Prison authorities in Hertfordshire lost contact with a former prisoner who was on immigration bail before he died.

Julian Van Rooyen left HMP The Mount near Hemel Hempstead on licence 11 days before his friend found him dead on July 17, 2023.

Adrian Usher, the Prisons and Probation Ombudsman, said the former prisoner did not engage with substance misuse services when he was in prison, so prison staff could not offer him naloxone – medication to reverse the effects of opiate overdose – when he left.

The Electronic Monitoring Service fit him with a tag when he left the facility on July 6, 2023, but service teams “would not be able to verify that the information being relayed from the tag was 100 per cent accurate” after “signal issues” when they set it up.

When Van Rooyen failed to attend a Probation Service appointment on July 12, nobody wrote to the former prisoner with a warning letter, according to the ombudsman.

Police “found 15 to 20 wraps of what appeared to be illicit drugs and a crack pipe” in the mobile home where Van Rooyen died.

Van Rooyen, from Zimbabwe, went to prison in October 2021, facing charges of assault and drug trafficking, according to Mr Usher’s report.

He told nurses at HMP Bullingdon in Oxfordshire that he spent £10 to £20 a day on heroin and was withdrawing from opiates before his charge.

They also noted he received tramadol – a very strong pain killer – from his GP following a 2005 motorcycle incident, and buprenorphine for heroin withdrawal from a substance misuse service in Milton Keynes.

Van Rooyen tested positive for cocaine, and a nurse referred him to the substance misuse service in Oxfordshire.

He was convicted in June 2022 and sentenced to three years and six months in prison, arriving at HMP The Mount in Bovingdon, near Hemel Hempstead, in July the same year.

When he arrived, he declined an assessment with the substance misuse service in Hertfordshire.

Van Rooyen told staff working towards his release that he would be homeless.

They liaised with his friend who offered the former prisoner a place on a farm in Northamptonshire.

“The community offender manager noted that Mr Van Rooyen was of interest to the Home Office, as he was a Zimbabwean national,” Mr Usher wrote.

“The Home Office agreed to give Mr Van Rooyen immigration bail while they assessed a claim for asylum that he had made.”

On July 6, EMS staff arrived at HMP The Mount to fit the former prisoner with a tag.

“Due to signal issues, they were not able to ‘successfully confirm installation’,” Mr Usher wrote.

“They said that they would not be able to verify that the information being relayed from the tag was 100 per cent accurate.”

Van Rooyen attended a Probation Service appointment in Milton Keynes on the same day, but on July 8, EMS staff visited his bail address and received a “withdrawal of consent from the homeowner, which they reported as a breach to the Home Office”.

Landlords and householders have to consent if the authorities want to tag someone at their address.

“A team manager at the Electronic Monitoring Service said that in these situations, they do not visit the address again until they receive an update from the Home Office in the form of a new installation request or a response to the breach that has been issued,” the ombudsman wrote.

“The investigator asked the Home Office what action they had taken following the breach, but they did not respond.”

On July 11, his battery’s tag failed and the EMS received no further data from it.

The following day, Van Rooyen did not attend a planned appointment in Milton Keynes.

Van Rooyen was aged 44 when his friend found him dead at the mobile home the following week.

“A post-mortem established that Mr Van Rooyen died from cocaine toxicity,” Mr Usher wrote.

“He also had bronchopneumonia – a lung infection – which contributed to but did not cause his death.

“A consultant histopathologist said that Mr Van Rooyen had used cocaine close to the time of his death.

“He said that the cocaine use could lead to arrhythmia – irregular heartbeat – and seizures.

“The histopathologist also said that Mr Van Rooyen had used heroin, but the morphine levels were very low at the time of his death.”

The ombudsman concluded: “Mr Van Rooyen might have benefitted from work with prison substance misuse services, and by choosing not to do so, they were unable to offer him naloxone – medication to reverse the effects of opiate overdose – on release or remind him of the dangers of returning to drug use on release due to reduced tolerance levels.”

He added: “A senior probation officer said that Mr Van Rooyen’s non-attendance on July 12 should have been recorded as an unacceptable failure of his licence conditions.

“She said that this should have resulted in a warning letter being sent within two working days, which should have given a new appointment within five working days.

“This was not done and there is no record that Mr Van Rooyen had any further contact with the Probation Service up to his death on July 17.

“The regional probation director will wish to consider the findings of this investigation.”

A Ministry of Justice spokesperson said: “Our thoughts remain with Mr Van Rooyen’s friends and family.

“We’ve noted the ombudsman’s findings and have taken action to ensure all incomplete probation appointments are investigated fully.”