Sheriff finds that man who took fatal overdose in Perth prison did not die as a result of an accident

A sheriff has determined that a prisoner who died in hospital following an overdose the day after his sentencing did not die as a result of an accident caused by failures in the prison system.

Gavin Williamson, who was sentenced to 6 months’ imprisonment and conveyed to HMP Perth the day before his death, died on 14 June 2018 at Perth Royal Infirmary. An investigation of his cell following his death revealed he had been in possession of a variety of drugs.

The inquiry under the Inquiries into Fatal Accidents and Sudden Deaths etc. (Scotland) Act 2016 was conducted by Sheriff Principal Marysia Lewis. Mr Williamson’s family did not participate in the inquiry.

No cause for concern

On 13 June 2018, a Dundee sheriff sentenced the deceased to 6 months’ imprisonment for repeated breaches of a restriction of liberty order. At 9am that morning he told his partner that he had taken five Valium tablets, but she did not believe it affected his walking and talking. He arrived at HMP Perth later that day and was interviewed by a reception officer, JD.

JD recorded that the deceased ‘presented well throughout’ and assessed him as ‘no apparent risk’. He also recorded that, although there had been a previous attempt at self-harm, he had no thoughts of suicide or self-harm, and that he was Valium dependant. A standard visual inspection was conducted by another officer, who did not find any illegal items, however the deceased was unable to produce a urine sample that day and was told he would have to provide one the next day.

The deceased was eventually placed in a cell with a relative of his, MD, after coming into contact with several other prisoners. None of the prison officers who gave evidence noticed anything strange about the deceased’s presentation for the rest of the day. The cells were locked down just after 8pm, and at 1:45am the following day MD awoke to find the deceased lying in a pool of black vomit.

Paramedics arrived to take the deceased to hospital at 1:58am, but all attempts to revive him were unsuccessful. A thorough brain stem assessment conducted at 5:30am found no signs of activity, and he was pronounced dead at 6:25am. The deceased’s post mortem determined that the cause of death was the combined acute and chronic adverse effects of Buprenorphine and Etizolam.

The deceased’s cell was found to contain wraps of crystal substance and Buprenorphine, as well as a Kinder egg capsule containing tablets concealed within a loaf of bread and a quantity of cannabis resin. A prisoner who had encountered the deceased told the police he appeared to be under the influence of drugs, with MD stating that the deceased had told him he had taken 40 Valium prior to his sentencing.

It was submitted for the Crown that there was nothing in the presentation of the deceased from the point of admission onwards to indicate risk or to indicate issues with the use of illicit drugs. The prison nurse had not identified the deceased as a cause for concern, and there was no intelligence that he was banking drugs. As such, there was no evidence indicating defects in the system attributable to the health service.

Innovative and imaginative ways

In her determination, Sheriff Principal Lewis began: “The prison service and the health service require to take reasonable precautions to prevent deaths in prison. On the evidence placed before me, the supervision and care of the deceased by the prison staff and medical staff cannot be criticised. I am satisfied that the Operating Procedures aimed at detecting and preventing the importation of illicit drugs into the prison are reasonable and were followed in this case.”

She continued: “If Mr Williamson was suspected as being under the influence of illegal substances during the admissions process or at any other point, any member of staff who was in contact with him could have placed him on the SPS Management of an Offender at Risk due to any Substance (MORS) policy. The healthcare staff would then have put an appropriate care plan in place.”

Turning to how the deceased had obtained the drugs he took in prison, she said: “It was not possible to establish from the evidence how the drugs consumed by the deceased made their way into the prison. He may have brought the items in himself as Mr MD suspected or he may have been supplied by another prisoner within the prison. If prisoners are determined to obtain illicit drugs then they will find innovative and imaginative ways of doing so.”

Sheriff Lewis concluded: “I do not consider that any additional findings in my determination are required in terms of section 26(1)(a) or any recommendations in terms of section 26(1)(b) and (4) of the 2016 Act. On the evidence available to me, there were no reasonable precautions that could have been taken that might realistically prevent other deaths in similar circumstances.”

For these reasons, Sheriff Lewis determined that there was no accident resulting in Mr Williamson’s death and no recommendations which might realistically prevent other deaths in similar circumstances.

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