Man with ‘sustained substance abuse and personality issues’ died days after leaving HMP Leeds

Stephen Silvester died aged 37 on September 4 last year following his release from the prison in Armley on August 26.

A report into his death by the Prisons and Probation Ombudsman found that there had been no handover between the prison’s mental health team and community mental health services when Mr Silvester was released.

It has been recommended that the prison ensures that discussions are made with community mental health teams before prisoners’ release and that they share relevant risk information with the probation service.

The report states that Mr Silvester was jailed in April last year for assaulting an emergency working and possession of a bladed weapon.

Upon arrival he told staff that he “heard voices telling him to self-harm” and so he was placed on suicide and self-harm prevention procedures (known as ACCT) and recommended for a mental health assessment.

Mr Silvester subsequently had meetings with a psychiatrist and prison chaplain, as well as regular one-to-one sessions with a mental health nurse.

It was considered whether the voices he heard and hallucinations he had were down to “sustained substance abuse and personality issues”. He was also prescribed medication that had a “positive effect” on his mental state and sleep pattern.

Mr Silvester also received support for alcohol misuse and told his support worker ahead of his release that he would need support from the community Drug And Alcohol Recovery Team (DART) once he was released.

An appointment was made for Mr Silvester with the Wakefield DART team after his release on August 26, at which point he told a nurse he had “no thoughts of suicide or self-harm”.

When Mr Silvester didn’t attend a probation meeting on September 5 and the Community Offender Manager and Mr Silvester’s housing officer were both unable to contact him.

On the same day a neighbour reported a “foul odour” coming from Mr Silvester’s flat. Police gained entry and found his body in a “state of decomposition”, with a pathologist estimating that he had died the previous day.

A pathologist’s report gave Mr Silvester’s death as “unascertained” as they “could not find any obvious evidence of a cause of death”.

The report reads: “He could not exclude the possibility of Sudden Adult Death Syndrome. Also, as a bottle of butane gas was found next to Mr Silvester’s body, the pathologist could not rule out gas inhalation as the cause of death. He noted however, that there was no way to test for this during the post-mortem examination.”

An inquest gave an open conclusion, with the coroner saying that the circumstances and “significance of the butane cylinder” were “unknown”.

In its findings, the ombudsman said that Mr Silvester was “well supported” by the mental health and substance misuse services but that he “should have been given the details of his community mental health team and an appointment arranged before his release from prison”.

The ombudsman also found that documentation from the mental health team in prison was not shared with the Community Offender Manager, which was against the prison’s policy guidance.