Tyrone Bwerinofa

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Independent investigation into
the death of Mr Tyrone Bwerinofa,
on 8 June 2023, following his
release from HMP Wayland
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. 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. Mr Tyrone Bwerinofa died from intoxication by multiple agents on 8 June 2023
following his release from HMP Wayland three days earlier. He was 25 years old.
We offer our condolences to those who knew him.
5. Despite Mr Bwerinofa’s history of substance misuse, staff did not offer naloxone nor
harm reduction advice to Mr Bwerinofa on his release from Wayland in line with
policy.
Recommendations
• The Head of Healthcare should ensure that all prison leavers with a history of
substance misuse are offered naloxone and harm reduction advice on release in
line with Practice Plus Group’s policy.
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The Investigation Process
6. HMPPS notified us of Mr Bwerinofa’s death on 26 June 2024.
7. The PPO investigator obtained copies of relevant extracts from Mr Bwerinofa’s
prison and probation records.
8. We informed HM Coroner for Essex 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 Bwerinofa’s next of kin, his mother, to
explain the investigation and to ask if she had any matters she wanted us to
consider. She had the following questions and comments:
• Why was Mr Bwerinofa in prison?
• The Probation Service arranged transport for Mr Bwerinofa to take him to his
accommodation when he was released from HMP Wayland. Why was this
cancelled?
• Why was Mr Bwerinofa accommodated in Kent but expected to attend probation
appointments in Southend?
• Was he being treated for substance misuse while in prison?
• Was he on any medication while in prison?
• Why was Mr Bwerinofa not housed near the open prison where he had lived?
• Was Mr Bwerinofa offered any prescribed medication to substitute drug use on
release from prison? If not, was he told of the dangers of taking multiple drugs?
• On the day Mr Bwerinofa died, his mother said she received a text from the
Probation Service as they thought it was Mr Bwerinofa’s phone number. She
said that Mr Bwerinofa’s appointment had been cancelled because another
person had become a priority. She felt this demonstrated that the Probation
Service did not consider her son was important enough.
• Mr Bwerinofa’s mother said that she texted the Probation Service and told them
they had the wrong number. However, on 12 June, when Mr Bwerinofa had
been dead for four days, the Probation Service sent her another text. Did they
not know where Mr Bwerinofa was and that he had died before she told them?
• Why has the Probation Service not contacted her since Mr Bwerinofa’s death to
offer their condolences?
We have addressed her concerns in our report.
10. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
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11. Mr Bwerinofa’s family received a copy of the draft report. They raised a number of
issues/questions that do not impact on the factual accuracy of this report and have
been addressed through separate correspondence.
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Background Information
HMP Wayland
12. HMP Wayland is a category C training prison which holds convicted male prisoners.
The healthcare provider at Wayland is Practice Plus Group.
Probation Service
13. 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 they 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.
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Key Events
Background
14. On 20 January 2023, Mr Tyrone Bwerinofa was convicted of assault and was
sentenced to nine months in prison. He was sent to HMP Chelmsford. He had a
history of misusing heroin, crack cocaine, cocaine and cannabis.
Pre-release planning
15. On 17 March 2023, Mr Bwerinofa was transferred from Chelmsford to HMP
Wayland. A nurse completed his initial health screen and he reported that he did not
have any problems with drugs.
16. On 20 March, the substance misuse team saw Mr Bwerinofa. He told them that he
did not want to engage with them as his substance misuse was not problematic.
17. On 26 April, Mr Bwerinofa’s community offender manager (COM) referred him to
HMPPS’ Community Accommodation Service Tier 3 (CAS3, a service open to adult
prison leavers who are at risk of homelessness on release from prison. The service
provides access to up to 84 days of accommodation).
18. On 28 April, Mr Bwerinofa was transferred to HMP Hollesley Bay, a category D
open prison, after he was assessed as suitable for open conditions.
19. On 4 May, Hollesley Bay received a Section 41 production order from Essex Police
regarding further charges for Mr Bwerinofa, namely driving offences. Following a
multidisciplinary assessment, Mr Bwerinofa was deemed no longer suitable to
remain in open conditions. He was therefore transferred back to Wayland. A nurse
completed Mr Bwerinofa’s reception screen, and it was recorded that he had a
history of heroin, crack cocaine, cocaine and cannabis misuse.
20. On 9 May, the substance misuse service saw Mr Bwerinofa. He declined
engagement with the service and said he did not use any substances. The
substance misuse team told us that Mr Bwerinofa would have been offered harm
reduction information at this point.
21. On 15 May, the COM referred Mr Bwerinofa to the local authority for them to help
him find accommodation under the statutory duty to refer those at risk of
homelessness.
22. On 22 May, the COM completed a housing referral to the Ministry of Justice’s
Commissioned Rehabilitative Services (CRS, a probation service which aims to
help break the cycle of reoffending by providing guidance, support and practical
help to tackle the barriers to rehabilitation).
23. On 24 May, Mr Bwerinofa had an appointment with CRS.
24. On 25 May, CAS3 accommodation in Essex was offered to Mr Bwerinofa.
25. On 30 May, a GP operating at Wayland prescribed Mr Bwerinofa his medications
for release (loratadine for hayfever and amitriptyline for neuropathic pain in his leg)
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so that he had continuity of the medications he had been taking in prison. Mr
Bwerinofa was not prescribed any substance misuse substitution medication while
in prison or on release.
