A prisoner fell to his death after climbing over a railing in protest after his prescribed medication had been stolen.
David Atkinson, 42, was on a methadone programme and was also prescribed the anxiety and painkilling medication pregabalin.
However, in January 2018, he told staff at HMP Humber that the pregabalin had been stolen and that he needed more, Hull Live reports.
He was told that a prison GP would have to carry out a review before more medication could be prescribed.
However after two days, he became more and more agitated, eventually climbing over a railing of the first floor in protest before stumbling and falling.
He sustained life-threatening injuries and was taken to hospital. But Mr Atkinson never recovered and died on January 16, 2018. Prison ombudsman Elizabeth Moody carried out an investigation and the report has now been published.
Mr Atkinson was convicted of assault and breaching a restraining order on 10 October 2017 and he was sentenced to 26 weeks in prison, with a conditional release date set for 8 January 2018 – just a few days after his death.
During his time in prison, Mr Atkinson had tested positive for illicit drugs and there were concerns about his behaviour and was described as “aggressive frequently and had a poor attitude to staff”.
On January 3, 2018, he was given seven-days’ worth of pregabalin but later that day told staff the medication had been stolen.
When he was told he would have to wait to see a GP before any more medication could be given, Mr Atkinson acted “aggressively and unpredictably”. He then threatened to kill himself if he didn’t get it.
Mr Atkinson told staff he was suffering withdrawal symptoms and was in pain. He then told a fellow prisoner he was going to climb over the railings to protest about his medication.
CCTV footage shows that once Mr Atkinson had climbed over the rail, he placed his foot on a red alarm bell to steady himself but it was unable to hold his weight and gave way causing him to fall to the floor.
Ms Moody identified a number of concerns following her investigation and listed three specific findings.
In the report she said: “Staff did not start ACCT (suicide and self-harm procedures) monitoring despite Mr Atkinson harming himself and threatening to kill himself.
"This decision might have been understandable if effective alternative steps had been taken to understand and address his concerns. They were not.
“A GP should have reviewed Mr Atkinson’s medication when he told staff that it had been stolen. This did not happen.
“Humber has started work on reviewing its policy of allowing prisoners to keep tradable prescribed drugs in their cells and to administer them themselves, known as holding medication in-possession. We consider that this work should be prioritised.”
Ms Moody then went on to make a number of recommendations following Mr Atkinson’s death.
She said: “The Governor should ensure that staff start ACCT procedures whenever a prisoner has recently self-harmed, expressed suicidal intent or has other significant risk factors.
"When, exceptionally, they decide not to begin ACCT procedures for prisoners with significant risk factors, they should clearly record the reasons.
“The Head of Healthcare should ensure that all clinical staff refer prisoners to GPs when they report their medication missing so that decisions on re-prescribing medication are fully considered and promptly taken.
“The Governor and Head of Healthcare should ensure the ongoing work on the administration of pregabalin and other tradable medications is completed as a matter of urgency and that Humber’s medication in-possession policy is updated to reflect any changes made.”
HMP Humber bosses were also asked why there was no safety netting on the wing. They told the ombudsman the railings on the wing were of a sufficient height to prevent prisoners from accidently falling or being pushed over them. They said that no concerns had previously been raised.
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