John Paul Pace · Prevention of Future Deaths report

On 30 July 2020 I commenced an investigation into the death of Mr John Paul Pace. The investigation concluded at the end of the inquest on 25 October 2023.

The conclusion of the inquest was a short form conclusion of “Drug Related Death”.

On 29 November 2019, Mr John-Paul Pace was recalled to prison after being arrested for a drug related offence. He was sent to HMP Chelmsford. When he arrived at Chelmsford, Mr Pace tested positive for both opioids and ████████. He was put on a drug detoxification programme and was prescribed methadone (an opiate substitute), which was progressively reduced over the following months. He was under the care of the GP to manage his depression and of the Integrated Drug Treatment Services to manage his drug use. On 28 May 2020, Mr Pace stopped taking methadone, before he had completed the methadone reduction programme. He was prescribed medication to help with the expected withdrawal symptoms. Shortly after 8.00am on 22 July 2020 Mr Pace was found unresponsive. An ambulance attended the prison and Mr Pace was certified dead at 8.16am.

• Mr Pace was serving a prison sentence at HMP Chelmsford for a drug related offence;
• Mr Pace was under the care of the Integrated Drug Treatment Service delivered by Forward Trust and was following a methadone detoxification programme;
• Mr Pace decided to stop methadone against medical advice before completing the detoxification programme;
• The post mortem examination concluded Mr Pace’s likely medical cause of death was “synthetic cannabinoid misuse”. The synthetic cannabinoid in question is known as ‘████████’.

The organisations responsible for the delivery of drug related services at HMP Chelmsford are Castle Rock Group (CRG) as the main contractor of health related services and Forward Trust as their sub-contractors for the drug treatment element of the service.

One of the material issues in evidence was about changes in the discharge pathway for prisoners on methadone detoxification as well as those who decided to stop the detoxification programme before completion. CRG identified the need for this change in their Root Cause Analysis review and their live witnesses provided evidence that this new process is now being followed. Forward Trust provided evidence that this is the new process now embedded in their operating procedure. However, no documentary evidence of this new drug detoxification discharge pathway seems to exist, no protocols, no written procedures, no policy, no addendum to existing policies and procedures.

It is my concern that this new discharge pathway aimed at providing monitoring and support to prisoners who stop or complete the programme whilst in prison, has not been embedded in your organisations’ operating procedure and as such, there is a risk to prisoners in the future as compliance with the new discharge pathway and consistency of operations cannot be ensured.