Toni Campbell

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Independent investigation into
the death of Ms Toni Campbell,
on 6 August 2024 following her
release from HMP Bronzefield
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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visit nationalarchives.gov.uk/doc/open-government-licence/version/3
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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 investigated 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. Ms Toni Campbell died from the inhalation of a volatile substance (butane) on 6
August 2024, following her release from HMP Bronzefield on 31 July 2024. She was
39 years old. We offer our condolences to those who knew her.
5. Although Ms Campbell had a history of drug use, she was not given harm reduction
advice before her release from Bronzefield. We therefore make the following
recommendation:
The Head of Healthcare and the Substance Misuse Service Lead should
ensure that prisoners with a history of substance misuse are offered harm
reduction advice before their release.
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The Investigation Process
6. HMPPS notified us of Ms Campbell’s death on 21 October 2024.
7. The PPO investigator obtained copies of relevant extracts from Ms Campbell’s
prison and probation records.
8. We informed HM Coroner for Essex of the investigation. She 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 Ms Campbell’s next of kin, her mother, to
explain the investigation and to ask if she had any matters she wanted us to
consider. She did not respond to our letter.
10. 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.
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Background Information
HMP Bronzefield
11. HMP Bronzefield is a women’s prison which holds convicted and remanded female
prisoners. It is managed by Sodexo and the healthcare provider is Central and
Northwest London NHS Foundation Trust (CNWL). The integrated substance
misuse service is subcontracted to The Forward Trust.
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
appropriate. Post-release, the Probation Service supervises people throughout their
licence period and post-sentence supervision.
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Key Events
Background
13. On 3 May 2024, Ms Toni Campbell was convicted of assault and was sentenced to
five months in prison. She was sent to HMP Peterborough.
14. Ms Campbell had a history of cocaine and benzodiazepine misuse. Before she was
admitted to Peterborough, she had been homeless since December 2023, having
been evicted from her accommodation.
Preparation for release from HMP Peterborough
15. On 3 May, a nurse completed an initial health screen in reception for Ms Campbell.
She disclosed a history of cocaine and benzodiazepine misuse but denied currently
taking illicit substances. He completed an alcohol assessment with Ms Campbell
and referred her to the substance misuse team.
16. On 7 May, the Resettlement Team saw Ms Campbell. She told them that she used
crack cocaine occasionally and considered herself a binge drinker. She said she
had been working with the community drug and alcohol recovery team.
17. On 13 May, the substance misuse team saw Ms Campbell. She told them she
mainly used alcohol in the community and that she wanted an appointment with the
community service on release so she could continue support. The substance
misuse team gave Ms Campbell harm reduction advice about the signs of overdose
and what to do in the event of an overdose.
18. It is recorded in Ms Campbell’s medical records that naloxone training was not
needed. The Operations Manager for the substance misuse service told us that she
was unable to confirm why not as Ms Campbell’s recovery worker had left
Peterborough. She said that alcohol-dependent patients were given the option to
have naloxone training but it was not always needed.
19. On 14 May, the substance misuse team referred Ms Campbell to the community
drug and alcohol recovery team.
20. On 3 June, Ms Campbell’s community offender manager (COM) completed a
Commissioned Rehabilitative Service (CRS) referral for housing and a referral to
the local authority under the legal duty to refer those at risk of homelessness. She
also completed a referral to approved premises and to HMPPS’ Community
Accommodation Service Tier 3 (CAS3, a service offering temporary accommodation
of up to 84 nights to adult prison leavers at risk of homelessness).
21. On 14 June, Ms Campbell was accepted at an approved premises (AP) in
Battersea.
22. On 11 July, Ms Campbell was released from Peterborough to the AP, where she
received an induction and was informed of the AP rules, curfew and her licence
conditions which included drug testing.
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23. On 12 July, Ms Campbell attended a probation induction by video call. It is recorded
that Ms Campbell’s behaviour was unacceptable during this appointment and the
AP worker also said her behaviour had been challenging to AP staff. AP staff had
tried to complete breathalysing tests for Ms Campbell on four occasions but she
jeopardised the tests by not blowing enough. Probation issued a licence compliance
letter to Ms Campbell for not complying with her induction.
Recall to HMP Bronzefield
24. On 18 July, Ms Campbell was recalled to HMP Bronzefield for 14 days for
contacting her ex-partner in breach of her licence. A nurse completed her initial
health screen in reception, and she reported that she had not previously used drugs
and never drank alcohol. Ms Campbell tested negative for drugs. The substance
misuse team at Peterborough told us that when Ms Campbell was recalled to
Bronzefield, the prison’s substance misuse service would have needed to assess
and re-refer her to the community substance misuse service. However, as Ms
Campbell did not disclose any drug use and she tested negative for drugs, this did
not happen.
25. On 19 July, the substance misuse team saw Ms Campbell to offer their support but
she declined their services and signed a disclaimer, stating that she did not need
their support. The substance misuse service manager told us that although Ms
Campbell was offered naloxone, she was not given harm reduction advice.
26. The COM contacted CAS3 to ask if she needed to complete another referral as Ms
Campbell had been recalled. She told us that her CRS and local authority
accommodation referrals remained open as Ms Campbell’s recall to prison was only
for two weeks. She submitted further referrals to various APs, but Ms Campbell was
rejected at three sites as there was insufficient capacity.
