William Bissett

Trust Management Offices
First Floor, The Curve
Bury New Road
Prestwich
Manchester
M25 3BL

Tel: 0161 358 2014
Web: www.gmmh.nhs.uk

PRIVATE AND CONFIDENTIAL
Mr Nicholas Rheinberg
Assistant Coroner
Preston and West Lancashire Coroners Court
2 Faraday Court
Faraday Drive
Fulwood
Preston
PR2 9NB

11th March 2025

Dear Mr Rheinberg

Re: William Bissett (deceased) Regulation 28 Preventing Future Deaths Response

Thank you for highlighting your concerns following Mr Bissett’s inquest which concluded on
22nd January 2025.  On behalf of Greater Manchester Mental Health NHS Trust, I would like
to offer Mr Bissett’s family our sincere condolences for their loss.

During the Inquest evidence was heard that:

1.  In  the  8-month  period  before  a  prisoner  is  released,  arrangements  for  release
are  the  responsibility  of  the  Community  Offender  Manager  with  the  Prison
Offender Manager acting as a conduit of information. Further it was said that the
Community  Offender  Manager  should  arrange  an  early  meeting  with  the
prisoner.  Mr  Bissett  a  man  aged  88  in  failing  health  only  saw  his  Community
Offender Manager on 5th October 2023, 8 days before his release.

2.  On  23rd  June  2023  Mr  Bissett  was  informed  of  the  terms  of  his  licence  upon
release.  He  was  informed  that  he  would  not  be  allowed  to  return  home.  No
to  discuss
sufficient  attempt  was  made 
accommodation in the event that he was unable to find a place to live himself.

to  engage  with  Mr  Bissett 

3.  56 days before release, it being clear that Mr Bissett had nowhere to go, planning
for accommodation should have been commenced with Fylde Borough Council
who  would  have  the  duty  to  provide  temporary  housing  and who  would  have
engaged with Mr Bissett to discuss his requirements.

4.  56 days before release HMP Wymott should have informed the Fylde Coast Local
Authorities that Mr Bissett would be homeless upon release so that his  name

Greater Manchester Mental Health NHS Foundation Trust, Trust Headquarters,
Bury New Road, Prestwich, Manchester M25 3BL.

Chair: 

Page 1 of 3

Chief Executive: 

 appeared on the agenda for the monthly Prison Release Meeting. This was not
done.

5.  Lack of planning for release and lack of engagement left Mr Bissett only with the
knowledge that he would probably have to live the rest of his life separated from
his wife. No attempt was made to help him come to terms with this reality.

Box 6 ‘Action should be taken’ sets out that:

Where  it  becomes  known  that  a  prisoner  is  likely  to  be  homeless  on  release,
consideration be given to instituting a regime whereby a meeting takes place, not less
than  56  days  before  the  release  date,  such  meeting  to  include  the  prisoner  and
representatives from the prison Offender Management Unit, Healthcare and the Local
Authority Housing Department which will bear responsibility for discharging a duty to
rehouse, in order to put in place arrangements to support the prisoner in the prisoner’s
transition from custody back to the community

Please see the Trust’s response in relation to the points you have raised below:

During his time in HMP Wymott, Mr Bissett was under the care of the healthcare team to
manage his various physical issues. He was frequently reviewed by the team for these
physical health concerns but was not under the care of the mental health team. Mr Bissett
was prescribed antidepressant medication, which was being monitored by the GP.

The Prison and Probation Service are responsible for the release and any release conditions
relating to prisoners and have a  statutory duty to refer to the Local Authority for housing of
prisoners where required. The Healthcare service works collaboratively with the prison service
and Offender Management Teams providing specific healthcare treatment and will attend any
multidisciplinary discharge meetings put in place by the teams to enable the correct community
healthcare to support release back to the community.

In the week leading up to his proposed release date, Mr Bissett had consultations with
healthcare staff to devise a plan to meet his physical health needs in the community, and he
was seen on the 8th, 11th and 12th October 2024, however it was not possible at that time to
formalise a complete plan given his accommodation arrangements had not been finalised by
prison staff and the Local Authority.

During the Inquest, evidence from the Head of Healthcare at HMP Wymott was heard, setting
out that the Healthcare service has implemented discharge clinics, 2 weeks prior to prisoner
release, to ensure that medication, GP registration and onwards community referrals are in
place prior to release.

In  addition,  healthcare  staff  now  attend  the  monthly  ‘through  the  gate’  meetings  with  the
Offender  Management  team,  which  will  highlight  any  prisoners  that  have  complex  health
needs and may require healthcare support post release.

I thank you again for bringing these matters of concern to the Trust’s attention. If you have
any further questions in relation to the Trust’s response, please do let me know.

Yours sincerely

Greater Manchester Mental Health NHS Foundation Trust, Trust Headquarters,
Bury New Road, Prestwich, Manchester M25 3BL.

Chair: 

Page 2 of 3

Chief Executive: 

 Greater Manchester Mental Health NHS Foundation Trust, Trust Headquarters,
Bury New Road, Prestwich, Manchester M25 3BL.

Chair: 

Page 3 of 3

Chief Executive:

HM INSPECTORATE OF PRISONS 
3rd floor 
10 South Colonnade 
Canary Wharf 
London E14 4PU 

E-mail: 

     Tel:  

30 January 2025 

Deputy Chief Inspector of Prisons 
MARTIN LOMAS 

Nicholas Rheinberg 
Assistant Coroner 
Lancashire and Blackburn with Darwen 
Royal Blackburn Hospital 
Haslingden Road 
Blackburn 
BB2 3HH 

Dear Mr Rheinberg, 

WILLIAM CAMPBELL BISSETT – Prevention of Future Deaths Report 

Thank you for sharing your regulation 28 report to prevent future deaths with His Majesty’s 
Inspectorate of Prisons (HMI Prisons). We are saddened to learn of the findings of your 
investigation.  

