Brett Anthony Marrs · Prevention of Future Deaths report

On 17th September 2018 an investigation into the death of Brett Anthony Marrs aged 40 was commenced. The investigation concluded at the end of the inquest on 22nd September 2020. The conclusion of the inquest was that the death of Brett Anthony Marrs who died as a result of synthetic cannabinoid and morphine toxicity was drug related.

The deceased who was a long-term drug user was found collapsed in his cell after morning unlock on 4th September 2018. The officer unlocking the cell had not checked on the welfare of the deceased and the two officers who commenced resuscitation had not had any first aid training during their time in the prison service.

1. Two long-serving prison officers who gave evidence at the inquest deposed to the fact that they had never been given first-aid training, including training in resuscitation techniques, during their service as prison officers despite the fact that prior to 2016 such training was meant to form part of core training for prison officers. Evidence was further given that first aid refresher training is to be rolled out but that no date has yet been fixed for completion of such training programmes.
These matters are drawn to your attention so that you might consider:
(a) Identifying any further officers who have never been given first aid training and rectifying this deficiency
(b) Setting a target date for completing refresher training.

2. CCTV footage viewed at the inquest showed a prison officer conducting a first morning cell unlock on C wing without conducting even the most basic of welfare checks and this despite clear notices from management drawing to the attention of staff the necessity of carrying out welfare checks, particularly at the time of the first morning unlock. Evidence was heard to the effect that this was not an isolated instance. Given that notices and reminders appear not to have achieved uniform observance, you are asked to consider how better compliance with welfare checks can be achieved.