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Investigation and inquest
On the 17th September 2016, an investigation was commenced into the death of Andrew Craig, born on the 1st November 1985.
The investigation concluded at the end of the Inquest on the 12th June 2018.
The Medical Cause of Death was:
1a Toxic Effects of Buprenorphine and Diazepam
The conclusion of the Inquest was misadventure.
Circumstances of the death
On the 16th September 2016 Mr Craig, a serving Prisoner at HMP Guys Marsh, was found in a collapsed and unresponsive condition in his cell, B57 on the Wessex Unit at the Prison. Mr Craig suffered with back pain and he disclosed that he was obtaining non-prescribed, prescription drugs on the Unit which he was taking illicitly.
Coroner’s concerns
1. During the inquest evidence was heard that:
i. The use of drugs on the Units at HMP Guys Marsh is rife and these drugs can be transferred between inmates at any time. One of the occasions when prescription drugs can be concealed in order that they can distributed by Prisoners, is following the dispensing of medication at the Healthcare Unit’s medication hatch.
ii. Evidence was given by the Head of Healthcare, ████████ that there are 3 allocated times during the day when Prisoners collect medication. During these times, there are around 70 prisoners collecting their medication. The room can be quite chaotic and loud, and prisoners can be in close contact clambering over each other. She described the hatch as overloaded. This is an ideal scenario to pass medication to one another without detection.
iii. In addition, during the routine medication dispensing, there are no checks done to confirm that Prisoners have actually swallowed the medication. This can allow them to retain the medication for redistribution.
iv. At the last inspection by Her Majesty’s Inspectorate of Prisons these issues were raised and attempts have been made to improve the situation. There are now Prison Officers at the Healthcare department during dispensing times, but usually only one Officer stood in the room where the medication hatch is located and another outside the room. Despite these changes, Mrs Jameson advised that the arrangements at medication dispensing times continue to be an ongoing problem that facilitates the illicit supply of prescription drugs in the Prison. She advised that the process could be made safer and more secure. Similar concerns were also raised by one of the Prison GPs ████████
████████
v. Mrs Jameson also gave evidence that the Prison is overwhelmed with illicit drug use, particularly psychoactive substances and that the Healthcare team receive 3 emergency calls a week at HMP Guys Marsh to assist in resuscitating Prisoners from drug overdoses.
2. I have concerns with regard to the following:
i. There is an ongoing problem with the use of drugs, both prescription and illicit drugs such as psychoactive substances, at HMP Guys Marsh and there have been a number of recent deaths either confirmed to be, or suspected to be, due to drug use.
ii. Although the Prison are working to address this, further consideration needs to be given to restricting the supply of such drugs. I would request that to prevent a future death at HMP Guys Marsh, there is a review of the policies and procedures by both the Prison Staff and the Healthcare Staff regarding the dispensing and monitoring of the medication administered at the medication hatch to ensure compliance and reduce distribution to others.
Information checked against the published report and official responses