Ricardo Wayne Holgate · Prevention of Future Deaths report

On 06/04/2018 I commenced an investigation into the death of Ricardo Wayne Holgate. The investigation concluded at the end of an inquest on 10th January 2019. The conclusion of the jury at the inquest was:

At the time of Ricky’s death in March 2018, there was a significant issue with the supply and use of illicit substances within Birmingham prison. There was a failure to adequately control the supply and use of illicit substances within the prison.

There was an insufficient ratio of staff to prisoners. The staff were inadequately trained and insufficiently experienced in dealing with the use and effects of illicit substances.

There was a failure to rigorously implement the zero tolerance policy on the dealing and use of illicit substances in the prison. In the absence of a formal procedure about how to manage prisoners observed to be under the influence, staff made their own judgment about the response to an individual’s use of illicit substances.
Management of symptoms and formal reporting of individual use of illicit substances was inconsistent.

The staff response to Ricky’s use of illicit substances on 25th March was in line with the accepted processes at the time but did not comply with the zero tolerance policy.

The jury recorded the following:

Ricky was transferred to Birmingham Prison on 7th March 2018 and placed on K wing.

At 9:30am on 25th March 2018 a prisoner on K wing was observed under the influence of an illicit substance and returned to his cell.

Between 3 and 4pm, during association, Ricky was observed by a prison Officer with red eyes, walking slowly but talking and was thought to be under the influence of an illicit substance. This was not a cause for staff concern.

At 16:45, healthcare staff were called to attend a number of prisoners on K wing who were under the influence of suspected psychoactive substances. A verbal report about Ricky was made to them by prison staff.

By 5pm, Ricky was locked in his cell having been spoken to, while sat on the toilet, by a prison officer. Roll calls of the wing completed by 09:15pm and in the morning of 26th March by 6am.

On the morning of 26th March, during routine unlocking of cell K1 -27 Ricky was discovered by a prison officer lying face down on his bunk with no pulse. He was declared dead at 7.54. The post mortem confirmed his death was due to coronary artery thrombosis contributed to by his use of synthetic cannabinoids and prescription codeine.

Following a post mortem the medical cause of death was determined to be:
1a. CORONARY ARTERY THROMBOSIS
1b. CORONARY ARTERY ATHEROSCLEROSIS

2. COMBINED EFFECTS OF SYNTHETIC CANNABINOID AND CODINE

1. The new Governing Governor confirmed that further steps are necessary to improve the management of illicit substance misuse. He confirmed the prison requires CCTV on all wings and airport style scanners – one in reception for prisoners and one in the visitor area.

2. Much progress has been made as a result of the appointment of the Governing Governor Paul Newton. His appointment was for 6 months. He advised at the inquest that there is much more work to do and extension of his appointment would allow further work to be undertaken to reduce the use and supply of illicit substances in the prison and to keep inmates safe.