Daniel Paul Mark Stokes · Prevention of Future Deaths report

On 4th December 2015 I commenced an investigation into the death of Daniel Paul Mark Stokes, 34. The investigation concluded at the end of the inquest on 2nd November 2018. The conclusion of the inquest was Misadventure.

Daniel Paul Mark Stokes was an inmate at HM Prison, Lindholme, Doncaster. On 30th November 2015, it is reported by another prisoner that the deceased had described taking an amount of MDMA and was acting erratically. The deceased showed features of physical agitation, culminating in cardiac arrest. Despite assistance from prison and paramedic staff, Mr Stokes could not be revived, being declared deceased on the same day at 20:05 hours on the 30th November 2015.

(1) Part of the evidence in this case related to the attendance of prison healthcare staff who were in the possession of diazepam, but not trained/authorised to administer it. Whilst there may be good reason for this (ie so that diazepam is available at the scene of an incident if someone attends who is so trained/authorised) nonetheless, the jury which considered the case clearly considered that this amounts to a failure to have proper systems in place. I therefore adopt their view as a matter of concern, such that I consider consideration should be given to the practicality of requiring healthcare staff working within prisons to be trained/authorised to administer diazepam in circumstances where a prisoner may be suffering from the effect of abuse of controlled drugs.