Health and Justice Insight: Winter 2022/2023

03/02/23

Legal Updates

Challenge to Coroner’s decision not to issue a Prevention of Future Deaths Report following a death in custody fails

Dillon v Assistant Coroner for Rutland & N Leicestershire [2022] EWHC 3186 KB (Admin)

Background

Mr Nile suffered from asthma and other allergies. He rang his call bell for assistance citing difficulty breathing and an inability to find his asthma pump. However, at the time that he called for assistance, the prison had been locked down and was in a ‘patrol state’.

The prison officer attended only one minute after the call bell was pressed and Mr Nile was given advice through the observation panel as his breathing difficulties were noted. The officer did not enter Mr Nile’s cell as he did not believe that he could enter without three prison officers being present – he was unaware that this was a discretionary procedure if it was deemed that there was an immediate risk to life.

Other issues identified included a delay in calling a ‘Code Blue’ which meant that an ambulance was not immediately called, there was no 24 hour healthcare available and there was a lack of first aid training amongst the prison officers.

The clinical reviewer found that the care received by Mr Nile was equivalent to the care he would have been given in the community. Article 2 was engaged at the inquest and the jury concluded that actions of the prison officers did not affect Mr Nile’s outcome.

Due to the issues identified above, the coroner considered making a Prevention of Future Deaths Report (“a PFD”), but ultimately did not. She concluded that changes within the prison’s systems regarding spot checks were easy to make.

Challenge by the family’s solicitors

This was challenged by the family’s solicitors. The coroner declined to make any comments on her reasoning on the basis that she could not now change her decision following the conclusion of the inquest. The coroner later accepted that this was incorrect. The family’s solicitor also asked the coroner to issue a PFD in relation to the lack of:

healthcare available after 5pm
first aid training for officers on duty during a patrol state.

The coroner did not do so as the prison had already implemented changes.

High Court decision

The High Court dismissed the appeal on every ground and found that the coroner’s decision was not unlawful.

If a potential PFD recipient had already implemented appropriate action to address the risk of future fatalities then the coroner may not need to make a report. The decision on whether to make a PFD is a judicial decision for the coroner to make on a case-by-case basis.

Capsticks comment

This case reminds us of the discretionary nature of PFDs. It also emphasises the need to quickly identify any lessons learned following a death in custody and to formulate an appropriate Action Plan, with any resulting actions to be implemented as swiftly as possible.

Article 2 clarification for inquests involving voluntary patients

R (Morahan) v HM Coroner for West London and others [2022] EWCA Civ

Ms Morahan’s family asked the Supreme Court to consider whether the coroner was correct to conclude that the death of Ms Morahan did not call for an Article 2 inquest. It focused on whether there was an operational duty, which is a duty to protect against particular risks to life, not all risks.

The case had previously been before the High Court and Court of Appeal, who had ruled that the coroner was correct to decide that Article 2 did not apply. Ms Morahan’s family appealed on both occasions.

Background

Ms Morahan was a voluntary psychiatric patient and was under the care of the Trust for schizophrenia. Under her treatment plan, it was agreed that she could go home to tidy her flat and return that evening for treatment, as she had done the night before.

However, Ms Morahan was noticeably absent from the hospital and she did not return that evening as agreed. She was later found deceased in her home. The autopsy found that she had died from cocaine and drug toxicity.

Coroner’s decision and the family’s appeal

The coroner found that Article 2 was not engaged and confirmed that a deceased person having been in state care or state custody alone will not necessarily engage Article 2. The claimant’s family appealed on three grounds:

the Article 2 operational duty was arguably owed by the hospital trust
an automatic duty to hold an Article 2 compliant inquest arose
there was an arguable breach of the operational duty.

Court’s decision

The court dismissed the first two grounds and did not therefore consider the third. The following reasoning was given:

The Rabone factors were not satisfied and there was no operational duty to protect Ms Morahan from the risk that eventually caused her death, which was accidental death by recreational drug taking of illicit drugs.

Ms Morahan was a voluntary patient and was at liberty to attend the hospital and to leave the hospital. There was no history of accidental overdose and there had been drug abstinence, evidenced by urine drug tests, throughout her Section 3 detention whenever she had had periods of unescorted leave. Therefore, there was no foreseeable ‘real and immediate risk’ of an accidental overdose.
There is no authority which decides that an Article 2 operational duty is owed to voluntary psychiatric patients to protect them from all risks of death. The court found that the circumstances around Ms Morahan’s death were far removed from the circumstances in Rabone where the very purpose of being in hospital was to protect against the risk of suicide.

