Grampian sheriff finds death of north-east prisoner from drug-related complications not reasonably preventable

A sheriff in Peterhead has found that the death of a north-east prisoner from possible drug and alcohol-related conditions the day after he was admitted to prison was not the result of an accident or any failure on the part of prison staff.

Sean Taggart, a prisoner at HMP Grampian, died on the morning of 10 March 2018 from complications arising from alcohol and drug use. At the time of his death, he was 37 years old, with no specific cause of death identified by pathologists.

The inquiry under the Fatal Accidents and Sudden Deaths etc (Scotland) Act 2016 was conducted by Sheriff Christine McCrossan.

Said he was feeling better

The deceased was remanded in custody for the purpose of obtaining an up-to-date Criminal Justice Social Work Report and was expected to return to court. He arrived at HMP Grampian before 2pm on 9 March 2018. It had been noted that he suffered from depression, but he was not considered to be a suicide risk or to be at risk of self-harm. No concerns were raised about him during the initial assessment by Scottish Prison Service staff.

The deceased was then assessed by a nurse, Ms Jepson, who was told by the deceased that he generally drank approximately 2 litres of spirit a day and was on a daily dispense of 30ml of methadone from his local pharmacist, which he had not received the day he entered custody. Ms Jepson therefore recommended that he should be given some medication prior to entering prison, as otherwise he would have an uncomfortable, if not distressing, night.

Following a consultation with the GP lead at HMP Grampian, the deceased was placed on a drug reduction programme which initially was to involve two daily doses of diazepam in reducing quantities for 17 days. That evening he was given 30mg of diazepam as well as 30ml of methadone in line with his community opiate substitute programme.

Mr Taggart was placed in a single occupancy cell. At 8:50pm prison staff found him sitting on a chair watching television, at which time he advised he was feeling better. However, at 8am the following morning he was found lying on his back on the floor of the cell showing no signs of life. He was pronounced dead at 9:48am.

At the time of the inquiry, no evidence was available that could confirm the exact cause of death; however, it was suspected that he may have suffered a cardiac arrhythmia or a withdrawal seizure. Nothing untoward about the deceased’s behaviour had been noted during the night, and he had not been identified as requiring any additional monitoring.

Sudden onset

In her opinion, Sheriff McCrossan said of the GP lead’s conduct: “Dr Graeme Strachan who commenced Mr Taggart on the drug reduction programme and prescribed methadone to him, acted wholly appropriately in doing so. It was his professional judgement that Mr Taggart required an immediate prescription otherwise he would have continued to suffer from symptoms of withdrawal and have had a distressing first night.”

Turning to the appropriate level of monitoring in this case, she noted: “To have any prospect of having realistically prevented Mr Taggart’s death the overnight observations would have required to be virtually continuous as any of the events which could have caused Mr Taggart’s death (seizure, drug intoxication, and cardiac arrhythmia) would be sudden onset with death following almost imminently.”

She continued: “The medical staff did not know, nor could they reasonably have known, that his condition was such that he was at a heightened risk. The medical staff had no reason to believe his condition was likely to deteriorate as it did and thus had no reason to request he be subject to any special treatment.”

Sheriff McCrossan said of the drug reduction programme the deceased was on: “Mr Taggart was not unique in the prison establishment. The drug reduction programme was common for prisoners. A very considerable number would be on it at the same time and generally for a number of weeks: with no requirement to be under continual observation. As a matter of fact the risks associated with the combination of prescription drugs was likely to be considerably less than the prisoners were exposed to while in the community taking non-prescribed drugs.”

She concluded: “The GP was not in a position to eliminate risk to Mr Taggart given his long history of poly-drug use and his underlying medical condition. There was no indication that his condition gave any cause for concern to NHS Grampian or SPS on the night he passed away. His situation was on all fours with many other prisoners within the establishment, who were also on the same or similar drug reduction programmes. It was not possible to subject all of these prisoners to monitoring throughout the duration of their drug reduction programme.”

Sheriff McCrossan therefore determined that there were no recommendations that could be made by the inquiry to prevent other deaths in similar circumstances.

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