Shalane Blackwood
3 May 2016 · Coroner Stephanie Haskey · Nottinghamshire
A similar concern from this report was raised again 4 times later. See the linked reports.
The coroner's concerns
1. lack of proper care and supervision of prisoners with complex physical and mental health needs
“That there is no proper provision for the care and supervision of prisoners who present with complex physical and/or mental health needs”
2. insufficient prison staff to provide proper regime and unlock prisoners in segregation
“That at present, if a prisoner is assessed as needing a four person unlock, and is within the Segregation Unit, there are insufficient prison staff to provide him with a proper regime and to unlock him after lunchtime”
3. continued prevalence of New Psychoactive Substances and inadequate staffing of Substance Misuse Team
“That the use of New Psychoactive Substances (NPS) remains rife within the prison, and presentations such as Mr [name redacted] are not diminishing, and that the Substance Misuse Team requires further staff to be effective in future”
4. unclear documentary tool for decision making between prison staff and healthcare staff regarding segregation fitness
“That the documentary tool for decision making between prison staff and healthcare staff, as to whether a prisoner is fit to remain in Segregation and should do so, is unclear in design or in use”
5. insufficient alertness of healthcare staff to physical symptoms occluded by mental health issues
“That healthcare staff are insufficiently alert to the issue that physical symptoms which require urgent medical attention may be occluded by mental health issues”
Linked reports
Closely relatedConfidence 0.80 · moderate
This report
“That the use of New Psychoactive Substances (NPS) remains rife within the prison, and presentations such as Mr [name redacted] are not diminishing, and that the Substance Misuse Team requires further staff to be effective in future.”
Later report
“Discipline staff have no meaningful training on the categories of self-induced intoxication and in particular "new psychoactive substances" such as the synthetic cannabinoid known as "Spice"”
Closely relatedConfidence 0.90 · high
This report
“That the use of New Psychoactive Substances (NPS) remains rife within the prison, and presentations such as Mr [name redacted] are not diminishing, and that the Substance Misuse Team requires further staff to be effective in future.”
Later report
“At the time of [the deceased]'s death, the use of psychoactive substances was a problem at HMP Guys Marsh as it was, and continues to be, across the prison estate. Psychoactive substances were said to be the most dangerous drug in prison.”
Closely relatedConfidence 0.80 · moderate
This report
“That healthcare staff are insufficiently alert to the issue that physical symptoms which require urgent medical attention may be occluded by mental health issues.”
Later report
“Poor Quality Acute Physical Healthcare in the mental health setting [the deceased]'s death demonstrates a further example of a failure by medical staff to recognise a deteriorating patient and a subsequent delay in escalating for acute secondary care intervention.”
Identical hazardConfidence 0.92 · high
This report
“That the use of New Psychoactive Substances (NPS) remains rife within the prison, and presentations such as Mr [name redacted] are not diminishing, and that the Substance Misuse Team requires further staff to be effective in future.”
Later report
“Prison Officer B ([REDACTED]) told the court: "[REDACTED] is a daily occurrence, it's too much to handle...some batches are bad and they can then be violent"”
Responses
No published response was found on judiciary.uk.