Ms. Amy Jo Cross · Prevention of Future Deaths report

On 4th July 2023 I commenced an investigation into the death of Ms. Amy Jo Cross age 31 years. The investigation concluded at the end of the inquest on 3rd October 2025. The conclusion of the jury was that the medical cause of death was 1(a) Consequences of chronic alcohol misuse with sudden cessation of alcohol consumption. The conclusion of the jury as to the death was natural causes.

On 9th June 2023 Ms. Cross was arrested by police officers in Torquay and taken to Torquay Police Station where she was detained. She reported withdrawal symptoms due to drugs and/or alcohol and was seen at the police station by a registered nurse from Mitie Care & Custody. No medication was administered at that time. That same day Ms. Cross was transferred to Exeter Custody Suite where she was seen the following morning, the 10th June 2023, by a paramedic from Mitie Care & Custody. There were concerns that she was still experiencing withdrawal symptoms and Ms. Cross was administered dihydrocodeine and diazepam for opiate and alcohol withdrawal respectively.

A short while later she was then taken to Exeter Magistrates Court for a court appearance. Whilst in the court cells she reported feeling unwell with nausea and gastrointestinal symptoms and was seen by a registered nurse from IPRS Aeromed. Ms Cross was administered cyclizine tablets for her nausea and omeprazole tablets for her gastrointestinal symptoms.

Following the court appearance Ms. Cross was remanded in to custody and transported to HMP Eastwood Park where she arrived at around 15:45 hours on 10th June 2023. Ms. Cross reported that she was feeling nauseous and had vomited on the journey to the prison. As part of the reception process at the prison she was seen by a paramedic from Practice Plus Group who was concerned that Ms. Cross had withdrawal symptoms. A video consultation then took place a short while later at around 16:52 hours with a GP also from Practice Plus Group who prescribed methadone and diazepam for opiate and alcohol withdrawal symptoms respectively.

At 18:43 hours, before any medication was administered to Ms. Cross, she was found unresponsive in her cell. A Code Blue was sounded and paramedics attended. Despite all efforts she could not be resuscitated and she was pronounced dead at 19:47 hours.

During the course of my investigation I became aware that the only information relating to Ms. Cross which was passed from the police, to the prisoner escort service operated by Serco, to the court, and to the prison was the digital Person Escort Record (PER). This document completed initially by a police officer in Torquay did not have up to date details of any medical interventions and no further details were added later. When Ms. Cross arrived at the prison it was not known to healthcare professionals at the prison as to what medication had been administered either at a police station or at the court. There was no system in place to transfer healthcare related information or any clinical records between the various organisations involved in Ms. Cross’ care on the 9th and 10th June 2023.

(1) There is no system to ensure that important healthcare information including recent administration of medicines and the results of physical observations is passed between separate providers of healthcare in the criminal justice system at the time a person is conveyed between the police, the court and the prison.
(2) There is no standard medical records system which can be accessed by each healthcare organisation to ensure the efficient and effective transfer of medical information.