HMI Prisons is an independent inspectorate. We provide scrutiny of the conditions for and 
treatment of prisoners and other detainees and report publicly on our findings. HMI Prisons’ 
inspections are carried out against published inspection criteria known as Expectations. 
Many of the issues highlighted in your report are covered via our Expectations, and are 
therefore matters which our inspectors will consider on each inspection. For example, in 
relation to preparation for release, our expectations state: “Helping prisoners to work towards 
and prepare for the day of release is understood as a central purpose of the establishment.” 

Other issues raised in your report such as prisons recognising the importance of family ties 
and that prisoners should have a named member of staff who knows them well and provides 
support with resettlement issues are also covered via our Expectations.  

Some of the particular concerns you raise in Mr Bissett’s case around a lack of adequate 
contact between prison offender managers and community offender managers and prisoners 
being released homeless are sadly issues on which we have reported all too often recently 
and on which we have raised concerns in our most recent annual report.  

We will keep your findings on file so that, when we next inspect HMP Wymott, inspectors are 
aware of this information and can follow up as appropriate. 

Yours sincerely, 

30/01/25 

www.justiceinspectorates.gov.uk/hmiprisons

OFFICIAL

To:  

Nicholas Rheinberg,  
Assistant Coroner Liverpool & Wirral 

Sent via email by GLD 

Dear Mr. Rheinberg,  

Regional Probation Director 
Unit 6, Albert Edward House 
The Pavilions 
Port Way 
Preston 
PR2 2YB 

E 

4th April 2025 

Re: William Bissett (deceased) Regulation 28 Preventing Future Deaths Response 

Thank  you  for  your  Regulation  28  Report,  issued  following  the  Inquest  into  the  death  of  Mr 
William Bissett. 

I know that you will share a copy of this response with the family, and I would first like to express 
my sincere condolences for their loss.   

You have raised concerns which you summarised as follows: - 

Where it becomes known that a prisoner is likely to be homeless on release, consideration be 
given to instituting a regime whereby a meeting takes place, not less than 56 days before the 
release date, such meeting to include the prisoner and representatives from the prison Offender 
Management  Unit,  Healthcare  and  the  Local  Authority  Housing  Department  which  will  bear 
responsibility for discharging a duty to rehouse, in order to put in place arrangements to support 
the prisoner in the prisoner’s transition from custody back to the community 

In response, a number of changes have taken place.  

The  OMiC  (Offender  Management  in  Custody)  POM  to  COM  Handover  Guidance  was 
amended and re-issued in March 2024. This provides clear instructions about the requirements 
for the handover process from a prison-based offender manager (POM) to a community based 
offender manager (COM).  The Guidance sets out very clear instructions on the timing of this 
meeting, who should attend and record keeping so that what is discussed forms the basis  of 
planning for release.   

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There  has  also  been  a  review  commissioned  by  the  Area  Executive  Director  to  look  at  the 
quality  of  POM  to  COM  handovers  which  proposes  relevant  recommendations  to  improve 
timeliness and quality in respect of the exchange and sharing of information with stakeholders 
both in the prison and the community.   

Locally, anyone managed by the Blackpool Probation Office in custody who is without a release 
address is discussed at the local  Prison Leavers Meetings which are attended by Probation, 
Prison, and the Local Authority. A list of cases for discussion  at these meetings is generated 
from the Probation case management system – NDelius, using the “No Fixed Abode” recorded 
status. The Prison Leavers Meetings are chaired by the Probation Delivery Unit (PDU) Senior 
Probation  Officer  which  ensures  they  have  insight  into  the  pre-release  work  required/being 
undertaken by their teams in a timely manner and have the links with the housing workers to 
facilitate assessments and discuss need, including duty to refer situations. 

In  the  North  West  Probation  Region,  I  have  commissioned  a  resettlement  review  and  the 
consistency of arrangements for multi-agency pre-release meetings will be considered as part 
of this review.   

We also have a number of PDU’s where housing workers are co-located at our offices and early 
indications are that this improves working relationships and the sharing of information. 

In other PDUs Local Authority housing workers regularly attend the Probation Offices to work 
with  Probation  Practitioners  to  support  them  with  addressing  prison  leaver  accommodation 
needs.  These  arrangements  are  demonstrating  improved  outcomes  such  as  helping  to 
understand when to make referrals under the Duty to Refer and referrals being assessed in a 
timely manner with each Service understanding need.  

There is also a new policy statement for Practitioners in respect of safeguarding adults at risk -   
The  Safeguarding  Adults  at  Risk  in  the  Community  Probation  Service  Policy  Statement  and 
care and support needs should be discussed at the POM to COM handover meeting.   

I  can  also  confirm  that  there  is  an  expectation  that  the  case  management  system  NDelius 
should be updated within twenty-four hours of all contacts taking place and recording of contact 
outcomes is currently being monitored at weekly performance meetings led by senior probation 
officers. 

Thank  you  for  bringing  these  matters  of  concern  to  my  attention.  Please  be  assured  that 
learning  from  the  circumstances  of  this  tragic  death  will  also  be  shared  more  widely  with 
colleagues across the Probation Regions.   

Yours sincerely,  

Andrea Bennett 
Regional Probation Director, North West 

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