A prisoner died after swallowing a bag of drugs smuggled into jail by his own mum.
Shaun Hughes died after suffering respiratory failure brought on by "the effects of a combination of drugs", a report by a prisons' watchdog has concluded.
The 34-year-old was sentenced to three years and four months at HMP Northumberland in January 2015 after being convicted of burglary, driving offences, and drug possession.
Prison staff saw his mother pass an item to him while she was visiting the jail in March 2016.
ChronicleLive reports staff intervened immediately, but Hughes swallowed the package during a struggle.
He and his mother told staff the package contained drugs.
Mr Hughes was taken back to his cell and staff recorded that he should be observed once every 60 minutes.
A nurse reviewed him immediately after the restraint and again in his cell at 5.40pm and assessed that he was "fit and well".
But the nurse did not arrange for him to be observed by staff and he was last seen to at around 5.45pm.
He was not checked on during the rest of the evening or overnight and was found unresponsive in his cell at 5.57am and pronounced dead at 6.47am.
The Prisons and Probation Ombudsman has now concluded the should have been taken to hospital after he was seen swallowing the package.
They also raised concerns that there had been 12 other deaths at the jail since his death, two of which were thought to be drugs-related.
The report said there were "no clear procedures in place" at Northumberland to deal with incidents such as this.
It added that concerns were raised about the nurse who saw Mr Hughes not recognising he was at risk of drug toxicity and failing to ensure he was assessed and monitored.
The report said: "Mr Hughes was not observed during the night and was found dead in his cell in the morning.
"If expert medical and nursing staff had monitored Mr Hughes in line with best practice guidelines, the outcome could have been different for him"
"There were some deficiencies in the emergency response. I am concerned that this has continued to be an issue at Northumberland.
"We have investigated further drug-related deaths at Northumberland since Mr Hughes' death and I am concerned that drugs still appear to be readily available in the prisoner."
A number of recommendations were made including ensuring that healthcare staff manages prisoners' risk after swallowing a package containing drugs.
"The prison was also advised to show evidence that there is now clear guidance for prison staff on what to do in cases where prisoners have swallowed packages containing drugs.
An HMP Northumberland spokesperson said: "Our thoughts remain with Mr Hughes and his family.
"All deaths in prison custody are subject to investigation from the Prisons and Probations Ombudsman (PPO) and are ultimately subject to a Coroner’s Inquest.
"We accepted the findings of the PPO report and continue to do all we can to support those with addictions issues and to prevent the introduction of drugs into prisons."
