The family of a woman who died in a Nottingham hostel have today spoken of their grief after the conclusion of her inquest.
Stacey MacDonald, 43, died of a drug overdose on 10 September 2021, following her release from HMP Peterborough just three days earlier.
Described by witnesses at the hearing as a kind, polite and determined woman who was ‘always looking and hoping for a clean start’, Stacey had been working hard on her recovery from substance misuse and had actively engaged with what is known as a rapid detox programme, whilst in prison.
However, at an inquest into her death which concluded last week in Nottingham Coroner’s Court, Area Coroner, Laurinda Bower, heard evidence of multiple failings in the care that Stacey had received both during her time in prison, and further to her release before her tragic death.
The coroner’s conclusion said Stacey’s death had been drug related, and while none of the failings directly contributed to her death she did say that Stacey’s substance misuse keyworker in prison had identified Stacey’s risk of accidental overdose and risk of death as being absolutely huge and high upon release.
The coroner’s conclusion also said that her release to Nacro BASS accommodation was wholly inappropriate to manage Stacey’s high risk of accidental overdose and that she ought never to have bene released there. This included insufficient information being provided about her substance misuse in her referral application for Nacro BASS accommodation.
The coroner found that had the prison release referral form been completed accurately, including an accurate description of Stacey’s substance misuse and mental health history, she would not have been released to that accommodation, which the coroner described as ‘inappropriate’ to meet and manage Stacey’s needs.
The evidence also highlighted that Stacey had been released without the appropriate prescriptions and had therefore not been given access to the necessary community rehab services needed to help her manage her addiction recovery.
Her family say that no matter how determined she had been to turn her life around, she had ‘fallen victim’ to a cycle that affects so many drug addicts of ‘imprisonment, rapid detox, release, and overdose’.
Speaking on the family’s behalf their lawyer, Aimee Brackfield from Simpson Millar, referred the case by the charity INQUEST, said that they had been somewhat encouraged by what they heard during the inquest about changes made to systems at HMP Peterborough.
This included the introduction of a women-specific drug recovery strategy, and a process which ensures that referral forms to accommodation providers are quality assured by a Senior Probation Officer to make sure it isn’t missing key information.
However, she added that it was essential that the lessons learnt were shared across other prison services to prevent further tragedies, and that more emphasis is placed on finding appropriate accommodation for women leaving prison.
"Stacey’s family continue to come to terms with their loss, and they are understandably heartbroken to hear of the multiple failings in the care that she received prior and after her release."
Associate Public Law Solicitor
Aimee added that further to the inquest, the family feel more strongly than ever that had the referral form regarding Stacey’s release been accurately and appropriately completed, she would not have been released from prison to Nacro BASS which they believe contributed to her sad death.
The family also echoed the concerns identified in an investigation carried out by the Prisons and Probation Ombudsman following Stacey’s death, which referred to a recommendation made by HM Inspectorate of Prisons in 2017 and 2021 about accommodation for women released from prison, and which said that ‘Ms MacDonald’s placement in a hostel was another example of a woman with complex needs being placed in short term accommodation’.
Stacey’s sister, Heather, said: “I would like to take this opportunity to encourage families that have lost loved ones in similar circumstances to engage with the inquest process if they can find the strength to do so.
“Although it won’t bring Stacey back and as difficult and heartbreaking as it was at times, the investigation was thorough and seems to have brought about some direct changes within the prison and probation systems that may just help to ensure the circumstances around the way future prisoners are released from prisons and their placements into unsuitable accommodation due to lack of information sharing can be prevented.
“Although there are elements of the coroner’s findings I don’t and will not accept, the Inquest process afforded me the answers to many unanswered questions I had regarding the immediate circumstances of Stacey’s tragic death, answers that I hope will enable me to come to terms with the loss of my beautiful sister.
"I give a great amount of gratitude and respect to the charity INQUEST for their help in facilitating the legal help my family required to navigate the process, provided to us by Aimee Brackfield (Simpson Millar) and Harriet Short (One Pump Court Chambers) without their unwavering guidance and support the proceedings would have been overwhelming."
In March 2021, the Ministry of Justice pledged to invest £5 million of cross-Government funding over two years in community provision for women. This included working with local and national partners to develop a pilot for ‘residential women’s centres’ in at least five sites across England and Wales.
Aimee continued: “While the family have been encouraged to hear that changes have been made at HMP Peterborough in response to the investigation carried out further to Stacey’s death. Sadly for them, however, those changes are too little, and they come too late.
“They are now desperate that nothing like this happens to another family, and that through the lessons learnt here today that there is better multi-agency working and communication around releasing vulnerable women into the community.
“As the inquest has highlighted, at the time of Stacey’s death women who were at risk of relapse and overdose were simply released into a system setting them up to fail due to a lack of appropriate accommodation.
“The family are calling on the Minister for Justice to give assurances that the issues identified with regards appropriate accommodation for women leaving prison have been acted upon.”
In January 2023 the Prisons and Probation Ombudsman published a bulletin on their 12 month pilot investigating deaths within 14 days of release from prison. Available here. They found:
- During the 12-month pilot (6 September 2021 and 5 September 2022), the PPO investigate 48 deaths within 14 days after release from prison. 6 of those were women.
- Half of the deaths investigated were drug-related.
- They make some important recommendations in the report, including recommendations around Naltrexone: “HMPPS should consider how the issuing of naltrexone should work alongside the release process given the time needed to prescribe and monitor the medication.”
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