Mother Warns Of ‘Broken System’ After Inquest Concludes Son Died Following Neglect By Staff In Prison

The mother of a prisoner who died while held on remand said her son was ‘poisoned by a broken system’, after a jury inquest concluded he died as a result of neglect.

Edward Hands, 42, was on remand at HMP Bedford when he ingested methadone – a prescription drug most commonly used to treat heroin addiction – despite not having a methadone prescription or a history of using the class A drug.

The six-day jury inquest reached a rare conclusion of neglect in December, after prison and medical staff failed to correctly follow prison protocol and provide adequate follow-up care after discovering he was under the influence of an unknown drug.

The jury heard how staff found Edward in a vulnerable state at 9:15 am but failed to follow the correct policy – many staff were unfamiliar with the policy or where to find it – and did not carry out the required checks on the father of two until 4:36 pm when he was found unconscious in his cell.

The jury in the inquest held before Bedfordshire and Luton Coroner, Bina Patel, found there was a ‘failure by healthcare staff to carry out a follow-up medical assessment’ and a failure ‘to use suction equipment to clear the airway when he was found unresponsive in his cell and in cardiac arrest with stomach contents in his mouth and throat’.

Edward Hands, known as Eddie to his friends, died on February 16, 2024, of Aspiration Pneumonitis and methadone use just two days before he was due to appear in court after being charged with stalking. The family believed he would be returning home from court after being advised that the charge was in relation to a ‘minor altercation’ that would result in a community order.

Eddie’s mother, Margaret Hands, 65 who was represented by law firm Hodge Jones & Allen, said after the neglect conclusion: “I don’t blame the individual staff who apologised during the inquest, but I do believe my son was poisoned to death by a broken system.

“A system that failed to keep my son safe. He didn’t even get his day in court, and now we have to live with this life sentence forever. We had feared he wasn’t safe in that prison. On multiple occasions, we, and Eddie, had requested that his heart monitoring machine – due to his irregular heartbeat – be allowed into the prison, but all the requests were ignored.

“I was incredibly shocked to hear that we will never know how he ingested that drug and why. After his relationship broke down, his mental health suffered dearly, and he began taking cocaine as a way to cope, but he never touched heroin. It doesn’t make sense that someone can die of a prescription drug while in prison in 2025.

“We were traumatised when we were told he had died, but it wasn’t until the toxicology report came in and the coroner informed us how he had died that our life was turned upside down, forever. My first thought was – they have poisoned my son.

“We are grateful to the jury for reaching a conclusion of neglect. We feel we have now achieved some form of justice for Eddie, who was constantly referred to as ‘courteous and helpful’ by many witnesses during the inquest. I’m grateful the court heard what kind of person he truly was.”

As part of their narrative conclusions, the jury found that Eddie’s death could have been prevented and identified seven factors that contributed to the death in a ‘more than minimal way’, including insufficient training, high staff turnover, inadequate onboarding of new staff, and a lack of cooperation between healthcare and prison management.

Margaret, a healthcare worker from Hertfordshire, added: “Eddie had been through an extremely difficult time with his mental health before he was arrested. We spent a long time trying to get him the right help, which we secured just before he went into prison. We were all devastated by his incarceration, and his father and I found it extremely difficult to visit him every week, but we did start to see a positive shift.

“He put on weight and was working in the kitchen. Everyone said he was so polite and kind to others, and he had already started to make plans to rebuild his life once he came out. He was committed to going to rehab and doing everything he could to get his life back on track.

“He had always worked hard as a landscape gardener and been a good dad to his two children. Circumstances had taken him down the wrong path, but he was not a bad person and should be alive today. This should never have happened.”

Claire Brigham, Civil Liberties lawyer at Hodge Jones & Allen, said: “Neglect is a high bar to reach at an inquest, which has brought some comfort to Eddie’s family. However, the inquest exposed a myriad of failings in Eddie’s care, which is disturbingly not uncommon. Eddie was on remand and could still be alive today if staff had followed the right prison protocol to keep him safe. We see many prisoners die while under the care of the state, and unless drastic changes are made within the system, more lives will be lost.”

The family was also represented by Counsel Jessica Elliot of 1 Crown Office Row and received advice from the charity, Inquest.

Jodie Anderson, senior caseworker at the charity Inquest, who also advised the family, added: “This year we have seen a record number of deaths in prison. Many people, like Eddie, should never have been there. For them – as it was for Eddie – prison became a death sentence. The evidence heard at his inquest exposed the brutal reality of prisons.

“A nurse accepted that she needed to return to review Eddie when he was found under the influence, but she failed to because she became busy. The chaos, mismanagement and indifference to human life are quite harrowing, and a reminder of the deep inhumanity embedded in these institutions. Now a jury has confirmed the family’s worst fears: Eddie’s death was entirely preventable and was contributed to by neglect. No policies or training can inject care into a system that is fundamentally broken.”

Margaret added, “We are eternally grateful to our legal team and the charity, Inquest, for helping us through the inquest process; we couldn’t have got through it without them.”