Carl David Roy SMITH · Prevention of Future Deaths report

On 29th November 2012 I commenced an investigation into the death of Carl David Roy SMITH, aged 35. The investigation concluded at the end of the jury inquest on 21st – 22nd July 2015. The conclusion of the inquest was Drug Related Death.

Mr Smith suffered with drug dependency and died of Methadone Toxicity whilst on a Methadone Stabilisation Programme within HMP Exeter. He was found collapsed and not breathing at 7.15am on 22nd November in Cell C1-01. He died sometime during the night of 21st - 22nd November 2012. Resuscitation stopped at 8.05hrs on the 22nd November 2012.

Mr Smith had taken illicitly obtained Methadone prior to his death.

The quality of custodial and welfare checks were insufficient for a prisoner on an ACCT and Methadone Stabilisation Programme.

PMH from GP - asthma, heroin dependency first noted in 2004. O/D in 2010 (unsure of what). He was last seen by a GP on 10/10/12 with anxiety and depression, denied currently taking drugs and was not on any prescribed meds. He was keen to be given some diazepam but this was declined. His Mother states that he had a long history of drug abuse including heroin, speed, Valium and cannabis. His Mother believes that he had not taken any illegal drugs in the 2 weeks prior to going to HMP Exeter. She states that he has suffered from fits in the past which she thinks is due to detoxing from drugs. Mother’s last contact with her son was a letter which she received on approx 19/11/12 in which he stated that he was planning to propose to his Girlfriend.

The deceased was at HMP Exeter on remand having arrived there approx 1 week ago. He was due for a court appearance on 22/11. He was at risk of self-harm so was on 30-60 mins obs an in a cell fitted with a camera.

On the evening of 21/11/12 he was given medication for seizures and detox.
On 22/11/12 at 0715 hrs Prison Officer called to him through the cell hatch but got no response so she entered the cell with another prison officer to find him unconscious with no signs of life. CPR was commenced whilst paramedics were called who found that his airway was blocked by vomit, resus attempted but unsuccessful and his death was confirmed at 0805 hrs.
Forensic PM with toxicology auth’d

Post mortem examination carried out during which histological and toxicological samples were retained.
An inquest was opened with evidence of identification and adjourned on 27/11/12.

The quality of custodial and welfare checks were insufficient for a prisoner on an ACCT and Methadone Stabilisation Programme and information sharing in relation to the checks made, appeared to be deficient.