A Chelmsford prisoner was subjected to “inhumane and degrading” treatment in the lead-up to his death, a report has found.
The Ministry of Justice has said the events that led to David Morgan’s death in August 2018 at HMP Chelmsford were “unacceptable”.
Mr Morgan, 35, died following a drug overdose at Chelmsford Prison on August 22 2018. He told staff that he had taken an overdose of medication at 9.45am. About an hour later he began to show signs of being unwell.
Staff had thought Mr Morgan had drunk ‘hooch’ – illegally made alcohol. Instead of being properly assessed by clinical staff, he was left in a holding cell for some two and a half hours, becoming increasingly distressed and unwell.
Eventually he was unable to speak properly and prevent himself from repeatedly falling onto the floor and a metal bench.
Despite the presence of several staff and the almost constant presence of a nurse, Mr Morgan sustained a broken nose, a broken eye socket and fractures to both his legs during these falls. He eventually lapsed into unconsciousness and was taken to hospital. He died eight days later.
Kimberley Bingham, who was acting Prisons and Probation Ombudsman at the time the final report was drafted was “disturbed by the uncaring and disrespectful culture that surrounded Mr Morgan”.
Her report said: “This is an extremely disturbing case where staff involved showed a shocking lack of compassion, empathy and concern for Mr Morgan’s well-being and decency. The treatment he received was nothing short of inhumane and degrading. We offer our condolences to Mr Morgan’s family and friends.
“The prison needs to demonstrate that it now has the strong leadership and positive partnerships needed to ensure that the awful treatment Mr Morgan received is never repeated.”
Mr Morgan had been prescribed baclofen – a muscle relaxant – and citalopram for anxiety which he was allowed to keep in his cell.
However, baclofen is toxic in overdose and is deemed not a suitable medication for prisoners to be allowed in possession.
Mr Morgan’s death was the tenth death at Chelmsford since August 2017.
Of the previous deaths, two were from natural causes, four were self-inflicted, and three were drug-related.
Since Mr Morgan died, there have been nine more deaths at Chelmsford, of which three were from natural causes, four were self-inflicted, one was drug-related, and one is awaiting classification.
The report follows the inquest into the death of 21-year-old Thokozani Shiri in which the prison was also heavily criticised for failing to provide HIV treatment during his time as an inmate, an inquest last year determined.
Mr Shiri, known as Thoko, died in April 2019 after pleading with prison staff to get him to hospital and after months of not receiving any medication for his condition. He had been diagnosed with HIV in Zimbabwe in 2013 when he was a teenager before moving to the UK.
The recent report said: “We found that the death, like Mr Morgan’s, was preventable. We also found that the next of kin were not informed that the prisoner had been taken to hospital, and that he had been restrained while unconscious. We repeat serious concerns about these matters in this investigation.
“In four other deaths (in September and October 2018 and in July and August 2019) we found that aspects of healthcare were not equivalent to that which would have been expected in the community.”
A Prison Service spokesperson said: “The events that led to David Morgan’s death were unacceptable and HMP Chelmsford has implemented all of the Ombudsman’s recommendations.
“We have invested £1.2m to improve safety and security at the prison, put staff through extra mental health training and provided extra leadership support to change staff attitudes and increase morale.”