Nicholas Tom Rose · Prevention of Future Deaths report

On the 28th May 2019, an investigation was commenced into the death of Nicholas Tom Rose, born on the 18th June 1981.

The investigation concluded at the end of the Inquest on the 24th March 2022.

The Medical Cause of Death was:

1a Airway Obstruction

1b Aspiration of Gastric Content

1c 5F-MDMB-PINACA (“Spice”) Intoxication

The conclusion of the Inquest recorded by the jury was that Nicholas Tom Rose died as a consequence of misadventure.

Nicholas Tom Rose was a serving prisoner at HMP Guys Marsh at the time of his death. He was a resident on Jubilee Wing. On Sunday 19th May 2019 at approximately 8.45 am at the morning “unlock”, a welfare check was conducted. Mr Rose was in bed in his cell at this time. At 12.15pm, when the roll call was conducted, Mr Rose was found deceased in his cell on Jubilee Wing. Mr Rose was still in bed. A post mortem examination, including toxicological analysis of samples of fluid, revealed that Mr Rose had consumed “Spice” prior to his death, which led to the aspiration of gastric content and airway obstruction.

1. During the inquest evidence was heard that:

i. When Mr Rose’s cell was unlocked on the morning of 19th May 2019 at approximately 8.45 am and the welfare check was conducted, the evidence given was that Mr Rose responded with a “grunt”. Evidence was also heard regarding the “Notice to Prison Officers” number 191/2017, issued on 30th August 2017, which requires that a verbal response is elicited from a prisoner during a welfare check. The corresponding “Notice to Prisoners” number 083/2017, issued on the same day, instructs prisoners that they “must give a verbal response such as Good Morning/Afternoon, Hello”.
ii. Evidence was heard that a “grunt” in response to a welfare check is considered acceptable, and fulfils the requirement for a “verbal response”.

2. I have concerns with regard to the following:

i. I am concerned that accepting a “grunt” as a verbal response to a welfare check does not fulfil the requirement as set out in the Notice to Prison Officers mentioned above. Such a response gives very limited information upon which a prison officer can assess a prisoner’s welfare. Accepting such a response potentially loses sight of the purpose of a welfare check, which must be to check that the prisoner is alive, immediately safe and well; that is, that they are conscious, breathing, not in a state of distress, not in a state of intoxication and that there are not any other factors that might require immediate intervention to prevent harm. A verbal response to a welfare check allows a prison officer to assess if a prisoner has responded in an appropriate manner, giving an indication as to whether the prisoner retains the cognitive function to provide an appropriate response. A “grunt” does not allow such an assessment. Therefore, I have a concern that future deaths could occur if accepting such a response remains the accepted practice.