Coroner calls for better guidance for prisons on hooch and medication following death of prisoner

In July 2025 an inquest jury found that Sheldon Jeans, who was discovered dead in his cell on or about 13 November 2022, had died as a result of consuming hooch and four different medications that had not been prescribed to him, recording death by misadventure.

Now, a coroner has issued a prevention of future deaths (PFD) report in response to findings at the inquest, highlighting national policy and guidance relating to the handling of hooch and medication in prisons as areas for concern.  

The PFD report has been sent to the Department of Health and Social Care, HM Prison and Probation Service, HMP Guys Marsh, and Oxleas NHS Foundation Trust, requesting a response by 19 September 2025 detailing actions to be taken and a timetable for that action. 

In the report, the coroner draws attention to evidence given about the continual problem of hooch in prison – which is illicitly brewed from substances legitimately available to prisoners. In September 2022, shortly before Sheldon’s death, 215.5 litres of hooch were seized at HMP Guys Marsh.  

Hooch was described as a dangerous substance during the inquest, and has sedative effects which can be increased when consumed alongside certain medications.  

The coroner said that while policies are in place concerning the possession and use of illicit substances in prisons, these focus on drugs or medication and “remain silent in relation to alcohol”.

The coroner also raised concerns over prisoners having access to prescription medication that is not prescribed to them.  

Sheldon was found to have taken four different types of medication, none of which had been prescribed to him, alongside consuming hooch.  

At the inquest, the jury concluded that the substances in isolation would not have been fatal, but taken together caused a sedative effect which, combined with Sheldon’s body posture, led to respiratory depression. 

At the inquest, it was heard that prescription medication at HMP Guys Marsh can either be taken under supervision, or a prisoner is provided with the medication for them to keep and take in their cells. 

While it is not known how Sheldon accessed the medication he consumed, evidence was provided at the inquest about how prisoners are able to access each other’s cells during states of unlock – such as during meal collection times. 

In the PFD report, the coroner referred to evidence given at the inquest which demonstrated the “chaotic life some prisoners lead”, with medication shown to be left around cells and in unsecured Tupperware boxes, despite lockable cupboards available. 

The coroner raises concerns in the PFD report about the lack of guidance and policy on the storage of medication in possession of prisoners, and what to do when a prescription is discontinued to ensure that prisoners do not continue to possess leftover medication. 

Following the inquest, the jury concluded that Sheldon’s death had been by misadventure, and that while he had deliberately taken the substances, he had not intended to end his life. 

Sheldon's family said: 

“Prison is not just a place of accountability – it is also a place of rehabilitation, where people who experience problems with their mental health and substance abuse should be helped and supported. This PFD report from the coroner shows that, sadly, there are not adequate safeguards in place to help people with these issues. 

“The loss of Sheldon has been an immeasurable one to our family. We can only hope that lessons are learned from these awful circumstances, and that improvements are made to stop anything like this from happening again.” 

Leigh Day partner Benjamin Burrows, who represents Sheldon’s family, said: 

“The coroner has highlighted some key issues in her PFD report, following the inquest into Sheldon Jeans’s death. The inquest laid bare how easy it can be for prisoners to access dangerous substances which, in combination or excess, can prove to be deadly. Our hope is that steps are taken in prisons across the country, not just HMP Guys Marsh, to address these issues and to safeguard against this kind of tragic death occurring again.”