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Inquest concludes that a vulnerable prisoner left in “inhumane and degrading” circumstances died after overdosing on medication which was not safe to be in his possession

An inquest found that allowing David Morgan, 35, a vulnerable prisoner with a history of self- harm and a previous victim of serious assault and bullying in prison, to have medication in his possession contributed to his death, while he was an inmate at HMP Chelmsford.

David Morgan died in Broomfield Hospital on August 30, 2018 – eight days after falling unconscious in a holding cell, where prison staff ignored his condition and mocked him as he was dying.

David’s family was represented by Tom Stoate of Doughty Street’s Inquests and Inquiries Team, instructed by Gimhani Eriyagolla of Hodge Jones & Allen.

David Morgan became unwell after being told he would be transferring to HMP Wayland, where he told prison staff that feared for his life from known associates. Despite David’s concerns for his own life and requests to go to hospital – and it being widely recognised in national prison policy that transfer to a new prison is a particularly vulnerable time for prisoners – HMP Chelmsford staff did not take any steps to investigate his fears.

As a result David, fearing that his transfer would go ahead, took an overdose of medication which had wrongly been prescribed to him “in possession”. He informed a prison officer he had done so, handing over two empty pill packets. These packets were handed to a supervising officer, who was persuaded by other officers to carry out an internet search for the drug, Baclofen (in the inquest the supervising officer denied that he had ever seen the blister packets and the packets, which one officer said were simply thrown in the bin that morning by the supervising officer, were never found).

Despite an attempt to call prison healthcare (a note in the prison wing observation book stating that healthcare had been informed David had taken an overdose “and what he has taken”.) No healthcare staff ever attended David’s cell on the prison wing.

During the morning of 22 August 2018 David called his mother from the phone in his cell, telling her he was terrified of moving prison; that he had taken an overdose and was being ignored. David’s mother telephoned the prison to raise her concerns, although the inquest heard there was no evidence that any action was taken or anyone informed. Prison staff attempted to contact healthcare but the nurses made no effort to prioritise David as a medical emergency and failed to check his prescription records.

National prison policy dictates that prison staff must begin Assessment Care in Custody and Teamwork (ACCT) procedures – aimed at reducing self-harm and violence amongst prisoners – as soon as they receive any evidence which may indicate a risk of self-harm. In clear breach of policy, this procedure was never started – one prison officer gave evidence that he was specifically told not to open an ACCT by the same supervising officer.

At the inquest, the current Governor of HMP Chelmsford, Garry Newnes, accepted that David should not have left the wing and that an ACCT should have been opened as soon as staff were informed of the overdose.

Instead, David was forcibly restrained, screaming in pain and telling prison staff he was “off his nut on medication” and needed to go to hospital. He was then forcibly and unnecessarily escorted to the prison in handcuffs to that he could be transferred.

Body-worn video footage taken en route to reception captured David repeatedly telling prison staff he needed to go to hospital. Staff continued to restrain David without asking him what he had taken or even acknowledging his overdose.

Officers from David’s wing in the prison told the inquest that they alerted reception staff to the fact that David had taken an overdose of his medication. One reception officer made a call to healthcare to alert them that someone was coming in ‘under the influence’ and that they required a nurse at reception. When the nurse arrived, the same officer gave evidence that she told the nurse in person that David had taken an overdose of his medication.

David was strip-searched in the prison reception. By this time body-worn video footage captured him looking dazed, confused, distressed and unable to speak or respond. David vomited into a bin whilst prison staff were heard on video telling him he was “drunk” or “pissed”. One officer laughed loudly at David, saying “had a bit of the old bubble hooch haven’t you?” (a reference to illicit alcohol brewed in prison) – to which David was unable to respond.

The nurse in charge of prison healthcare that day, who was present and looked on during this strip search said of David: “He does always look this gormless”.

David was then taken to a holding cell in reception, where his condition deteriorated over a period of three hours before an ambulance was finally called.

CCTV and body-worn video footage shows that, during that time, David was mocked, laughed at, imitated and ignored, and referred to as “this idiot” and “acting like a child” by a nurse and various prison staff when he was barely conscious, seriously injured, covered in blood and screaming in pain.

As the effects of the medication overdose took hold David lost control of his body, repeatedly smashing his head hard against the floor and metal bench in the holding cell, breaking his nose and causing injuries to his face. At one point David fell over and fractured both ankles.

Throughout this time, the nurse in charge that day remained outside the cell, at no point does the nurse enter to check on David, to attend to his wounds or to protect him from further injuring himself.

Prison officers passed by the cell or stood outside drinking cups of tea and laughing together – giving evidence that the nurse told them an ambulance was not required. Various prison officers said they continued to believe that David was simply drunk on “hooch”, and denied that they were ever aware that David had taken an overdose.

The current Governor of HMP Chelmsford, Mr Newnes, told the inquest accepted that the treatment David suffered was “nothing short of inhuman and degrading”, and that there had been a total failure of healthcare and prison staff to discharge their duty of care towards David.

Despite the fact that only three prison officers were disciplined following David’s death, Mr Newnes accepted that there should have been disciplinary action against all officers involved with David on that day, including those at a senior level.

The inquest was also told by the current head of Prison Healthcare, Paula Unwin of Castle Rock Group, that the culture of the prison healthcare provider at the time, Essex Partnership University Trust (EPUT) – which is currently the subject of a non-statutory independent inquiry - was “toxic” and “dysfunctional”; that “bullying” from management was commonplace, and that and prescribing practises were unsafe and often misunderstood by prison GPs. One experienced prison officer gave evidence that healthcare at HMP Chelmsford was the worst he had ever seen in his career.

Eventually, after being in a holding cell for over two hours, a healthcare assistant (a junior member of the healthcare team who is not a qualified nurse or medic) arrived on shift and told the inquest she was “shocked” at the state that David was in. She entered the cell to check David’s observations, clean his wounds and ensure that he was kept in a safe position without causing further injury or damage to himself. She also asked prison staff to contact an ambulance.

The ambulance arrived shortly after 14:00 by which time David was in the deepest level of coma measurable.

David was taken to hospital where treatment was unsuccessful, and he died eight days later of multiple organ failure as a result of a multiple drug overdose.

The current governor of HMP Chelmsford, Mr Newnes, offered an apology to David’s family and acknowledged that the lack of any such apology in nearly four years was “shocking”. EPUT declined to offer the family an apology.

David’s inquest was covered by Simon Israel for Channel 4 News.

David’s family was supported by INQUEST, whose coverage of this case can be found here.