Investigation and inquest
On 24th April 2016 an investigation was commenced into the death of Harold Chukwudemu Uzomechina then aged 34. The investigation concluded at the end of the inquest on 12th September 2019. The conclusion of the jury at the inquest was that Mr Uzomechina died a drug related death to which a failure to recognise signs of cardio respiratory depression contributed. A factor preventing such recognition was an inadequate process of physical monitoring during the night state of Mr Uzomechina , the medical cause of death being:
1a – aspiration pneumonia
1b – cardio respiratory depression
1c – multi-drug toxicity
Circumstances of the death
Mr Uzomechina was remanded to HMP Wormwood scrubs on 20th April 2016. At reception health screens, he reported physical and mental health problems as well as longstanding dependence on drugs and alcohol. A prison GP prescribed methadone for management of heroin dependency and chlorodiazepine for alcohol withdrawal and symptom relief medication. Mr Uzomechina was transferred to the substance misuse stabilisation unit for detoxification. Late at night on 23rd April, Mr Uzomechina’s cellmate asked to move cells because he said Mr Uzomechina was snoring so loudly that it was keeping him awake. At 8:55 the following morning, 24th April, officers were unable to wake Mr Uzomechina and a nurse was called. Despite attempts at CPR Mr Uzomechina was confirmed dead at 9:32 am
Coroner’s concerns
1. There appeared to be differential treatment of detainees on the substance misuse unit at night compared to treatment they received during the day – specifically, detainees had the benefit of dedicated prison officers during the day time but not during the night.
2. The totality of the evidence given by staff suggests that the at-risk population of detainees on the substance misuse unit were not afforded the same level care and attention given to detainees who were formerly on an ACCT. This needs to be addressed.