Capsticks comment

Article 2 has prompted a number of decisions over the last few years, and this case helpfully provides further guidance.

It reminds us that the question as to whether there has been an arguable breach of Article 2 depends on the facts in each case, and that where an operational duty arises it does so in relation to specific risks of death only. The death of a voluntary psychiatric in-patient does not automatically trigger an arguable breach of Article 2.

Supreme Court still yet to decide on important medical Article 2 case

R (on the application of Maguire) v His Majesty’s Senior Coroner for Blackpool & Fylde and another

The Supreme Court was asked to consider whether the state’s Article 2 obligation was engaged when a disabled woman who was deprived of her liberty died. This case had previously been before the Divisional Court and Court of Appeal, who had dismissed all grounds and ruled that Article 2 did not apply.

Background

Ms Maguire lived in a residential placement for adults with learning disabilities and was subject to Deprivation of Liberty Safeguards under the Mental Capacity Act 2005. She had been unwell in the weeks preceding her death and the evening before she died had lost consciousness and collapsed.

It was known to the care staff that she had a fear of medical interventions and when the ambulance attended she refused to attend hospital. An out of hours GP advised that she should attend the hospital, but if she did not wish to attend, she could stay at her residence.

Unfortunately, she collapsed again, was taken to hospital and was found to be suffering with acute kidney injury and dehydration. She subsequently suffered a cardiac arrest and died.

Her cause of death was a perforated gastric ulcer and pneumonia.

The coroner did not feel that sufficient evidence had been advanced to suggest that Ms Maguire’s death may have resulted in a violation of the state’s operational duty to protect life, and found therefore that the procedural duty under Article 2 did not apply.

Judicial review and Court of Appeal’s decision

Ms Maguire’s family sought a judicial review on the following grounds:

In accordance with the reasoning in Rabone v Pennine Health Care NHS Trust, the circumstances of Ms Maguire’s care meant that the procedural obligation under Article 2 applied.
The Divisional Court had been wrong to find that the medical care given to Ms Maguire did not evidence systemic failures.
The Divisional Court had erred in failing to take into account the wider context of premature deaths of people with learning difficulties which were relevant to the application of Article 2.

The Court of Appeal dismissed all grounds. Specifically, the court held that medical negligence could only give rise to a breach of the operational duty under Article 2 in very exceptional circumstances.

Further, the court held that a person in the care of the state does not necessarily trigger the statutory duty to undertake an Article 2 inquest. The scope of any operational duty should be considered with a focus on what the state’s duties were, in order to identify whether the operational duty under Article 2 was engaged.

The Court also made it clear that this case was different on the facts to Rabone, which considered a psychiatric patient, and should be distinguished accordingly.

The Supreme Court considered the Court of Appeal’s judgment in November 2022, a decision is expected over the coming months.

Capsticks comment

The question as to whether Article 2 is engaged in these types of medical cases frequently arises, and the legal arguments can often be very difficult to navigate for those acting on both sides of the debate.

It is hoped that the Supreme Court’s consideration of these issues will provide much needed clarification for all involved.

Until then, the engagement of Article 2 remains a high hurdle.

Covid-19 Public Inquiry

The Covid-19 enquiry has now opened its third enquiry Module 3, which is primarily focussed on the impact of the Covid-19 pandemic on healthcare in England, Wales, Scotland and Northern Ireland.

Module 3 will examine the impact and consequences of the pandemic on primary, secondary and tertiary healthcare sector systems and how this evolved during the Covid-19 pandemic.

The window for applying for core participant status closed on 5 December 2022 and the first preliminary hearing for Module 3 will be held on Tuesday 28 February 2023. It will be available to watch via the Inquiry’s Youtube channel.

