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Inquest Finds HMP Forest Bank Inmate Died Following Serious Failings In The Management Of A Methadone Prescription

The conclusion comes after GP and Nursing expert witnesses criticised the decision to prescribe Methadone and in the management of the prescription. 

An inquest has today concluded that Michael McDonagh died following the misadministration and mismanagement of a methadone prescription issued to him just three days before his death.

The jury found that the medical professionals responsible for the prescription of methadone failed to carry out adequate enquiries into Michael’s dependence on and tolerance to opiate medication before deciding to prescribe the drug and failed to monitor him in the days that followed in line with prison and national health guidelines. They found that the latter failing probably contributed to Michael’s death.

Michael McDonagh, aged 27, was found unresponsive in his cell at HMP Forest Bank, a private prison operated by Sodexo Services Limited, on 19th February 2019. After attempts for over an hour to resuscitate him failed, he was pronounced dead at the scene by paramedics. His post-mortem concluded that he died as a result of Bronchopneumonia, precipitated by acute central nervous system depression resulting from the combination of drugs in his system that included four prescription drugs of which one recently commenced was methadone.

The inquest was held at Manchester Bolton Coroner’s Court before HM Assistant Coroner for Manchester West, Lisa Judge, and a Jury between 29th August and 8th September. The inquest received evidence from over 40 witnesses.

Michael’s family were represented throughout the inquest by Cormac McDonough, partner at Hodge Jones & Allen and legal counsel Philip Rule KC of No.5 Chambers.

Cormac McDonough, partner at Hodge Jones & Allen, representing Michael’s family, said: “We welcome the decision of the jury and hope that this case highlights the need for urgent improvements in healthcare within the prison system. Michael deserved a much better standard of care than he received and every inmate deserves the right to serve their time in a safe environment. The inquest evidence portrayed HMP Forest Bank as a somewhat chaotic environment, with a chronically understaffed and underfunded mental healthcare system, and with absent process to ensure basic checks occurred after methadone prescription mid-sentence. It is unsurprising that mistakes happened in this context. It is a tragedy that it happened to Michael in this way. My thoughts are with Michael’s family, whose bravery and determination to get answers and justice for Michael has led to these serious issues being brought to public attention.”

Michael’s mother, Margaret Pomeroy, said: “HMP Forest Bank failed my son. I have been campaigning for over four years to get this inquest heard, to find out what happened to Mickey. It should never have come to this. Mickey was a prisoner, but he deserved to be treated with care and kindness, just like any other person. I cannot understand how a mistake like this was allowed to happen by the people that were supposed to be taking care of him. The day that they handed him methadone they handed him a death sentence.

This verdict will not bring Mickey back but I hope that lessons will be learned so that no one else has to die in this way. I do not want another family to have to go through what we have gone through. Although Mickey had his struggles, he was a kind and sensitive boy. He had his whole life ahead of him. We will never forget the happiness and laughter he brought into our home and we are grateful every day for the time we got to share with him. I feel his loss every single day.”

Chronology of the case

Michael had a history of complex mental health concerns. He had long-term prescriptions for medications, including olanzapine (an antipsychotic), Pregabalin (to treat anxiety) and mirtazapine (an antidepressant).

On 7 September 2018, Michael was remanded in custody at HMP Forest Bank. His prescriptions in the community were continued within the prison.

On 7th February 2019, a psychiatrist at the prison, Dr Plunkett, reduced Michael’s Pregabalin prescription by 25% with the view of taking him off it altogether at a later date. This decision was taken in Michael’s absence and no-one visited him to inform him or explain and discuss the step once it had been taken. Dr Plunkett recorded at the time that this reduction was because of concerns about the cardiac risks associated with the combination of drugs Michael was on. However, evidence heard during the inquest also identified that there was a firm policy within the prison to eradicate Pregabalin prescriptions generally due to the risk of the drug being illicitly used and traded.

Michael had been prescribed Pregabalin for several years, and the prospect of its removal caused him anxiety, which he expressed to healthcare staff, including suggesting that if it were removed he would acquire and take illicit drugs to replace it. Nurse Ivy Dhokwani recorded at the time that there was an amber (moderate) risk that Michael could harm himself through illicit drug use and that he required close monitoring to manage any risk.

On 8th February 2019, Michael informed a nurse that he had been using an opiate drug, Buprenorphine, illicitly for over three months. Michael expressed that he wanted to stop and asked to be prescribed methadone to manage withdrawal. He was referred to a substance misuse nurse who examined Michael and observed no symptoms to indicate that he was withdrawing from opiates. She declined to refer him for a methadone prescription.

On 12th February 2019, Michael met with an experienced substance misuse worker Jake Costello and again claimed he had been taking Buprenorphine. In his evidence to the inquest, Mr Costello expressed surprise at Michael’s claim, stating that in all of the time he had known Michael and been engaged with him between September 2018 to 31 January 2019, he had displayed no signs of illicit opiate use. His case had been closed to the Recovery team on 31 January 2019 because there were no concerns Mr Costello had that he was using any illicit substances.

Mr Costello referred Michael to substance misuse nurse Margaret Gilmurray who arranged a urine test for Michael, which returned negative for Buprenorphine, indicating there was none present in his system that day or for a period of time beforehand as the drug would have remained in his system. Ms. Gilmurray told Michael that because of the negative urine test, she could not refer him for a methadone prescription, however she promised to retest him again soon and to refer him to a GP to prescribe methadone if positive.

