Ben Maslin: Jury find multiple failings from healthcare and prison staff at HMP Chelmsford contributed to death of vulnerable 36-year-old

Ben Maslin died on 17 October 2018 at Broomfield Hospital. Ben was transferred to Broomfield Hospital from HMP Chelmsford on 4 October 2018 after being found unresponsive in his cell that afternoon. Ben had also been found unresponsive on the morning of 4 October 2018, resulting in an emergency call. Multiple failings were found across both prison and healthcare staff, a number of which were possibly causative of Ben’s death.

During 11 days of evidence, the inquest jury heard:

• At HMP Chelmsford around the time of Ben’s death, drugs were as easy to access as tea bags;
• The nurses who treated Ben described the situation within the prison as “dangerous” due to low staffing levels around the time of Ben’s death and one revealed that she had been part of a whistleblowing complaint made by six nurses to Essex Partnership University NHS Foundation Trust prior to Ben’s death;
• Prison staff were aware that illicit substances would be gifted to vulnerable people in prison by those distributing the substances within the prison in order to test the potency of new substances or batches;
• Ben was prescribed various medications with sedative effects from multiple prescribers within the prison, which may have placed him at higher risk of adverse effects from his known illicit drug taking. Despite this, no person had overall responsibility for the management of his prescriptions and the risk of dangerous interactions; and,
• Despite being managed under ACCT procedures (the Prison Service care-planning system aimed at supporting those at risk of suicide or self-harm), Ben’s triggers for self-harm were not recorded or managed effectively, leading to a lack of adequate safeguards.

The jury concluded that prison and healthcare staff did not sufficiently consider or adequately manage the inter-relationship between Ben’s mental disorder, self-harm and illicit drug taking, which possibly contributed to his death. The jury also found further failings, including:

• The healthcare response and subsequent level of observations and processes were inadequate after Ben was found unresponsive on the morning of 4 October 2018, which possibly contributed to his death;
• Insufficient safeguards were in place and maintained upon Ben’s transfer to D Wing on 1 October 2018;
• There was a delay by prison officers in calling an emergency ‘Code Blue’ when Ben was found unresponsive for the second time on 4 October 2018;
• The quality of recorded observations, in place to protect Ben’s safety, were lacking; and,
• There was insufficient training and support available to healthcare staff in relation to the symptoms and effects of Novel Psychoactive Substances (NPS).

In addition to the failings identified by the inquest jury, the Ministry of Justice admitted that there was a delay in the wing emergency bag containing oxygen being brought to Ben’s cell in response to both of the emergency calls on 4 October 2018. The inquest jury heard that nurses would have administered oxygen earlier if the bag had been brought before they arrived at the cell.

HM Coroner is considering a number of matters of concern which may give rise to her duty to issue a Preventing Future Deaths report and has requested that further information be provided by the prison and healthcare provider within 21 days of the conclusion of the inquest hearing.

Since 2018, HMP Chelmsford has been in special measures¹ as a result of concerns about safety, a negative staff culture, a lack of accountability and management oversight and a poor daily regime for prisoners. 

The full inspection of HMP Chelmsford by Her Majesty’s Inspectorate of Prisons (HMIP) prior to Ben’s death (in May and June 2018) raised numerous concerns at prisoners at risk of self-harm and suicide were managed, including that repeated recommendations from the Prison and Probation Ombudsman had not been implemented – including poor assessment and management of prisoners’ risk of suicide and self-harm.

Following an unannounced inspection of HMP Chelmsford in August 2021, the Urgent Notification process was invoked following significant concerns about the treatment of and conditions for prisoners.² Inspectors emphasised that the findings of this inspection were particularly disappointing bearing in mind the observations made in 2018. 

Ben’s family were represented by INQUEST Lawyers Group members Sam Hall of ITN Solicitors and Adam Wagner of Doughty Street Chambers.

[1] https://www.justiceinspectorates.gov.uk/hmiprisons/media/press-releases/2021/08/hm-chief-inspector-of-prisons-demands-urgent-action-from-secretary-of-state-over-continued-safety-concerns-at-chelmsford-prison/#:~:text=Since%202018%2C%20HM%20Prison%20and,governor%20has%20also%20been%20appointed.

[2] https://www.justiceinspectorates.gov.uk/hmiprisons/inspections/hmp-yoi-chelmsford-urgent-notification/