Module 3 will consider:

impact of Covid-19 on people’s experience of healthcare
core decision-making and leadership within healthcare systems during the pandemic
staffing levels and critical care capacity
111, 999 and ambulance services, GP surgeries and hospitals and cross-sectional co-operation between services
healthcare provision and treatment for patients with Covid-19
decision-making about the nature of healthcare to be provided for patients with Covid-19, its escalation and the provision of cardiopulmonary resuscitation, including the use of do not attempt cardiopulmonary resuscitation instructions (DNACPRs)
impact of the pandemic on doctors, nurses and other healthcare staff, including on those in training and specific groups of healthcare workers. Availability of healthcare staff. The NHS surcharge for non-UK healthcare staff and the decision to remove the surcharge
preventing the spread of Covid-19 within healthcare settings, including infection control, the adequacy of PPE and rules about visiting those in hospital • communication with patients with Covid-19 and their loved ones about patients’ condition and treatment, including discussions about DNACPRs
deaths caused by the Covid-19 pandemic, in terms of the numbers, classification and recording of deaths, including the impact on specific groups of healthcare workers, for example by reference to ethnic background and geographical location
shielding and the impact on the clinically vulnerable (including those referred to as “clinically extremely vulnerable”)
characterisation and identification of Post-Covid Condition (including the condition referred to as long Covid) and its diagnosis and treatment.

A more detailed update, and guidance as to how Capsticks can help you in relation to the COVID-19 Inquiry can be found here.

Statistics

Below are detailed quarterly statistics on offenders in custody (including offence groups, sentence lengths and nationalities), and quarterly statistics on prison receptions, prison releases, adjudications, licence recalls and offenders under probation supervision:

81,309 prisoners in England and Wales as of 30 September 2022 - this represents a rise of 3% compared to the same period in the previous year
15,944 first receptions into prison between April and June 2022 - this represents a rise of 5% compared to the same period in the previous year
11,478 releases from sentences between April and June 2022 - this is 1% lower than the same period in 2021. As the prison population shifts towards those serving longer sentences, we expect fewer releases in each period
38,277 adjudication outcomes between April and June 2022 - this represents a rise of 4% than the same period in 2021
additional days were awarded as punishment on 642 occasions – this represents a 6% rise compared to the same period in 2021
5,726 licence recalls between April and June 2022 - this was a 7% increase on the same quarter in 2021
243,127 offenders on probation at the end of June 2022 - this number increased by 5% compared to the number of offenders supervised as at end of June 2021.

A full link to these statistics can be found here.

Capsticks comment

The above statistics still cover a period when Covid-19 restrictions were applicable within prisons.

There has been an increasing remand population (a 12% increase between 30 September 2021 and 30 September 2022). It is possible that this reflects the impact of partial court recovery following Covid-19 restrictions. The large increase in the ‘untried’ population (15% increase) this quarter could also have been impacted in part by strike action by the Criminal Bar Association during the month of September 2022.

The remand prison population as at 30 September 2022 was the highest for at least 50 years.

Prisons and Probation Ombudsman (PPO) Annual Report

The PPO dealt with 4,442 complaints in 2021/ 2022, an increase of 11% compared the preceding year. 329 fatal incidents were investigated which is a 23% decrease from the previous year.

The key findings are highlighted below:

Most complaints, over 500, were to do with property going missing.
In respect of deaths in custody, there was a spike in 2020 – 2021, where of the cases investigated, the highest amounts were found be deaths of natural causes. This was likely due to the Covid-19 pandemic.
There were 128 investigations into the deaths of prisoners aged 60 and over, with this cohort having specific challenges and also being the fastest growing. HM Prison & Probation Service (HMPPS) must ensure they have access to the appropriate health and social care needed to address long-term health conditions.
There were cases where prisoners with significant care and support needs were not effectively safeguarded. Prisoners with care needs were left in unsafe conditions and engaged in self-neglecting behaviour without intervention. This is a complex issue, but the input and expertise of prison, health and social care staff is required, especially with the rising elderly population.
A year-long pilot was launched in September 2022 to investigate the deaths of those who die within 14 days of their release from prison. Investigations have been started into 25 post-release deaths and so far, the investigations have highlighted the need for strong communication between prison, probation and other agencies to meet the complex needs and support the wellbeing of people released from prison.

A full copy of the PPO report can be found here.

Capsticks comment

We have focused upon the ‘fatal incidents’ (deaths in custody) aspect of this report and note that between 2021 and 2022 the PPO issued 378 final investigation reports, making recommendations in 308 of those cases.

Health provision recommendations covered a wide range of issues such as the need for robust record-keeping, following National Institute for Health and Care Excellence (NICE) guidance, timely referrals for health appointments and prescription medications.

Recommendations in relation to the emergency response following a death included the correct use of the emergency code system, administering CPR in line with best practice, entering cells without delay, carrying the correct equipment and calling ambulances.

The recommendations relating to suicide and self-harm prevention included:

assessing prisoners based on their risk factors
accurate record keeping and care plans
carrying out meaningful welfare checks – including after court appearances and family/friend deaths
following Care in Custody and Teamwork (ACCT) procedures.