Two days later, on 14th February 2019, Ms Gilmurray re-tested Michael for Buprenorphine and this time the urine test came back positive. Michael had been expecting to be tested on that day. Ms Gilmurray also assessed Michael as experiencing moderate withdrawal symptoms; however, she did not record any details of how she made her assessment on any paper form nor on Michael’s medical record. She gave him a total score of 14 which is at the lower end of the moderate symptoms bracket on the COWS scoring system.

Ms Gilmurray then sent an electronic task to the prison non-specialist GP requesting that he issue a methadone script. She then followed up by taking the unusual step of telephoning the doctor on duty, Dr. Imran Malik. A few minutes later after their discussion, Dr Malik prescribed Michael methadone without seeing him in person. The prescribed dose was 20mg on the first day, and was prescribed to be the same on the second day though in the event he was immediately given an increase. The dosage increased each day by 10mg to reach 40mg in the first few days. Dr Malik did not record any risk assessment consideration given to how the methadone might interact with the other medications Michael was prescribed, nor Michael’s care plan going forward.

National clinical guidance, and clear prison policy required Michael to be monitored and reviewed twice daily for a minimum of five days following the methadone prescription, to assess him for signs of over-sedation, which is a potential effect of the methadone toxicity, with a view to changing or stopping his methadone dosage if necessary. The inquest heard the view of senior healthcare staff that it was the responsibility of Ms Gilmurray as the nurse requesting the prescription outside of a clinic to arrange these reviews. Ms Gilmurray admitted in her evidence that she had failed to make those arrangements, and as a result, no reviews took place.

In the days that followed, other prisoners noted that Michael had started sleeping more than usual. Anthony Cornfield said that on 16th February, Michael appeared very pale, had red eyes and appeared very tired. He claimed that Michael told him he was feeling “rough”. On 18th February 2019, the day before his death, other prisoners observed that Michael appeared more unwell. They recalled that he slept all day, did not attend work and did not collect his food. Lyndon Newman said that when he saw Michael, his eyes were bloodshot, he was shaking and shivering, and he seemed very ill. Mr Newman said Michael looked “obviously ill” to anyone who saw him. Peter McNicholas reported that at around 5pm on 18th February, Michael “looked a mess” and was much more tired than usual. Kevin Paton said that Michael’s skin looked “grey”. Mr McNicholas visited Michael at 7pm to remind him to collect his medication and said it was difficult to wake him, and he had to shout a few times.

A prison officer unlocked Michael’s cell at 7.08am on the morning of 19th February but failed to look into his cell to carry out a welfare check as required.

At 7.44am, another prisoner entered Michael’s cell and tried to rouse him but found him unresponsive. He alerted staff who radioed a “Code Blue” indicating that someone was unresponsive or had stopped breathing. Prison medical staff attended Michael’s cell to attempt to revive him. He was pronounced dead by paramedics at 8.55am, after attempts to save him with naloxone and adrenalin shots and CPR conducted prior to that time.

A toxicology report conducted after Michael’s death showed the presence of methadone, olanzapine, mirtazapine, pregabalin and quetiapine in his bloodstream. Each of these had been prescribed to Michael except quetiapine, an antipsychotic, which he may have taken illicitly and was present in a quantity at a lower end of the level seen in therapeutic use. The post-mortem, conducted by pathologist Dr Naomi Carter, concluded that the most likely cause of Michael’s death was bronchopneumonia and acute central nervous system depression resulting from polypharmacy. Dr Carter stated in her report that the combination of drugs Michael was taking could have led to a decreased rate of breathing, decreased heart rate and loss of consciousness. She suggested that low tolerance to methadone may have been a factor in Michael’s death, particularly if it was combined with the cumulative central nervous system depressant effects of anti-psychotic and psychoactive medications.

The inquest heard evidence critical of the decision to prescribe Michael with methadone, the dosage he was prescribed, the rate of dosage increase and the failure to monitor him in the days that followed.

The Coroner’s independent nursing expert, Annie Dale, in her report prepared for the inquest, criticised the decision to refer Michael of a methadone prescription after just one Buprenorphine-positive urine test, suggesting it would be usual to wait for a second positive urine test at least 7 days later before referring for a methadone prescription, to be satisfied that Michael was dependent on Buprenorphine and could tolerate methadone. She was also critical of the quality of Ms Gilmurray’s opiate-dependency assessment which she said was over reliant on Michael’s self-reporting and her failure to make a proper record of her findings. In her opinion the decision to refer Michael for a methadone prescription was wrong and would not ‘have been made by the majority of specialist substance misuse nurses practicing in this environment under similar circumstances’.

The Coroner’s independent GP expert, Dr Jake Hard, was similarly critical of the decision by Dr Malik to prescribe methadone, suggesting in his evidence to the inquest that there was insufficient evidence that Michael was dependent on opiates and that further investigation should have been conducted before the methadone prescription was issued. He pointed to the known fatality risk associated with methadone prescription and suggested that even if it was appropriate for the methadone prescription to be issued, it should have been initiated at a lower dose and increased much more slowly, with Michael being monitored to ensure he could tolerate the dose before it was increased.

Further Reading