“Evidence was given by prison staff that it was not uncommon for prisoners to be under the…”

The coroner’s concerns

(1) Evidence was given by prison staff that it was not uncommon for prisoners to be under the influence of substances, particularly spice at HMP Rochester. During the day when it was suspected that someone was under the influence, healthcare would attend to assess whether medical attention or monitoring was required there was however no access to in house health care during the night state. OSG officers without medical training or knowledge of the prisoner's medical history had to use their own judgement whether to monitor a prisoner or to escalate the matter. The prison orderly was not notified immediately when someone appeared to be under the influence and that the individual was thought to be under the influence was not documented. Prison staff did not have any guidance or policy to assist them as to when to escalate matters or what monitoring should be undertaken and staff did not routinely use the GP on call service for advice. (2) Prison staff did not receive a briefing about prisoners with medication in possession in accordance with PS24/2011 (3) In evidence there were discrepancies between the policies in place and the understanding of healthcare staff as to what information could be shared with prison staff and when it should be shared. Some healthcare staff in evidence indicated they would not share information about medication in any circumstances. The healthcare policy and practice of healthcare staff in relation to information sharing does not align with PSI64/2011 that information can be shared without a prisoner's consent if it is considered necessary to protect the individual or anyone else from the risk of death or serious harm. There was no clear process as to how or where the information would be shared and recorded either where a prisoner had consented to information sharing or where consent had not been given but it was nevertheless necessary to share the information. 6. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you Oxleas NHS Foundation Trust and Governor HMP Rochester have the power to take such action. 7. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 13th September 2024. I, the coroner, may extend the period.

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, 2024-0394

Added to Minute Book

8 Oct 2026

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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