The PPO have also made recommendations related to Covid-19. These included:

identifying those at risk and advising them to shield
accurate record keeping
appropriate care plans put in place
staff being aware of who is positive for Covid-19
appropriate use of the National Early Warning Score (NEWS) 2 scoring system.

Some of the issues identified above were the subject of PFD reports, and we have highlighted various examples below.

Safety in custody statistics, England and Wales: Deaths in prison custody to September 2022, assaults and self-harm to June 2022

Detailed quarterly statistics on safety in custody up until June 2022 are:

Number of deaths decreased from the previous 12-month period

In the 12 months to September 2022, there were 307 deaths in prison custody, a decrease of 22% from 396 deaths the previous 12 months. Of these, 70 deaths were self-inflicted, a 16% decrease from the 83 self-inflicted deaths in the previous 12 months. In the most recent quarter there were 84 deaths, a 20% increase from 70 deaths in the previous quarter.
The number and rate of self-harm incidents were almost unchanged in both male and female establishments from the previous 12-month period

There were 52,972 self-harm incidents in the 12 months to June 2022, almost unchanged from the previous 12 months (0.4% increase), comprising increases of 0.2% in male establishments and 1% in female establishments. Over the same period, the rate of self-harm incidents per 1,000 prisoners, which takes account of the increase in the prison population between this and the previous year, decreased 1% in male establishments but remained unchanged in female establishments. In the most recent quarter, there were 13,052 self-harm incidents, up 7% on the previous quarter, comprising increases of 3% in male establishments and 17% in female establishments.
The number of individuals who self-harmed decreased

There were 10,965 individuals who self-harmed in the 12 months to June 2022, down 3% from the previous 12 months. The number of self-harm incidents per individual increased from 4.6 in the 12 months to June 2021 to 4.8 in the 12 months to June 2022.
Assaults increased from the previous 12-month period

There were 20,551 assault incidents in the 12 months to June 2022, up 12% from the 12 months to June 2021. In the most recent quarter, assaults were up 13% to 5,319 incidents.
Assaults on staff increased from the previous 12-month period

There were 7,459 assaults on staff in the 12 months to June 2022, up 4% from the 12 months to June 2021. In the latest quarter the number of assaults on staff increased by 4% to 1,780 incidents.
The number of serious assaults increased (11% of all assaults were serious)

In the 12 months to June 2022, there were 2,225 serious assault incidents, an increase of 16% from the previous 12 months. Serious prisoner-on-prisoner assaults increased by 21% to 1,545, and serious assaults on staff increased 8% to 718 in the 12 months to June 2022.

A full link to the statistics can be found here.

HMPPS Offender Equalities Annual Report 2021 to 2022

In March 2020 changes to the prison regime were introduced to limit the spread of Covid-19 and to protect the lives of those who live and work in our prisons. These regime changes were in place throughout 2021/22 except for the two months of October and November 2021. As of March 2022, all regime changes have been removed.
The overall prison population had been steadily declining since 2017 and dropped sharply in 2020/21 because of the Covid-19 pandemic where just over 78,000 males and females were in prison that year.
The mix of sexual orientation of prisoners has remained consistent with previous years with 97% (or 65,400) identifying as heterosexual. 3,600 chose to not disclose their sexual orientation in the quarter ending March 2022. There were slightly more transgender prisoners in prison as 230 were recorded in the year ending March 2022 compared to 197 last year. 187 prisoners recorded their legal gender as male and 43 as female. 197 of the 230 transgender prisoners were from a white ethnic background.
In the year ending March 2022, there were 88 applications made to Mother and Baby Units (MBU) for admission. Last year there were 62. This resulted in 26 mothers and 23 babies in an MBU by the end of the year. 72% of women from a white ethnic background and 63% of women from a black, Asian and minority ethnic (excluding white ethnic) background had their applications approved by a board for admission into an MBU.
The proportion of prisoners on Standard Incentives status was highest for ‘other ethnicity’, ‘mixed ethnicity’ or ‘black and black British’ ethnicity where 60%, 51% and 48% respectively were recorded in 2022. The proportion of prisoners on Standard Incentives decreased with age where 68% of prisoners between 18 and 20 had this status and 31% of those aged 60 and over had a Standard Incentives status.
In the year ending March 2022, 2,300 accredited programmes started compared to only 744 the previous year. Nearly all the accredited programme starts were made by male prisoners (95% or 2,100). 36% (or just over 800) of accredited programmes were started by offenders aged between 30 and 39 years.
Offenders from mixed ethnic groups and white ethnic groups were more likely to breach their orders in the latest year’s data (34% from mixed ethnic groups, 33% from white ethnic groups compared to 25% from other ethnic groups and 24% from Asian ethnic groups). Offenders identifying as gay/lesbian were less likely to breach their orders (23% breach rate compared to 31% of offenders overall).

