“During the inquest evidence was heard that apart from some hourly checks by prison…”
Dated 1 Aug 2018, from the coroner for Shropshire, Telford and Wrekin. Sent to 2 organisations or people.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
Report put online after its 56 daysOrganisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk; a reply may have been sent and not yet published.
judiciary.uk put this report online on 10 May 2019, after the 56 days for replies had ended (26 Sep 2018). These dates can’t tell us whether a reply was due before it went online. A reply may have been sent and not yet published.
- Report dated1 Aug 2018
- Deadline26 Sep 2018
- Published on judiciary.uk10 May 2019
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| HMP Stoke | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
| Shropshire Community Health NHS Trust | Response publishedPublished on judiciary.uk in May 2019. |
The coroner’s concerns
– (1)During the inquest evidence was heard that apart from some hourly checks by prison officers during the evening of the incident on 20/10/17 (the third known instance of NPS use by the deceased) no other specific checks were made on the deceased leading up to the date of his death . This was a prisoner who had 3 known instances of NPS use within a relatively short space of time. I heard evidence that the requirement for further checks would have had to come from the Healthcare team rather than from prison officers. I was told here is no policy or guidance to cover additional checks for a prisoner in a situation such as this. (2)The inquest heard evidence from two Forward Trust Drug workers who although not medically qualified, considered that Mr Jones was at a ‘higher’ risk from NPS use due to using NPS with his existing congenital heart defect. I was told there was no method of communicating this to either Healthcare or prison officers to enable further periodic checks to be undertaken particularly in light of the recent incident on 20/10/17. 6 (3)The two Forward Trust Drug workers were only aware of Mr Jones existing heart condition because he disclosed this to them himself. This enabled them specifically to tailor their advice to cover the impact of Mr Jones continued NPS use on his heart. Forward Trust do not appear to have access to prisoner medical records for reasons of patient confidentiality and there does not appear to be any alternative way of ensuring they have all the information about a prisoner in order to help them with their drug use.
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports, 2018-0369
- Added to Minute Book
- 8 Oct 2026
- Reuse
- We show short extracts and link to the original. We don’t host the full report.
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
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