Report into drug death of Doncaster serial offender two days after release from prison

In 2017 Clifton, from Cross Bank, Balby, was jailed for six years for burglary offences.

He had many previous convictions for theft, burglary and other serious offences, usually linked to his lifelong substance misuse.

He died, aged 43, of mixed drug toxicity on 25 June 2022 following his release from HMP Lindholme on 23 June 2022.

The Ombudsman Adrian Usher’s report stated: “Mr Clifton was recalled to prison on 26 August 2020, for committing a further offence while on licence. He had a long history of substance use and an extensive offending history, which was predominantly linked to his substance misuse.

"Mr Clifton was dependent on heroin and cocaine and when he returned to prison, he was highly motivated to engage with the Substance Misuse Team. He completed a methadone and alcohol detoxification programme and was prescribed mirtazapine for low mood and difficulties sleeping.

"Mr Clifton’s recall was reviewed, and the Parole Board directed his re-release. On 23 June 2022, Mr Clifton was released to CAS3 accommodation (for people leaving prison who would otherwise be homeless) in his local area. He was also working with a community housing service, Nacro, to secure more permanent accommodation.

"He had additional licence conditions which required him to engage with the community substance misuse team, Aspire, and comply with drug testing.

“An initial appointment with Aspire was arranged for the day after his release. Mr Clifton was offered naloxone for his release, which he refused, and a number of other opioid substitution treatments were discussed and offered to him.

"However, Mr Clifton’s preferred option was not available in his release area. Mr Clifton was released with a supply of mirtazapine, but without opioid substitution treatment.

"A duty officer at the probation office met with Mr Clifton for his initial appointment on 23 June.

“On 27 June, Mr Clifton’s sister informed his Community Offender Manager (COM) that Mr Clifton had died on 25 June.

“We did not find any issues of concern and identified good practice by the substance misuse worker at Lindholme.”

He went on: “At 8.35pm on 25 June, an unknown female called the ambulance service to report a male struggling to breathe, gurgling, and choking. An ambulance arrived at the address and found drug paraphernalia and discarded needles.

"Mr Clifton was taken to hospital by emergency ambulance and went into cardiac arrest. At 10.38pm, it was confirmed that Mr Clifton had died. Paramedics who attended the scene believed that Mr Clifton might have been taking drugs with two occupants immediately prior to his death.

“The post-mortem report concluded that Mr Clifton died of mixed drug toxicity.

“Toxicology tests showed that Mr Clifton had used cocaine, benzoylecgonine, mirtazapine, morphine, codeine, pregabalin, bromazolam and etizolam. The toxicology report said that the time Mr Clifton had spent in prison custody, might have led to a loss of tolerance to these various drugs leading to the combined toxicity from morphine (opiate), along with pregabalin, and the benzodiazepines.

“The report also noted that Mr Clifton had also used of cocaine and that this potentially could have created the risk of sudden death from mixed drug toxicity.”

He concluded: “The substance misuse worker recognised the risk of potential overdose and made extensive and commendable efforts to explore and encourage opioid substitution treatments, liaising with others to explore alternatives. Mr Clifton left prison without a prescription for opioid substitution therapy by his own choice. The substance misuse worker offered Mr Clifton naloxone on several occasions prior to his release,

however he refused this.”

The Ombudsman publish their reports only after an inquest into a death in custody is concluded.