Communication failures at HMP Peterborough contributed to the death of 34-year-old Lee Chignell just days after he was released from custody, according to a watchdog report.
The Prisons and Probation Ombudsman report says Mr Chigwell, who died from drug toxicity, was discharged with the wrong licence details, without accommodation, and with important information not properly shared between prison, healthcare and probation staff.
Mr Chignell was released from HMP Peterborough on August 6, 2025, and died on August 12 after being found collapsed in a supermarket car park in Peterborough.
The post-mortem concluded he died from combined cocaine, methadone, olanzapine, mirtazapine, morphine and clonazepam toxicity, and the coroner later ruled the death drug-related.
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The Ombudsman said he had been wearing several layers of clothing, was hyperthermic, and died in hospital at 6.30pm after a cardiac arrest despite efforts by hospital staff to resuscitate him.
The report says Peterborough prison failed to ensure Mr Chignell was released with the correct licence, despite his community offender manager having provided the information in advance.
It also says the prison did not respond to emails from the community offender manager, which made release planning difficult.
The Ombudsman found there was no agreed practice in place for sharing information between healthcare staff, prison offender managers and probation staff.
Mr Chignell had been recalled to prison on July 11, 2025, after breaching licence conditions, having previously been released from HMP Peterborough on July 7.
During his time back in custody, he tested positive for several substances, was prescribed methadone, and told staff he wanted to live in Norwich after release.
However, the community offender manager was not told that, and housing referrals were instead made in areas where he had known connections.
In response to the Ombudsman’s recommendation, the prison said healthcare representatives will now attend relevant multi-disciplinary and pre-release meetings to improve communication and release planning.
The action plan also says healthcare staff will seek prisoner consent when sharing information, unless there is a lawful basis to disclose it without consent under Caldicott Guardian principles.
The prison marked the recommendation as completed.
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