Thomas McMahon

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Thomas McMahon,
on 31 October 2023,
following his release from
HMP Nottingham
A report by the Prisons and Probation Ombudsman
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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. Since 6 September 2021, the PPO has been investigating post-release deaths that
occur within 14 days of the person’s release from prison.
3. 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.
4. Mr Thomas McMahon died of combined use of synthetic cannabinoids, morphine
and cocaine on 31 October 2023, following his release from HMP Nottingham on 20
October. He was 33 years old. I offer my condolences to those who knew him.
5. We note that there are wide regional differences in approach to and criteria for
distributing naloxone on release. However, we found that the current policy for
offering naloxone to prison leavers from HMP Nottingham relies too heavily on them
having engaged with the prison’s substance misuse team.
Recommendation
The Head of Healthcare should work in partnership with Nottingham
Healthcare NHS Foundation Trust, the regional Health and Justice Leads and
regional drug providers to satisfy themselves that the local policy on the offer
and issue of naloxone on release captures prison leavers with previous
opiate use and other relevant risk factors, not just those on the substance
misuse caseload.
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The Investigation Process
6. HMPPS notified us of Mr McMahon’s death on 19 April 2024.
7. The PPO investigator obtained copies of relevant extracts from Mr McMahon’s
prison and probation records.
8. We informed HM Coroner for Derbyshire of the investigation. They gave us the
results of the post-mortem examination. We have sent the Coroner a copy of this
report.
9. The Ombudsman’s office contacted Mr McMahon’s mother to explain the
investigation and to ask if she had any matters she wanted us to consider. She said
that she believed that Mr McMahon had sustained a head injury during a previous
sentence in prison which made him vulnerable, and he had mobility issues since
August 2023. She wanted to know why Mr McMahon was not released to the Derby
area or to her address. She also said that she asked probation staff about an
alcohol monitoring tag, but they said no such thing existed. We have addressed her
concerns in this report. Other questions have been addressed in separate
correspondence.
10. Mr McMahon’s family received a copy of the draft report. They did not make any
comments.
11. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
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Background Information
HMP Nottingham
12. HMP Nottingham is a resettlement and local prison serving the courts of
Nottinghamshire and Derbyshire. Healthcare for the prison is provided by
Nottinghamshire Healthcare NHS Foundation Trust.
Probation Service
13. The Probation Service work with all individuals subject to custodial and community
sentences. During a person’s imprisonment, they oversee their sentence plan to
assist in rehabilitation, as well as prepare reports to advise the Parole Board and
have links with local partnerships to whom, where appropriate, they refer people for
resettlement services. Post-release, the Probation Service supervise people
throughout their licence period and post-sentence supervision.
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Key Events
14. On 25 July 2023, Mr Thomas McMahon was convicted of assault on a police officer
and was sentenced to 24 weeks in prison. He was released from HMP Ranby on a
home detention curfew (HDC) conditional licence on 14 September 2023. He was
then recalled to HMP Nottingham for breaching his HDC on 25 September 2023. He
had a history of substance misuse and mental health problems.
Pre-release planning
15. On 25 September 2023, a nurse completed Mr McMahon’s reception screening,
and he was assessed as fit to keep and administer his medication himself. Mr
McMahon told the nurse that he had mental health problems, and he was referred
to the mental health team.
16. Mr McMahon’s history of opioid misuse was noted. He reported that he had
problems with drugs and had previously used many different types of drugs. A urine
sample was taken, which tested positive for cannabinoids and cocaine, and he was
moved to the stabilisation unit for substance misuse monitoring for five days. Mr
McMahon was offered but declined a referral to the substance misuse team.
17. The primary care clinical matron told us that Mr McMahon did not raise any
concerns about a head injury or mobility issues during his reception screen or
throughout his time at Nottingham. She said she expected that if staff observed an
issue, they would document it in the medical records. There is nothing recorded in
Mr McMahon’s medical records about either concern.
18. On 26 September, Mr McMahon’s Community Offender Manager (COM) completed
a Commissioned Rehabilitative Service (CRS) referral for housing to Nacro (an
accommodation advice service) and a referral to the local authority under the legal
duty to refer those at risk of homelessness.
19. On 1 October, a nurse completed a mental health assessment with Mr McMahon.
The nurse found no evidence of acute mental health concerns. Mr McMahon told
him that he was due to be released soon and that he would contact his GP for
further support if necessary.
20. On 4 October, the COM completed an assessment of Mr McMahon’s risks and
needs in the community following his release. She assessed that Mr McMahon
should engage with substance misuse support to reduce his risk of reoffending and
the risk he posed to himself. Mr McMahon’s Prison Offender Manager (POM)
contacted the COM about referring Mr McMahon to NHS Reconnect (a care after
custody service that seeks to improve the continuity of healthcare for people leaving
prison).
21. On 9 October, the mental health team discussed Mr McMahon’s mental state at a
multidisciplinary team (MDT) meeting, and they agreed to discharge him from their
care as no further treatment was appropriate.
