A prisoner died after staff provided him with adequate life support after he was found unconscious on his bunk, a coroner has ruled.
Nathan Forrester, 36, died at HMP Thameside in south London on July 2, 2019, of a drug overdose, just one day after being called up to prison.
The inquiry heard that staff were unable to start resuscitation immediately and when they did, the attempts were poor.
Preventing future deaths reports were issued to both England’s NHS and the Ministry of Justice following the investigation after a clinical review found that prison staff did not have the level of expertise to provide effective life support to Mr. Forrester.
The reports are issued by medical examiners in cases where they have heard evidence that more preventable deaths could occur within institutions if preventative measures are not taken. The report is sent to the person or authority that has the power to make the suggested changes.
The Inquest charity said the case identified “crucial lessons” for prisons and their staff to prevent a repeat of the “fatal consequences of inadequate provision of medical care across the prison grounds”.
“If future deaths are truly to be prevented, resources must be redirected from the criminal justice system towards welfare, health, housing, education and social care to ensure that people like Nathan receive the support they need,” the organization said. beneficial.
This decision comes weeks after a report confirmed that the deaths of black and mixed-race men, like Mr. Forrester, in prison are overrepresented among the prison population.
Forrester, from east London, was described by his family as “outgoing”. After finishing college, he was introduced to drugs, which led him to become dependent on substances for much of his life.
When he was called to prison on July 1, 2019, staff noted that he appeared to be abstaining from drugs. Following a nightly assessment by a prison GP, the decision was made not to prescribe methadone, which is often used to treat heroin dependence, due to his low pulse.
He received a dose of methadone the next morning, but was found in his bed with a blue arm, not breathing, and a blue arm by a cellmate a few hours later.
When the first three officers arrived, they were unable to move Mr. Forrester from the top bunk or initiate resuscitation. An ambulance was later called and medical care staff began resuscitation attempts, but they were subpar, the inquest heard.
Forrester died shortly after from the acute toxic effects of heroin, cocaine, and methadone.
The coroner expressed concern about the level of resuscitation training received by nurses throughout the prison, as well as the lack of training given to prison staff on the need to remove inmates from the top bunk before starting support. basic life.
Tara Mulcair, of Birnberg Pierce Solicitors, said: “Nathan’s family is relieved that the investigative process has come to a close, almost four years after Nathan’s death. NHS England and the Ministry of Justice must now take urgent action to ensure lessons are learned from Nathan’s death.”
The Justice Ministry and Serco declined to comment. nhs england has reached out for comment.