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Jury find a number of failings in drug-related death at HMP Brixton

52-year-old man who was found dead in his cell in 2010 had been prescribed detoxification regime without being assessed by a doctor

27 June 2014

Following a 3-week Inquest at Southwark Coroner’s Court, a jury has concluded that the death of a 52-year-old Scottish man at HMP Brixton in July 2010 was caused by the simultaneous use of methadone and diazepam.

Mr John Hay was remanded into custody at HMP Brixton on 10 July 2010. Prior to that, he had been homeless and had a complex history of substance misuse problems for both alcohol and drugs.

Upon his imprisonment, Mr Hay was prescribed a treatment plan of methadone for his opioid addiction and diazepam for his benzodiazepine addiction. However, seven days after his imprisonment, he was found dead in his cell by prison officers on 17 July 2010.

The Jury heard evidence from Dr Marcus Bicknell, a substance misuse expert appointed by the Coroner, who stated that the simultaneous use of methadone and diazepam “quadrupled” the risk to a patient, and was of particular risk to those patients who were older, such as Mr Hay. Accordingly, a cautious approach should be adopted when prescribing the drugs and reviewing their effects.

In concluding that Mr Hay’s death was caused by the simultaneous use of methadone and diazepam, the Jury found that “there were a number of failings during his time in custody”.

These findings included the failure of a doctor to see and assess Mr Hay before prescribing the methadone and diazepam regimes and the failure to have a comprehensive system for observing and monitoring Mr Hay for signs of oversedation. The Jury concluded that, without these failings, Mr Hay’s treatment plan may have been adjusted to meet his personal medical needs.

The Jury, who heard evidence from over 30 witnesses, heard evidence that the practice of patients being prescribed drug and alcohol detoxification regimes without being seen or assessed by a doctor was “common and not unusual” at HMP Brixton at the time. The Coroner, as part of her duty to take action to prevent future deaths, is shortly to hear submissions from the interested persons to the Inquest on whether or not the circumstances of Mr Hay’s death give rise to a risk of future deaths.

There were seven interested persons to the Inquest in addition to the Family, who are represented by solicitors Leigh Day and supported by the charity INQUEST. In commenting on the Jury’s conclusions, Benjamin Burrows a solicitor in the prison law team at Leigh Day, stated:

"The Family are relieved that the Inquest process is finally over. It has taken almost four years for the Family to find out the cause of John’s death and for them to obtain some form of closure. However, the Family were shocked by some of the evidence they heard relating to the circumstances of John’s death at HMP Brixton in July 2010.

It must be recognised that prisoners with complex histories of substance misuse, such as John, are at particular risk when they come into prison. Therefore, particular caution should be taken when deciding how to treat them. However, the picture that was painted of HMP Brixton at that time was one of chaos, with a lack of clinics for doctors to see and assess prisoners before prescribing treatment plans.

Therefore, the Family welcomes the Jury’s findings and hope that the circumstances of John’s death will help to highlight the risks associated with treating prisoners with substance misuse problems and ultimately prevent any such future deaths.”

Mr Hay was represented at the Inquest by Maria Roche of Doughty Street Chambers, a recognised expert in inquests, healthcare and human rights law.

Please contact Benjamin Burrows for further details.

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