Jerome Jason Omri JONES · Prevention of Future Deaths report

On the 30th October 2017 I commenced an investigation into the death of Jerome Jason Omri JONES, 26 years of age.
The investigation concluded at the end of the inquest on the 18th to the 20th July 2018. The conclusion of the Jury in the Record of Inquest (ROI) was a narrative conclusion recorded in Box 4 as: The deceased passed away due to a combination of an underlying heart condition and the effects of a synthetic cannabinoid on his heart.

Recorded in Box 3 of the ROI the jury found that ‘proactive steps were taken to safeguard Mr Jones prior to the incident but these were ultimately insufficient’.

The deceased was a serving prisoner at the time of his death in HMP Stoke Heath. He had been transferred there in July 2017. He had a pre existing congenital heart defect and was a known user of New Psychoactive Substances (NPS). He died on 27/10/17 in the Princess Royal Hospital, Telford. Earlier that evening he had been found unresponsive in his cell having been suspected of using NPS. A post mortem revealed the cause of death as 1a) Sudden cardiac death 1b) congenital heart disease with fibrosis of the left ventricle and toxic effect on myocardium. Toxicology found a synthetic cannabinoid known as 5F-ADB in his blood. Between his arrival at Stoke Heath and his subsequent death on 27/10/17, Mr Jones had at least 3 known instances of NPS use the most recent on which was only a week before his death where he received emergency treatment although he was not admitted to hospital. A week later, he was again found unresponsive in his cell and was determined by paramedics to be in cardiac arrest. Despite concerted efforts to save his life by prison staff and paramedics he remained in PEA and was last duly pronounced dead at 21.10 pm at the Princess Royal Hospital. The inquest focused on the following central issues;

• The events leading up to the discovery of Mr Jones in his cell on 27/10/17;
• The measures taken by HMP Stoke Heath to manage both his heart condition and his known use of NPS with particular reference to the incident on 20/10/17;
• The measures taken by HMP Stoke Heath to Mr Jones mental health in so far as it related to his drug use;
• How Mr Jones was able to access NPS and what policies and procedures were in place at H M Prison, Stoke Heath to prevent this?
• If there was any delay in calling an ambulance to Mr Jones, the impact of any delay if it is possible to say.

(1)During the inquest evidence was heard that apart from some hourly checks by prison officers during the evening of the incident on 20/10/17 (the third known instance of NPS use by the deceased) no other specific checks were made on the deceased leading up to the date of his death . This was a prisoner who had 3 known instances of NPS use within a relatively short space of time. I heard evidence that the requirement for further checks would have had to come from the Healthcare team rather than from prison officers. I was told here is no policy or guidance to cover additional checks for a prisoner in a situation such as this.

(2)The inquest heard evidence from two Forward Trust Drug workers who although not medically qualified, considered that Mr Jones was at a ‘higher’ risk from NPS use due to using NPS with his existing congenital heart defect. I was told there was no method of communicating this to either Healthcare or prison officers to enable further periodic checks to be undertaken particularly in light of the recent incident on 20/10/17.

(3)The two Forward Trust Drug workers were only aware of Mr Jones existing heart condition because he disclosed this to them himself. This enabled them specifically to tailor their advice to cover the impact of Mr Jones continued NPS use on his heart. Forward Trust do not appear to have access to prisoner medical records for reasons of patient confidentiality and there does not appear to be any alternative way of ensuring they have all the information about a prisoner in order to help them with their drug use.