Mohammed Shabol AHMED · Prevention of Future Deaths report

On 6 March 2019 I commenced an investigation into the death of Mohammed Shabol AHMED, aged 33. The investigation concluded at the end of the inquest on 14 March 2019. The conclusion of the inquest was that the medical cause of death was unascertained and the conclusion Open. The jury also made the following findings of fact which caused or contributed to the death:

a) The system at the prison relied upon the hospital and healthcare to tell the prison what to do regarding prisoner welfare
b) There was a serious failure in the sharing of information between the prison, healthcare and the hospital
c) There was inadequate training in the prison to deal with drug related incidents and their aftermath.

Shabol Ahmed, a long-term illicit drug user, had been imprisoned at HMP Highpoint South for offending behaviours linked to his drug use. He was first imprisoned at the age of 18 and had been detained at different prisons. At the time of his death he had been an inmate at Highpoint since 21 June 2012, with a period at HMP Grendon from August 2016 to January 2016. He arrived at Highpoint with a diagnosis of Schizophrenia for which he had been prescribed olanzapine. He also had a Learning Disability. His olanzapine prescription was maintained in prison, although he was not always compliant. The evidence before the inquest was that he may have regularly used Spice in prison and had succumbed to the effects of it on at least three occasions. On two of those occasions he collapsed activating a code blue on 27 May and 18 July 2016. On 18 July he collapsed at 5pm. Healthcare attended and an ambulance transferred him to hospital. The effects of Spice were beginning to wear off by the time the ambulance arrived at 5.15pm. At 6.45pm the ambulance left the prison arriving at the hospital at 7pm. When seen by the Consultant at 7.10pm his observations were
normal. He required no treatment and was returned to the prison at 9.25pm with no requirements for observation overnight. After having eaten he slept in his cell. The following morning at 6.20am Mr Ahmed was found deceased at roll call.

(1) The expert evidence of ████████ (Emeritus of Forensic Medicine) gave evidence that the use of Spice can prime a person for an allergic reaction. In the case of Mr Ahmed Olanzapine and Spice combined to cause an adverse allergic reaction. He had been prescribed Olanzapine throughout his imprisonment in the knowledge of Spice use.

(2) Healthcare records demonstrated that his eosinophilia count was recorded as reduced following a change in medication from Olanzapine to Risperidone.

(3) The expert evidence was that it was a very rare side effect but one which the U.S. Food and Drug Administration has warned that drug reaction with eosinophilia and systemic symptoms has been reported with olanzapine exposure.

(4) The jury was not able to find that the death was caused or contributed to by the use of Spice. It remains unclear whether the expert opinion is one which is or should be made known to clinicians nationally.