26. On 31 May, the COM conducted further checks on the CAS3 accommodation.
27. On 1 June, police checks were completed on the CAS3 property, and it was
deemed suitable for Mr Bwerinofa. Mr Bwerinofa’s COM at the time of his death
confirmed that the property was based in Grays, Essex and no referrals were
completed for a property in Kent. He told us that Mr Bwerinofa was not housed near
Hollesley Bay as CAS3 accommodation is dependent on availability and is not
geographically assigned. The CAS3 referral form completed also shows that Mr
Bwerinofa’s preferred area was Essex.
28. On 2 June, Mr Bwerinofa’s COM changed. A Senior Probation Officer (SPO)
decided that a probation practitioner would complete Mr Bwerinofa’s induction at
Laindon probation office in Basildon to ensure he could find it easily before going to
his CAS3 address. It was noted that he was using class A substances daily before
going to prison.
Post-release management/release from HMP Wayland
29. On 5 June, Mr Bwerinofa was released from Wayland. He was not offered naloxone
on release. He was given a travel warrant to Basildon so he could attend Laindon
probation office. Mr Bwerinofa attended an induction with the probation practitioner,
but arrived one and a half hours late, so they were unable to complete the full
induction pack. She went through Mr Bwerinofa’s licence with him, and he agreed to
the conditions which included that he should attend appointments to address his
drug dependency and that he would be subject to drug testing. She gave Mr
Bwerinofa another travel warrant and directions to the CAS3 property. The new
COM told us that there was nothing further documented about his travel
arrangements, and it was standard practice for travel warrants to be issued for rail
fares.
30. On 7 June, Mr Bwerinofa attended an appointment with his COM, and they
completed the rest of the induction pack. The COM told us that Mr Bwerinofa stated
that he was currently clean of substances and intended to remain so. He did not
therefore refer Mr Bwerinofa to community substance misuse services. He said that
he intended to test Mr Bwerinofa for drugs at his next appointment (scheduled for
13 June), and if the outcome was positive, a referral would have been made to
substance misuse services at this point.
31. On 8 June, the COM emailed the community substance misuse service in Essex to
inform them that Mr Bwerinofa had been released and may need their support. He
told us that Mr Bwerinofa was known to them before he went to prison, so he only
needed to visit during their drop-in hours to reinitiate support.
32. The COM texted Ms Bwerinofa’s mother (as he thought in error that it was Mr
Bwerinofa’s phone number) to explain that his appointment had been moved from
12 noon to 1.00pm on 13 June as another person on probation had become a
priority due to urgent safeguarding concerns. He told us that there are instances
where probation staff have to react to situations as they occur and make
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adjustments based on urgent priority. He said that the appointment with Mr
Bwerinofa was not cancelled but pushed back one hour. It is not clear from the
records whether Mr Bwerinofa was aware that his appointment had been
rescheduled.
33. On 12 June, the COM sent another text to Mr Bwerinofa’s mother, which was again
meant for Mr Bwerinofa. He told us that this was a human error as he had updated
probation records when Mr Bwerinofa’s mother had replied to his first text to explain
but had not updated his own phone.
Circumstances of Mr Bwerinofa’s death
34. That day, the COM received a phone call from Mr Bwerinofa’s mother, who told him
that Mr Bwerinofa had died at a friend’s house. He told us that he was not aware of
Mr Bwerinofa’s death before this phone call. He said that he recalled offering his
condolences to Mr Bwerinofa’s mother during this phone call. He told us that it was
not standard practice for probation staff to contact family members as they may not
be aware of the family dynamics and any associated risks.
35. Essex police confirmed that the Ambulance Service had called them at around
5.00pm on 8 June after a friend had found Mr Bwerinofa unresponsive and called
emergency services.
Post-mortem report
36. The post-mortem report concluded that Mr Bwerinofa died from intoxication from
multiple agents. The toxicology results and post-mortem report identified the
presence of cannabinoids, morphine and related products, cocaine, amitriptyline,
pregabalin, zopiclone and a low level of alcohol.
37. The post-mortem report also noted that it was not insignificant that Mr Bwerinofa
had only recently been released from prison and might have lost some of his
tolerance to the noxious effects of these illicit agents - tolerance which can build up
with repeated use.
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Findings
38. During his reception screen at Wayland on 4 May 2023, Mr Bwerinofa disclosed
that he had a history of crack cocaine, heroin, cocaine and cannabis misuse. He
was offered a referral to the substance misuse team on both admissions to
Wayland but declined twice. Although there is no record of it, the substance misuse
team told us that Mr Bwerinofa would have been offered naloxone when they
initially saw him.
39. On the day of his release, Mr Bwerinofa was not offered a naloxone kit. The
substance misuse team told us that this was because naloxone is only offered to
those who engage with the substance misuse service and are on their caseload.
The pharmacist at Wayland told us that the healthcare team are responsible for
offering naloxone to prison leavers on release, and that the substance misuse team
confirms their names from their caseload and offers them training on how to use
naloxone and harm minimisation advice.
40. The substance misuse team and pharmacist told us that they do not have a local
naloxone policy, but the pharmacist provided Practice Plus Group’s policy which
states that a take-home supply of naloxone should be considered for all patients
with a history of opiate misuse. It also states that harm reduction interventions
should be in place for patients who have a history of drug misuse and should form
part of the take-home naloxone pathway.
41. In line with this policy, Mr Bwerinofa should have been offered naloxone and harm
reduction advice on release. This did not happen, and we make the following
recommendation:
The Head of Healthcare should ensure that all prison leavers with a history of
substance misuse are offered naloxone and harm reduction advice on release
in line with Practice Plus Group’s policy.
Inquest
42. At the inquest into Mr Bwerinofa’s death, which was held on 26 September 2023,
the Coroner concluded that his death was drug-related.
Adrian Usher
Prisons and Probation Ombudsman March 2025
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