© Zack Griffiths – HMP Prisons Justice Group
The Prisons and Probation Ombudsman (PPO) has released its findings into the death of Martin (also known as John) Casey, who died on 9 January 2025 at HMP Birmingham. The report highlights ongoing concerns about illicit drug use in prisons and makes a formal recommendation aimed at improving clinical oversight for prisoners with substance misuse needs.
Mr Casey was first remanded to HMP Birmingham on 5 July 2017. On 4 September 2017, he was sentenced to nine years and three months’ imprisonment for serious offences including kidnapping, burglary, attempted robbery, theft, and racially or religiously aggravated assault.
Throughout his time in custody between 2017 and 2022, Mr Casey had a documented history of substance misuse. He:
* Tested positive for drugs on multiple occasions
* Was found under the influence of illicit substances
* Was discovered in possession of fermenting liquid (commonly used to produce illicit alcohol in prison)
* Required hospital treatment twice following suspected use of psychoactive substances
On 10 March 2022, Mr Casey was released from HMP Garth on licence. However, he was recalled to custody twice for breaching licence conditions. His final recall occurred on 31 December 2024, when he was returned to HMP Birmingham.
At the time of his death, Mr Casey was known to the prison’s Substance Misuse Service (SMS). He was undergoing an alcohol detoxification programme and had received harm minimisation advice relating to illicit drug use. However, he declined further ongoing support.
The Ombudsman noted that while Mr Casey had contact with healthcare services, engagement with support mechanisms beyond detoxification was limited by his refusal to participate in additional intervention.
At approximately 5:39pm on 9 January 2025—just hours after receiving a social visit from his partner—a prison officer found Mr Casey unresponsive on the floor of his cell.
Staff immediately called a medical emergency. Prison officers and healthcare personnel began cardiopulmonary resuscitation (CPR), continuing until paramedics arrived. Despite sustained efforts, paramedics pronounced life extinct at 6:58pm.
A post-mortem examination concluded that Mr Casey died as a result of:
* An enlarged heart
* Synthetic cannabinoid intoxication
Synthetic cannabinoids—often referred to as “Spice”—have been linked to numerous deaths and medical emergencies in prisons across England and Wales.
Mr Casey was the third prisoner to die from drug-related causes at HMP Birmingham within three years. Alarmingly, another drug-related death occurred just two days after his passing.
The prison reported a noticeable increase in illicit drug use in January 2025. In response, HMP Birmingham plans to introduce tamper-proof vapes in October 2025, aiming to prevent devices from being modified to consume synthetic substances.
The recurrence of drug-related deaths underscores the persistent challenge prisons face in controlling contraband and managing substance misuse among inmates.
An independent clinical reviewer assessed the healthcare Mr Casey received. The review concluded that his care was partially equivalent to what he could have expected in the community.
While Mr Casey was enrolled in detoxification treatment and had received harm reduction advice, the Ombudsman identified shortcomings in the implementation of follow-up procedures.
The PPO issued a formal recommendation directed at the Head of Healthcare at HMP Birmingham:
The ‘5 day SMS review’ must:
* Be conducted as a face-to-face appointment
* Include a review of SystmOne medical records beforehand
* Incorporate a review of medication concordance
* Comply with BRT Standard Operating Procedures and the Department of Health’s
*Drug misuse and dependence: UK guidelines on clinical management
The aim is to ensure more robust and clinically consistent engagement with prisoners identified as having substance misuse issues—particularly during the crucial early days of custody or recall.
The death of Martin Casey highlights the complex and ongoing issue of drug misuse within custodial settings. Despite existing detoxification programmes and harm minimisation efforts, synthetic cannabinoids continue to pose a serious risk to prisoner health and safety.
The Ombudsman’s findings emphasise the need for stronger clinical oversight, more consistent face-to-face engagement, and rigorous adherence to national guidelines. As HMP Birmingham implements changes—such as tamper-proof vapes—the effectiveness of these measures will be closely watched.
Ultimately, the case serves as a sobering reminder of the vulnerabilities faced by individuals with substance misuse histories in custody, and the importance of proactive, consistent healthcare interventions to reduce preventable deaths.
HMP Prisons Justice Group 