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Coroner raises concerns over emergency response at Wormwood Scrubs following death of inmate

Following an inquest into the death of a 50-year-old inmate at HMP Wormwood Scrubs in March 2016, the coroner last month issued a Regulation 28 Preventing Future Deaths Report to the Governor of the prison. The Regulation 28 report is the highest level of response available to a coroner.

The jury at the inquest into the death of John O’Meara at West London Coroner’s Court in October 2017 blamed lack of staff, inadequate medical supervision and a missed opportunity to raise concerns over his health on the day he died as contributing to his death from a methadone overdose.

Assistant Coroner Sarah Ormond-Walshe said she was particularly concerned that prison officers failed to follow the Code Blue guidelines of responding to an emergency that meant there was a delay in calling an ambulance. She also said that despite being questioned at the inquest, the officer who found Mr O’Meara still did not understand why a Code is called.

John O’Meara, who had three children and five grandchildren, was sentenced to 12 weeks in the prison in March 2016.

According to his son Shane, Mr O’Meara had struggled with drug and alcohol misuse for years. Although he regularly attended community drug therapy and managed long periods of abstinence, he had relapsed at the time he was imprisoned.

Mr O’Meara was referred to the prison’s Conibeere Stabilisation Unit, a specialist medical wing, for a methadone stabilisation and alcohol detoxification programme and was prescribed different medications to treat the symptoms of withdrawal, including regular doses of methadone.

Four days into his sentence, however, on 29 March 2016, Mr O’Meara was found unconscious in his cell and, despite attempts to resuscitate him, was pronounced dead by paramedics. A toxicology report revealed Mr O’Meara died from methadone toxicity.

At the inquest, the jury concluded that insufficient staffing levels led to inadequate medical supervision of Mr O’Meara on the day of his death and that he died in part because of a missed opportunity to raise concerns over his health following an interaction with prison staff at midday.

On the morning of his death, no vital signs check was performed on Mr O’Meara before he was given his morning dose of methadone due to a staff shortage.

At around 12 o’clock, Mr O’Meara was observed lying on his bed and being very drowsy by a member of prison staff but who did not alert medical staff to his presentation. Two hours later, prison staff found Mr O’Meara unresponsive in his cell.

During the inquest, the coroner raised concerns about the delay of the prison officer first on the scene to call a Code Blue, which generates the request for an ambulance, before calling for assistance from staff on the Unit.

Civil liberties solicitors Clair Hilder and Joanna Bennett, from London law firm Hodge Jones & Allen and Tom Stoate of Garden Court Chambers represented the O’Meara family. Ms Bennett said that there had clearly been a missed opportunity to alert medical staff to Mr O’Meara’s presentation and that the lack of medical supervision given to an extremely vulnerable man was completely unacceptable.

“Mr O’Meara was noted as very drowsy and sweating but staff did not monitor him closely enough, with tragic consequences. It is crucial that when a drug like methadone is prescribed there is adequate monitoring in place to ensure the prisoner’s safety.”

29-year-old Shane O’Meara from Harrow described his father as a very caring person who did everything he could for his family.

“He had battled with drugs and alcohol after his parents died within five months of each other, leaving him distraught,” Shane said.

“We knew he was troubled, but you would hope that an institution such as a prison would properly care for people with known drug problems. My father had never taken methadone before as part of his rehabilitation in the community.


For further information, please contact:
Kerry Jack or Nicola Pearson at Black Letter Communications or
020 3567 1208

Notes for Editors

Hodge Jones and Allen

  • Hodge Jones and Allen is one of the UK’s most progressive law firms, renowned for doing things differently and fighting injustice. Its managing partner is Patrick Allen, recently awarded a lifetime achievement award by Solicitors Journal.
  • For 40 years’ the firm has been at the centre of many of the UK’s landmark legal cases that have changed the lives and rights of many people.
  • The firm’s team of specialists have been operating across: Personal Injury, Medical Negligence, Industrial Disease, Civil Liberties, Criminal Defence, Court of Protection, Dispute Resolution, Employment, Family Law, Military Claims, Serious Fraud, Social Housing, Wills & Probate and Property Disputes.
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