Fallon Leanne ADAMS · Prevention of Future Deaths report

On 10 February 2023 I commenced an investigation into the death of Fallon Leanne ADAMS aged 37. The investigation concluded at the end of the inquest on 28 November 2025. The conclusion of the inquest was that:

Fallon came to her death by intoxication of mixed drugs where the illicit obtaining of ████████ had a high probability of causing her death.

Failure to conduct adequate welfare checks and observations allowed for missed opportunities to intervene. Evidence of this was staff admitting to not being able to confirm respiratory movement observations, observations of movement and general observations of inmate.

Unsatisfactory training was also highlighted in the evidence however this did not cause or minimally contribute to Fallon's death.

Fallon came to her death between 18:33 on the 8/2/23 and 7am on the 9/2/23.

She came to her death on the top bunk of cell 8, wing B1 of HMP Peterborough.

On Thursday 9ᵗʰ of February 2023 at approximately 0657hours, the alarm was raised by the cell mate of Ms ADAMS in her cell at HMP Peterborough. Staff arrived on scene and found Ms ADAMS unresponsive and cold to the touch, they called for an ambulance and an ambulance crew arrived and declared Ms ADAMS deceased at 0715hours after a negative heart trace. CPR had been attempted by Prison staff.

Ms ADAMS had arrived at HMP Peterborough 8 days prior to her death and had been sharing a cell for the entirety of her time at the prison. Ms ADAM’s cell mate describes that during the days prior to her death, Ms ADAMS was heavily medicated ████████ and described her has “BEING OFF HER FACE MOST OF THE TIME”.

Onthe day before her death, 8th of February 2023, Ms ADAMS’ states that during the evening, Ms ADAMS was lying on the top bunk and she was slouching over the top, she then fell off the bunk and hit her head. Ms ADAMS’ cell mate states that she then put Ms ADAMS to bed and tucked her in, she checked her head for injuries no lumps but could not see any. She last spoke to ADAMS at 1930hours when Ms ADAMS asked her if another prisoner had dropped off the laundry. Ms ADAM’s could be heard snoring until 2000hours when the cell mate herself fell asleep. Staff checked on the cell at 0559hours it was a visual check through the cell hatch, the officer recorded that he could see Ms ADAMS moving.

Ms ADAMS’ cell mate woke at 0625hours and confirmed this was the time by turning on the TV in the cell. She shouted to Ms ADAMS to wake up but got no reply. She then went to check on her and touched her neck, she states it was cold, she then lifted her leg and describes it as a dead weight, she then raised the alarm and staff arrived on scene and began CPR.

According to prison medical records , Ms ADAMS was on the following medications:

• Chlordiazepoxide 10mg
• Ibuprofen 400mg
• Mebeverine 135mg
• Methadone 1mg
• Metoclopramide 10mg
• Thiamine 100mg
• Sertraline 50mg

• Whilst an inmate at HMP Peterborough Fallon ADAMS was prescribed methadone (for opiate withdrawal) and chlordiazepoxide (for alcohol withdrawal). She also took non-prescribed ████████ apparently obtained from an illicit source within the prison. All of these medications have a sedative effect which in combination have the potential to cause over sedation and death.

• The evidence seemed to show that at no stage was Ms ADAMS given a specific warning or advice stating that taking additional non-prescribed medication ████████ could result in over sedation and death.

• I also heard evidence in relation to Regulation 28 issues. Whilst it is clear that a number of relevant changes were being made it was not clear that a specific warning in relation to the risks of over sedation was being implemented.