Investigation after death of inmate two weeks after arrival at Lancaster Farms prison

John Robinson, 38, died at HMP Lancaster Farms on December 14, 2023 - two weeks after his arrival. A report into the circumstances has been released by the Prisons and Probations Ombudsman (PPO) in the past week.

Background

On February 24, 2023, Mr Robinson was remanded to custody and taken to HMP Forest Bank, charged with violent offences. He was moved to Lancaster Farms on November 30, having been sentenced to two years imprisonment.

On December 11, staff suspected that Mr Robinson was under the influence of drugs. They called a medical emergency code and more staff attended Mr Robinson’s cell. As Mr Robinson refused to let a nurse take his medical observations, the nurse asked prison staff to monitor him. Staff searched the cell for drug paraphernalia and removed some suspicious pieces of paper. (These tested positive for psychoactive substances after Mr Robinson’s death.)

Thirty minutes later, staff found Mr Robinson with a telephone cord wrapped around his neck. When questioned, Mr Robinson was disorientated and incoherent. Staff started suicide and self-harm support procedures, known as ACCT. Mr Robinson continued to behave erratically, and when he refused to give staff a suspicious vape, they used force to retrieve it. Staff put Mr Robinson on regular observations and found more suspicious paper when searching his cell. On December 12, staff put Mr Robinson’s ACCT into post-closure as he said he had no thoughts of suicide and self-harm and had plans for the future.

On December 14 at approximately 6.54pm, a prisoner alerted an officer that Mr Robinson was lying unresponsive on the floor of his cell. The officer went to Mr Robinson’s cell, immediately called a medical emergency code, and started CPR. Healthcare staff also responded and continued CPR. At 7.18pm, paramedics arrived and took over Mr Robinson’s medical care. They took him to hospital but at 8.01pm, hospital doctors pronounced that Mr Robinson had died.

Toxicology tests found psychoactive substances in Mr Robinson’s system. The post-mortem concluded that the cause of his death was unascertained but was likely to be drug related.

Ombudsman Adrian Usher concluded: “Mr Robinson had a history of substance misuse but often denied using illicit substances in prison. Three days before he died, prison staff suspected that he was under the influence of drugs. They acted appropriately by removing suspected drug paraphernalia, conducting cell searches and monitoring Mr Robinson via regular welfare checks. They also offered him support from the prison’s substance misuse service.

“I am satisfied that Lancaster Farms did all they could to manage the risks associated with Mr Robinson’s substance misuse. They have also made considerable efforts to combat drug supply and demand, both before and since Mr Robinson’s death.”

HMP Lancaster Farms

The most recent inspection of HMP Lancaster Farms was in August 2022. Inspectors reported that access to and the quality of health care services was reasonably good. Inspectors reported that around 80 mental health referrals were received each month and prisoners were routinely seen within four working days. Urgent cases were reviewed on the day by a duty worker, which included attending all initial ACCT reviews.

A multidisciplinary team reviewed new cases each week and patients were assigned to practitioners based on need and risk. Every prisoner was offered support with substance misuse problems by the psychosocial team and advised how they could self-refer. At the time of the inspection, support was being provided to 202 prisoners and included harm minimisation advice as well as self-directed help through the use of workbooks, one-to-one work, group sessions and pre-release targeted support.

Caseloads were high and priority was given to patients receiving treatment and/or preparing for release. This had led to some short waits for non-urgent care, but these were reducing and support for prisoners was good. The team was competent and motivated, and prisoners valued their support. Naloxone treatment (to prevent opiate overdose) was routinely provided.