27. On 22 July, the COM completed a referral to CAS3.
28. On 26 July, a CAS3 placement was agreed in Southend-on-Sea, but this was
cancelled the following day due to Ms Campbell’s risk level.
29. On 30 July, a CAS3 placement was agreed in Bedford.
Release from HMP Bronzefield
30. On 31 July, Ms Campbell was released from HMP Bronzefield at 10.30am. She was
given a supply of discharge medication but refused to sign a copy of her licence at
the prison. Ms Campbell failed to attend her probation induction at 2.30pm. Due to
this, she did not find out her CAS3 address and therefore remained homeless. The
COM asked for Ms Campbell to be recalled to prison, as homelessness was likely
to increase her risk of serious harm.
31. At approximately 6.00pm, Ms Campbell attended the probation office. A Probation
Officer tried to call the CAS3 accommodation, but they did not answer, so she
asked Ms Campbell to return to the office at 10.00am the following morning to see if
the accommodation was still available. The Probation Officer told Ms Campbell that
the CAS3 accommodation would not be available until the morning and advised her
to contact the council. It is recorded that Ms Campbell then became verbally
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abusive. Probation initiated a fixed term recall due to Ms Campbell’s behaviour and
her failing to attend her initial appointment.
32. On 1 August, the CRS and probation staff tried to contact Ms Campbell but they
were both unable to reach her. The CAS3 booking was cancelled due to her failing
to arrive and being recalled into custody. Ms Campbell’s whereabouts were
unknown from this date.
33. The COM told us that Ms Campbell had engaged with substance misuse services
and alcoholics anonymous sporadically over the years, but she never engaged for
long enough to complete any meaningful long-term work. She said that if Ms
Campbell had moved into the CAS3 accommodation as planned, she would have
referred her to the substance misuse service in that area. She also told us that this
would usually have been discussed at a second appointment when detailed
information is gathered for the purpose of risk and needs assessment.
Circumstances of Ms Campbell’s death
34. On 7 August, probation staff received an email from the community mental health
service, stating that Ms Campbell’s ex-partner had told them that she had died. It
was discovered that emergency services were called to an address at
approximately 3.00pm the previous day and the paramedics pronounced life extinct.
Post-mortem report
35. The post-mortem report concluded that Ms Campbell died from the inhalation of a
volatile substance (butane). She was found holding a butane gas cannister. The
post-mortem toxicology results and post-mortem report identified the presence of
cocaine, alcohol and heroin in Ms Campbell’s system. There was also evidence of
naloxone (a medication used to reverse an opioid overdose) administered in the
hours before her death.
36. The post-mortem report also noted that the risk of toxic effects may be increased in
individuals with reduced tolerance to morphine and related compounds (for
example, following a period of abstinence).
37. At an inquest held on 14 August 2025, the Coroner concluded that Ms Campbell’s
death was drug related.
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Findings
38. While Ms Campbell was at HMP Peterborough, she engaged with the prison’s
substance misuse team and was referred to the community service. During her
initial health screen in reception at HMP Bronzefield, Ms Campbell reported that she
had not previously used drugs and she tested negative for drugs. When the
substance misuse team initially saw her, she declined their support. This meant that
she was not re-referred to community substance misuse services.
39. As Ms Campbell’s accommodation was not in place until the day before her release,
the COM did not refer her to community substance misuse services in preparation
for her release. The COM said that once Ms Campbell moved into the CAS3
property assigned to her, she would have completed the referral. Ms Campbell
unfortunately did not attend her probation induction appointment on the day of her
release and therefore did not find out the CAS3 address.
Harm reduction advice
40. The substance misuse team saw Ms Campbell on 19 July and offered her naloxone
but she declined it. However, she was not given any harm reduction advice about
the risk of overdose or her reduced tolerance to drugs. The substance misuse
service manager told us that this was because she declined their service offer.
41. Medical records also indicate that Ms Campbell was not given harm reduction
advice when healthcare staff saw her before her release on 31 July. We appreciate
that Ms Campbell was given harm reduction advice on 13 May while at HMP
Peterborough. However, staff at Bronzefield gave no indication that they were
aware of this, and would have only known if they went through Ms Campbell’s
medical records.
42. While we appreciate that Ms Campbell signed a disclaimer stating that she did not
want the substance misuse service’s support, she should have been given harm
reduction advice, particularly as staff recognised her substance misuse history and
had offered her naloxone. In light of this, we make the following recommendation:
The Head of Healthcare and the Substance Misuse Service Lead should
ensure that prisoners with a history of substance misuse are offered harm
reduction advice before their release.
Good practice
43. There are particular complexities and challenges faced by HMPPS and their
stakeholders in finding post-release accommodation and referring prison leavers to
services when they have received very short sentences or served very short recall
periods. Although Ms Campbell was only recalled to prison for 14 days, the COM
managed to secure accommodation for her release. It is unfortunately not standard
practice for accommodation to be arranged and confirmed in such a short
timescale. Ultimately, however, Ms Campbell did not benefit from the CAS3
accommodation provision as she did not attend her probation appointment on
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release and therefore did not obtain the address for her temporary accommodation.
Adrian Usher
Prisons and Probation Ombudsman June 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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