Jury at inquest find failings contributed to death of a prisoner

May 13, 2024

David Baines represented the family of a prisoner in a six-day inquest heard at the Lancashire and Blackburn with Darwen Coroner’s Court.

The deceased had been found collapsed in his prison cell on 15 August 2022. An ambulance had been called but was stood down after staff assumed the deceased was under the influence of Psychoactive Substances. Instead a welfare log was opened and the deceased was monitored intermittently, remaining in a semi conscious state on the floor of his prison cell for nearly 15 hours before he tragically died.

Post mortem analysis revealed the presence of Amitriptyline, a controlled drug, in his system. A quantity of this medication had been found in his prison cell when he was initially found collapsed, although a differential diagnosis was not considered by staff namely that he had been suffering from the adverse effects of Amitriptyline, a highly cardio-toxic drug.

The jury found that there was a failure to identify that the deceased had not been prescribed Amitriptyline, and a failure to consult ‘TOXBASE’, the national poisons database, in order to determine the toxicity of Amitriptyline if taken in excess.  If TOXBASE had been consulted, the evidence was that this would have informed staff of his condition and resulted in an immediate referral to hospital for assessment and treatment, and had this occurred early enough the deceased would not on the balance of probabilities have died when he did on 16 August 2022.

The jury concluded that the death was accidental, and was contributed to by the above failures.

Following a submission by the family, the Coroner issued a Regulation 28 report to Prevent Future Deaths.

David Baines was instructed by Kelly Darlington of Farleys Solicitors.