NEGLECT: Thamesmead prisoner died after taking methadone despite antidote being available, inquest hears

Darren McConnell suffered a toxic reaction to the commonly-used heroin substitute in Thameside Prison on the evening of December 4, 2014 - the day after he was jailed - having been prescribed methadone at 4.37pm that day, an inquest held at Southwark Coroner’s Court heard.

Darren McConnell

The 41-year-old convict had been locked in his cell on the 18-bed in-patient ward, which is monitored 24-hours-a-day, since 5pm – and appeared to have been dead for some time when he was discovered at 9.43pm, the inquest heard.

Prison GP Dr Talal Al-Mekhlafi had ordered the dad-of-two to be put on half-hourly vital sign checks, which would require unlocking his door and taking his pulse and blood pressure, throughout the night – a jury was told last Thursday.

However, between 6.30pm and 7.10pm there were no nurses or healthcare assistants on the ward.

At the time of his arrest on December 2, Mr McConnell was prescribed 110ml of methadone-a-day, and was also taking street benzodiazepines, sometimes known as benzos, and £60 worth of crack cocaine and heroin on a near-daily basis.

After being taken to Thameside via Lewisham Hospital and Camberwell Magistrates’ Court, the Peckham resident went without methadone for up to 56 hours, Coroner Sarah Ormond-Walshe calculated.

In some people, it takes just 24 hours for tolerance to methadone to drop – rendering the 65ml given to Mr McConnell on the day of his death a “potentially fatal” dose, according to Dr Stephen Metcalf, an expert asked to give his opinion in court.

After a post-mortem examination, Mr McConnell’s medical cause of death was listed as the “acute toxic effects of methadone”.

Darren McConnell

By the time prison officers Michael Ellis and Jeff Rowland unlocked Mr McConnell’s cell and found him “obviously dead” he had been lying under his bed, with only half his torso and legs visible, for a number of hours.

Mr McConnell “had blood around his head and on the floor”, the coroner said. Ms Ormond-Walshe added: “It could have been caused by a seizure or a fall.”

Healthcare assistant Olawade Sremhum made three “signs of life” checks, as opposed to the vital signs ones ordered, between 7pm and 9pm – the jury heard.

In a prison ombudsman investigation Mr Sremhum originally claimed to have made five checks, but this did not match up with CCTV footage from Thameside.

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Mr Sremhum also claimed to be able to see into Mr McConnell’s cell from the healthcare room, although his colleagues disagreed this was possible.

Dr Metcalf said allowing Mr McConnell to lie undisturbed for so long was in the “bracket of seriously below acceptable practice”.

Naloxone, an antidote to toxic methadone reactions, was kept on the ward.

Ms Ormond-Walshe said: “He (Dr Metcalf) has seen people who are blue who still recover to normal without brain damage after being given the drug. It reverses the effects of methadone.”

Returning a verdict, the jury concluded that Mr McConnell’s death was drug-related but contributed to by neglect during his time at the prison.

They added that had the correct vital signs checks been carried out and had Mr McConnell been given the antidote to toxic reactions in time, his death “may have been prevented”.

The jury also concluded that the prison was “insufficiently staffed” at the time of Mr McConnell’s death, staff were “insufficiently supervised and handovers were inadequate” meaning the overall quality of care fell “significantly below acceptable practice.”