Investigation and inquest
A jury concluded the inquest into the death of Liam Turner on 31st January 2024 and recorded that he died from:
1a Toxicity of ADB-BUTINACA (“████████ / novel psychoactive substance) in combination with ████████
The jury returned a conclusion of Drug related death.
Circumstances of the death
The Deceased died at HMP Manchester on 6th December 2021. His death was caused by a mixed toxicity of a psychoactive substance and prescription medication. There were admitted failings made by the Ministry of Justice (on behalf of HMP Manchester) relating to the fact that a prison officer should have raised concerns that the Deceased was under the influence of an illicit substance with healthcare earlier than he did; however, these failings did not contribute to the Deceased’s death.
When three officers found the Deceased unresponsive in his cell, they moved him from his bed to the floor in preparation to commence cardiopulmonary resuscitation (CPR); however, CPR was not commenced until the healthcare nurses (and subsequently paramedic) arrived.
I sought evidence about training for CPR, and I was informed by one witness that he received training in 2006 as part of his Emergency First Aid at Work (EFAW) training; however, he had never had any refresher training.
The training certification expires after 3 years, and it is not mandatory for prison officers to receive refresher or additional training.
Coroner’s concerns
It is not mandatory for prison officers to have basic first aid training (which includes the provision of CPR) which is in-date. Once a prison officer’s three-year period has expired, whilst they may be reminded by the prison establishment that their certification is no longer live, it is not mandatory for them to renew this. For example, at HMP Manchester, at present 52% of prison staff received Emergency First Aid at Work (EFAW) training within the past three years as part of their initial officer training. Therefore, 48% of prison staff will have training certification (which includes CPR) which has expired. The evidence admitted was that the main reason for this is due to it not being mandatory for prison staff to have up-to-date training.