Scott Patrick Carton · Prevention of Future Deaths report

On 12 January 2017 an investigation was commenced into the death of Scott Patrick Carton, aged 38. The investigation concluded at the end of the inquest on 6 September 2018. The conclusion of the jury inquest was a narrative conclusion, including a medical cause of death of 1a Mixed Drug Poisoning.

Scott Patrick Carton was released from Prison on Thursday, 5 January 2017 subject to licence conditions which included the requirement that he reside at approved premises known as the Westgate Project Hostel, Wakefield.

After a turbulent weekend he was found dead in his room at the hostel on Tuesday, 10 January 2017. He died from the synergistic combination of drugs which had been prescribed for him - methadone, pregabalin and tramadol.

1. A probation report dated 18 July 2016 recommended Mr Carton’s release on licence, notwithstanding a failed release on licence in summer 2015, in which he swiftly reverted to illicit drugs. The 18 July 2016 report envisaged specialist psychological input at Approved Premises which had access to psychological resources and a ‘robust risk management plan in place’ In the event Mr Carton was sent to a different hostel which did not provide psychological inputs of the type envisaged, nor was any clear management plan communicated to the hostel staff who had to deal with Mr Carton's challenging behaviour. The likelihood of the hostel placement proving beneficial was thus compromised from the outset.

2. The parents’ strenuous attempts to alert the Probation Service to the difficulties their son faced and the need for a placement at Approved Premises in a different area so as to avoid his drug connections, went unheeded.

3. Evidence was taken from several witnesses who expressed views to the effect that the Westgate Project was not the appropriate place for Mr Carton as he needed ‘medical help’

4. Having been diagnosed with an emotionally unstable personality disorder in 2013 Mr Carton needed to be allocated to a prison establishment which did provide appropriate psychological interventions. In the event he was placed in HMP Wealstun which did not provide such services. This diminished any prospect of him succeeding in the community when released.

5. Evidence taken at the inquest emphasised the paucity of psychological resource available to prisoners released on licence with emotionally unstable personality disorder and drug dependence issues. In consequence, individuals such as Mr Carton are released into the community when they are ill prepared. Unless adequate resources are available the result is likely to be that individuals will consume police and hospital resources as their condition deteriorates to the point where they are recalled to prison or their life ends in tragedy.

6. To maximise the prospect of a successful reintegration into society, prisoners with mental health issues and/or drug dependence need appropriate support services to be in place prior to their release and arrangements made to have them registered with a GP immediately (so as to provide a conduit to community mental health services)