A full link to the report can be found here.

Joint Thematic Inspection Report: Offender management in custody

HM Inspectorate of Prisons (HMIP) and HM Inspectorate of Probation for England and Wales are independent inspectorates which provide scrutiny of the conditions for, and treatment of prisoners and offenders. They report their findings for prisons, Young Offender Institutions, and effectiveness of the work of probation, and youth offending services across England and Wales to Ministry of Justice (MoJ) and Her Majesty’s Prison and Probation Service (HMPPS).

In response to the report HMPPS and MoJ are required to draft a robust and timely action plan to address the recommendations. The recommendations from the action plan are below:

Her Majesty’s Prison and Probation Service should:

review the Offender Management in Custody (OMiC) Model to ensure that:
- there is an element of flexibility in how it is deployed in different establishments (for example reception prisons, resettlement, and training prisons), as in the high security and women’s estate
- responsibility and accountability for delivery clearly sits with the Head of Offender Management Delivery
- handover from Prison Offender Manager (POM) to Community Offender Manager (COM) should take place at the same point before release, removing the distinction between National Probation Service and Community Rehabilitation Company legacy cases
- COMs have sufficient time to build effective working relationships with individuals to inform parole reports and to allow sufficient time for referrals before release
- keyworkers are directly involved in sentence planning, and support prisoners and POMs to achieve their targets
- resettlement activity is coordinated and fully integrated with OMiC
undertake a fundamental review of the probation POM role to ensure a clear focus on the prisoner’s progress in custody and preparation for release • ensure that prison and probation service leaders at all levels work together to facilitate the successful transition of prisoners to the community
ensure that prison and probation IT systems are further aligned to support full information-sharing between keyworkers, POMs and COMs
provide each prison with a directory of interventions, to help staff and prisoners to identify progression routes
carry out a strategic prisoner needs analysis to set a baseline against which to commission and deliver services
establish a strategic forum for resettlement and a regional performance system to monitor progress.

Prison directors / governing governors should:

ensure that the prison regime provides the protected time needed for prison officers to undertake the keyworker role
ensure that offender management staff in every prison have private spaces for personalised one-to-one meetings between prisoners and their POM and keyworker
co-locate offender management units and psychology and resettlement services where possible
ensure that there is a strong link between key work, offender management and resettlement work.

Regional probation directors should:

ensure that there are sufficient staffing levels for senior probation officers in prison, probation offender managers in prison and community offender managers
ensure that COMs understand their role in relation to prison-based resettlement teams, and that this may be different in different prisons
ensure that probation services work with training and resettlement prisons to fully address the resettlement needs of those who are due for release
ensure Professional Qualification in Probation (PQiP) training equips new learners to deliver OMiC
ensure that all required OMiC tasks are completed in a timely way.

The full action plan, including the recommendations, whether they were agreed, the response, owner and target date can be found here.

Regulation 28 Reports / Recent Trends

Coroners are under a duty to make a Regulation 28 Report, also known as a Prevention of Future Deaths Report:

if they have concerns relating to circumstances creating a risk to life
it is felt that action needs to be taken to prevent these circumstances from arising again
to reduce the risk of death created by them.

They are normally made after the inquest when the coroner has considered all of the evidence, however they can be made before the conclusion where the coroner concludes that there is an urgent need for action. The Reports are published on the Government website and below we have summarised the recent trends in the Health and Justice Sector.

Capsticks comment

Recent Regulation 28 Reports have highlighted the following issues:

Assessing and managing risks other than of self-harm and suicide

Escalation routes (ACCT and CISP) are more focussed on violence and self- harm, leaving at the very least a conceptual gap in how best to deal with injurious activity which is neither violent nor directly/obviously contributory to self-harm, such as self-neglect. Potential issues with the safeguarding escalation processes were either inadequate, inappropriately trained or both.

