A released Bristol prisoner should have had better healthcare and support before he fatally relapsed with drugs at a hotel in the city centre days after his release. Christopher Knight was released from HMP Portland in Dorset on October 5, 2022 after serving 11 months of his sentence for assault, racially-aggravated public disorder and possession of an offensive weapon.
The 28-year-old was found temporary accommodation at the Bristol Marriott Hotel despite his concerns he would be homeless and admitted he could relapse into consuming drugs again. On October 7, 2022, hotel staff found him dead on the floor of his room, with drug paraphernalia and medication discovered in the room.
Due to concerns surrounding the former inmate’s death, the Prisons and Probation Ombudsman launched an investigation to find any lessons to be learned. Oxleas NHS Foundation Trust, which provides healthcare at HMP Portland, has been told to create a pre-release care treatment plan for prisoners and to highlight any abnormal test results with a community GP or the prisoner.
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Mr Knight’s mother told the ombudsman that she was concerned her son was released homeless when he had ADHD, poor mental health and was a recovering heroin addict. She said that this would have contributed to his state of mind. The report also stated Mr Knight had a history of bipolar affective disorder, mixed personality disorder, depression and self-harm.
Mr Knight had regularly used crack cocaine and cannabis prior to imprisonment and was prescribed methadone. While the methadone dosage was carefully eased, Mr Knight admitted he was under the influence of illicit substances in May 2022 and stated he used psychoactive substances 'because he was fed up with being in prison'.
Mr Knight was initially unhappy about the mental health support at HMP Portland but received better care and guidance. For several months, Mr Knight admitted he was anxious because he had nowhere to live following his release.
On September 15, 2022, Mr Knight saw a healthcare discharge flow coordinator and admitted he was struggling with his mental health and said that, unless he was released homeless, he was confident that he would not relapse and take drugs. Mr Knight continued to decline naloxone, a drug designed to rapidly reverse opioid overdose.
As discussions about his accommodation post-release continued, a nurse told Mr Knight about the number of drug-related deaths in Bristol and gave him harm minimisation advice. The report notes Mr Knight was 'quite dismissive of the information given and the offer of naloxone'. He later stated he 'would not use drugs again' and declined opioid replacement therapy and naloxone.
On September 28, a GP at HMP Portland reviewed blood tests taken for psychotropic medication and found them to be abnormal. He passed the results to the mental health team but investigations found there was no evidence that this was picked up by this team before Mr Knight was released.
Mr Knight’s social worker secured him the hotel room as a temporary measure and later accommodation in supported living, which he was due to move into on October 10, 2022. On the day he was discovered dead, a social work apprentice tried to contact Mr Knight several times to let him know the room booking at Bristol Marriott Hotel had been extended until October 10, but the calls went to answerphone. Mr Knight had also missed his probation appointment.
Hotel staff went to Mr Knight’s room to check on him and found him lying on the floor at 3.30pm on October 7, 2022. Police officers searched the room and found drug paraphernalia.
Hotel staff said that Mr Knight’s room key was last used at 1.55pm on October 6, 2022. A post-mortem established Mr Knight died from acute morphine toxicity. Ischaemic heart disease secondary to coronary artery atheroma, narrowing of the coronary arteries caused by a build-up of plaque, contributed to but did not cause his death.
Toxicology tests showed that Mr Knight had morphine in his blood indicating that he had taken either morphine or heroin, as well as other drugs. An inquest at Avon Coroner's Court concluded his death was drug-related.
A clinical reviewer believed the pre-release planning and onward support in the community for Mr Knight’s neurodevelopmental needs was 'lacking' and noted he needed a referral to neurodevelopmental services. The clinical reviewer added abnormal electrolyte and liver blood results would have been passed to a community GP, but he was not registered with one. Therefore Mr Knight should have been given them to arrange a follow-up appointment with a GP.
The report concluded the head of healthcare should ensure that there is a pre-release care planning process for prisoners known to healthcare, which should include actions with timescales and an identified lead, with onward referrals to community services. A second recommendation stated the head of healthcare should ensure that when a prisoner has abnormal test results close to their release date, they should be passed to the community GP or given to the prisoner for them to make a medical appointment.
A spokesman for Oxleas NHS Foundation Trust said: "Oxleas NHS Foundation Trust has received the Prisons and Probation Ombudsman report and we are fully aware of the recommendations made. We have taken immediate action to implement the recommendations highlighted, including sharing information with prisoners before release about onward referrals to community services and informing the prisoner’s community GP of any abnormal test results.
"As always, we look to continue to learn from any recommendations made to us and offer our condolences to Mr Knight’s family and friends."
