staff who saw him in the hours preceding
his drug overdose, we conclude that staff could not reasonably have known that Mr
Blake intended to take his own life imminently.
In-possession medications
111. Medicines are routinely prescribed to prisoners to treat health conditions. However,
there are risks associated with this and healthcare providers are required to have a
policy and risk assessment process in place to determine if an individual should be
allowed to hold a medication in possession (known as MIPRA). It is mandated that
the MIPRA is completed when a prisoner arrives in a prison and also when a
prescriber prescribes a new drug which is highlighted as one with the potential to
cause harm if wrongly taken. All risk assessments should be reviewed regularly and
at least every six months.
112. When Mr Blake arrived at Haverigg In February 2023, a risk assessment was
completed. Although it was noted in his medical record that Mr Blake had taken an
overdose within the preceding twelve months Mr Blake was assessed as being
suitable to hold his medications in possession.
113. On 1 March, a GP saw Mr Blake and prescribed him propranolol. Spectrum’s (the
healthcare provider at Haverigg) medicines in possession policy states that
propranolol is deemed an ‘amber drug’ which means that there is a risk associated
with the drug but that it can be held in possession with the appropriate risk
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assessment. However, a new MIPRA was not completed when Mr Blake was
prescribed propranolol so he was able to have one month’s supply of his prescribed
drugs in his cell. We make the following recommendation in line with the clinical
review:
The Head of Healthcare at HMP Haverigg should ensure that:
• information relating to incidents of self-harm by overdose reported as part of the
medicine in-possession risk assessment should be checked against the medical
records to ensure accuracy; and
• all prescribers are aware of Spectrum Community Health CIC’s medicines in
possession policy in relation to propranolol.
Clinical care
114. The clinical reviewer found that the majority of the clinical care Mr Blake received at
Haverigg was of a good standard and was equivalent to that which he could have
expected to receive in the community. The clinical reviewer pointed out a number of
areas of good practice which included the range of therapeutic interventions offered
by the mental health/Improving Access to Psychological Therapies (IAPT) service at
Haverigg.
115. The clinical reviewer identified that healthcare staff had not followed the policy on
medicines in possession in relation to completing the MIPRA and prescribing
propranolol. The clinical reviewer has made a recommendation about medicines in
possession which the Head of Healthcare at HMP Risley (Mr Blake’s former prison)
will need to address.
Governor to note
116. Although Mr Blake died at 8.20pm on 28 April, the prison asked the police to break
the news of his death to his father. While we accept that Mr Blake’s father lived
some distance from Haverigg, national guidance stipulates that assistance breaking
the news of a death should first be sought from a prison geographically nearer to
the next of kin. No attempt was made to ask a family liaison officer from another
prison to visit Mr Blake’s next of kin to inform them of his death and the police
confirmed they had done so on the morning of 29 April. Mr Blake’s father asked why
he had not been informed sooner. The Governor will want to consider the learning
from this case.
Good practice
Emergency response
117. The body-worn video camera footage shows that the officers and the prisoner who
attended to Mr Blake did so with diligence and compassion.
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Family support
118. On 10 May 2024, an officer contacted Mr Blake’s family to offer support as they
approached the anniversary of his death.
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