22. That day, the COM completed a referral to HMPPS’ Community Accommodation
Service Tier 3. (CAS3, a service open to adult prison leavers who are at risk of
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homelessness on release from prison. The service provides access to up to 84
days of accommodation.)
23. On 10 October, the COM had a pre-release meeting with Mr McMahon. She told
him that he had an appointment with the Department for Work and Pensions on the
day of his release and that the police had offered to take him to his accommodation.
Nacro completed referrals to NHS Right Care and to various charities which
supported prison leavers, young people and homeless people.
24. On 19 October, Mr McMahon was accepted at a CAS3 accommodation in Derby
city centre. Probation staff told us that Mr McMahon’s mother’s property was
discussed for his previous HDC release in September but it was not approved
because his two children lived at the property and it was not deemed appropriate for
Mr McMahon to live there.
25. The COM looked into move-on accommodation and completed a referral to St
Andrews House, a community-based drug and alcohol support service. An
appointment was arranged with them for 3 November. The POM referred Mr
McMahon to NHS Reconnect.
26. On 20 October, Mr McMahon refused to collect his seven-day supply of medication.
The primary care clinical matron confirmed that Mr McMahon was released without
his medication because of this.
Post-release management/release from HMP Nottingham
27. On 20 October, Mr McMahon was released from Nottingham and attended his
induction with Probation. The COM went through Mr McMahon’s licence conditions
with him. These included that he was to attend appointments to address his drug
misuse and that he would need to wear an electronic tag to monitor his alcohol
intake. Mr McMahon consented to the CAS3 rules, and she told Mr McMahon to
attend another supervision appointment at the probation office on 26 October.
28. On 22 October, electronic monitoring services (EMS) attended Mr McMahon’s
CAS3 accommodation to fit his tag for alcohol monitoring but he was not there. The
COM received information that Mr McMahon had been staying at Safe Space,
instead of his CAS3 accommodation, and an ambulance had been called for him
the previous day after he presented with a head injury.
29. On 23 October, the COM issued a breach of licence notification to Mr McMahon
because he failed to comply with his tag as he had missed appointments with EMS
to have it fitted.
30. On 25 October, the manager at Safe Space emailed Probation and confirmed that
Mr McMahon was last seen there on 23 October, and he had presented as under
the influence since his release.
31. On 26 October, Mr McMahon failed to attend his planned appointment with
Probation. Probation staff had arranged for a Reconnect Support Officer to attend
this appointment. The COM phoned the CAS3 accommodation, and they told her
that a number of agencies were looking for Mr McMahon. They told her that there
was no evidence that Mr McMahon had stayed there since 20 October. As no-one
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knew where Mr McMahon was, he had not been in contact with Probation and he
had missed visits from EMS to fit his tag, she initiated a fixed term recall.
Circumstances of Mr McMahon’s death
32. On 31 October, a CAS3 support worker phoned Probation and told them that Mr
McMahon had died, and they had found his body at the accommodation. Probation
told us that Mr McMahon’s whereabouts were unknown up until this point.
Post-mortem report
33. The post-mortem report concluded that Mr McMahon died of combined use of
synthetic cannabinoids, morphine and cocaine. Mr McMahon also had depression
which did not cause but contributed to his death.
Inquest
34. At an inquest held on 28 October 2024, the Coroner concluded that Mr McMahon’s
death was drug related.
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Findings
35. Mr McMahon had a known history of opioid misuse and during his reception health
screen, he had reported current substance misuse. Although he was monitored in
the stabilisation unit following a positive test for cannabinoids and cocaine, he
declined a referral to the substance misuse team at HMP Nottingham.
36. On the day of his release, Mr McMahon was not given harm reduction information
or a naloxone kit. The substance misuse team told us that this was because he had
not engaged with their service and was not on their caseload.
37. The local naloxone policy at Nottingham states that it can be supplied to anyone in
the course of lawful drug treatment services. As Mr McMahon chose not to engage
with the service, he did not meet the policy’s criteria for a naloxone kit, even though
he had a history of substance misuse.
38. We appreciate that staff adhered to the local naloxone policy. There are wide
regional differences in approach to distributing naloxone on release across the
prison service and we cannot know whether it would have changed the outcome for
Mr McMahon, especially because he died from the effects of a combination of
substances. However, he had a number of risk factors, including previous opiate
use and mental health problems. He may therefore have benefitted from being
offered naloxone on release. We make the following recommendation:
The Head of Healthcare should work in partnership with Nottingham
Healthcare NHS Foundation Trust, the regional Health and Justice Leads and
regional drug providers to satisfy themselves that the local policy on the offer
and issue of naloxone on release captures prison leavers with previous
opiate use and other relevant risk factors, not just those on the substance
misuse caseload.
Good practice
39. The COM noted Mr McMahon’s history of drug misuse and appropriately referred
him to a community substance misuse service before his release, even though he
had declined substance misuse support in prison and did not raise any specific
concerns about substance misuse in their appointments.
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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