Record Keeping/ Reviews

Sparse record keeping and underutilisation of the daily log which was to be used as a multidisciplinary tool has caused failings.
Successive inquests have heard evidence about the failure by clinical staff to use the NEWS2 assessment system, resulting in substandard healthcare. In addition, it appears that that there is an issue relating to the review of GP records when received and arranging follow up appointments if these records show a history of mental health concerns.

Availability of healthcare

Lack of healthcare during the night has been a common theme and a recognition that night staff should have adequate training to respond effectively to ligature or self-harm incidents.

Evidence gathering and retention

Failings around the keeping / taking of evidence that assist in coronial investigations. Failure to take witness statements of key personnel and failures in complying with its obligations pursuant to National Prison policy to retain and preserve evidence likely to assist all agencies in learning from deaths in custody.

Independent Advisory Panel on Deaths in Custody; 2 December 2022

An Independent Advisory Panel on Deaths in Custody report brings together, for the first time, a wide range of policing practice across England and Wales to prevent deaths at the point of arrest, during and after custody. It makes 25 recommendations, addressed to police forces, police and crime commissioners, policing organisations, health trusts, ambulance associations, local authorities and others. Including:

greater collaboration across agencies, particularly healthcare, to support people experiencing a mental health crisis
improved support for vulnerable individuals who are released, particularly those at risk of suicide
better sharing and embedding of learning, particularly learning from bereaved families, the Home Office, coroners and investigatory bodies.

A full link to the recommendation and report can be found here.

MoJ and HMPPS – Searching Policy Framework; 3 October 2022

A joint MoJ and HMPPS policy framework sets out the mandatory searching requirements and guidance needed to maintain high levels of security and maintain a secure and stable environment for staff and prisoners. It contains requirements, guidance and additional information on searching of the person, cells, areas and vehicles. It applies to all public sector prisons, contracted prisons and young offender institutions. Its implementation date was 3 January 2023.

A copy of the framework can be found here.

PPO - Policy into practice – Prevention of Escape Framework

This is part of a new Policy into Practice series from the PPO which they have worked on with HMPPS policy leads to share learning from PPO investigations to improve policy.

This publication combines policy and case studies to show some of the important changes that have been made to the External Escorts Policy Framework.

The policy framework sets out the standard level of restraints for each prisoner security category. However, the policy makes it clear that this should only be adopted after an individual risk assessment has been completed (i.e. no medical concerns are raised, and the security assessment deems the use of restraints appropriate). In addition:

The escort risk assessment now makes it clear that the healthcare section must always be completed (unless there are no healthcare staff on duty prior to the escort).
Healthcare staff must always be included in the risk assessment process and authorising managers should evidence on the risk assessment that medical information has been taken into consideration.
The escort risk assessment must take into consideration the prisoner’s current medical condition and the impact this has on the prisoner’s mobility and their ability to escape. The assessment form now specifically asks healthcare to answer these questions.
Prisons must use the escort risk assessment form annexed to the policy. This will help staff consider all the relevant factors and provide a record of defensible decision making.

The full article can be found here.

Psycho active substances: Drug related deaths in prisons 2015 - 2020

Drugs and drug related deaths in custody continue to be a prevalent issue. The Journal of Community Psychology has examined the drug‐related deaths in prisons in England and Wales between 2015–2020, which we note includes a period where the pandemic was prevalent and Covid-19 restrictions were in place. We understand that this period of time was chosen as the basis for the review as there was a marked increase in the amount of deaths in the non-natural category – 100 deaths recorded. NPS or synthetic cannabinoids alone accounted for 26% of the deaths.

The research outlines that there are additional risks for people in prison who may use a combination of different substances, both illicit and prescribed and also that medications were stockpiled resulting in large quantities of drugs being taken at one time. However, it is also noted that there are other risk factors that contribute to drug related deaths, such as:

88% of people who died in prison from “non-natural” deaths over the 2015-2020 period had a recorded history of substance use
57% were recorded as having mental ill health
26% as having an underlying physical condition
65% of this group were in prison for violent offences.

PPO reports have raised some issues around the operational response to overdose events including:

a delay in calling a code
lack of monitoring for overdoses that occurred in the night and resuscitation not being called promptly.

In addition, it was highlighted that prisons are identified as risky environments, where the risk is increased due to staff turnover. This in turn can produce a lack of experience amongst staff, poor standards of health care and a lack of specific resources such as drug treatment, testing staff and sniffer dogs. An additional risk is the entrance of new and undetectable drugs into the prison populations. As per our previous newsletter, the lack of purposeful activity continues to be an issue.

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