Ian Anthony Charles Miller · Prevention of Future Deaths report

On 27/9/2019 an investigation was opened into the death of

Ian Anthony Charles Miller

The investigation concluded at the end of the inquest on 9/12/2021 when a jury determined the following:

The conclusion of the inquest was recorded as a narrative in the following terms

Ian Miller was serving a term at Her Majesty’s Prison Usk and was due for release on 27th October 2019.

On 20th September 2019 Ian attended a probationary meeting during which he was informed that he would not be able to live at the family home or with his father-in-law. He could not have unsupervised contact with his children, and he might be homeless.

Key persons present at the meeting did not have a prior relationship with Ian and did not know how devastating this news would be to him, and he was not placed under closer supervision.

On 21st September 2019 Ian Miller took his own life by suicide. Ian ████████. Despite efforts by prison staff and the emergency services, Ian could not be revived, and he died in the prison at 16:55 hours.

The medical cause of death was:

1a) Hypovolaemic shock
1b) Bleeding from radial artery
████████.

The circumstances of Ian Miller’s death are set out in the narrative provided by the jury and need no further explanation.

1. The management of medication prescribed to prisoners.

At post mortem examination the toxicologist determined that there were a number of drugs in Ian’s blood and urine that he had not been prescribed.

The court was informed that at HMP Usk, all prisoners are required to be capable of managing their own medication. The medications are not kept in a locked facility. The evidence provided clearly indicated that prisoners were trading prescribed medication which had become a form of currency within the prison. Ian’s former cellmate indicated this practice was rife and indeed Ian bought medication from other prisoners. Evidence was heard from the Governor / Head of Safety at HMP Usk who informed the court that he was not aware of this practice, and it appears this was also not known by the prison officers.

The court was informed that there is a system of randomised checks in place within the prison to attempt to determine whether prisoners are appropriately managing their medication, however prisoners have clearly found ways around this.

Whilst the ingestion of unprescribed medication did not contribute to Ian’s death, this practice, if left unchecked, clearly puts the lives of other prisoners at risk in the future.