Edward Hands

Coroner's concerns

AI summary

Confusion and differing policies between prison and healthcare staff regarding prisoners under the influence led to inadequate observation, failed recognition of clinical deterioration, and delayed medical assessment.

View full coroner's concerns

The evidence at the inquest revealed that the (primary) prison healthcare provider (within the prison) and prison staff are working to different policies and protocols in relation to those suspected to be ‘under the influence of illicit substances’; there is confusion and lack of awareness of those working in the prison as to the role and responsibilities and expectations about how to alert and manage a concern that a prisoner may be under the influence.

In this instance this confusion resulted in Eddie not being observed; had these checks and monitoring taken place, it would have been clear Eddie was not improving and that a follow up medical assessment was required. This meant his clinical deterioration was not recognised and escalated.

It is understood that the NHFT policy is designed to cover the entire Trust and may well, therefore, have relevance beyond Bedford prison. However, it is essential that the policy is clear on what happens when the individual institutions have their own local protocols. Eddie’s inquest has revealed how clarity on steps and paperwork required under the policy is essential amongst frontline staff to ensure the safest possible environment for prison residents at Bedford Prison.

Responses

3 respondents

Northamptonshire Healthcare NHS Foundation Trust NHS / Health Body

10 Apr 2026 PDF

Action Taken

• A common, local protocol for managing those suspected to be under the influence of illicit substances (UTI) at HMP Bedford has been agreed and implemented with the Prison Governor and Head of Safety. • The protocol clearly articulates the roles, responsibilities, and expectations of both healthcare and prison staff in the identification, assessment, and management of those suspected to be UTI. • The protocol makes it clear when prison staff should escalate to healthcare staff and states that healthcare staff are responsible for taking the lead on (AI summary)

View full response

Dear Ms Patel

RE: Regulation 28 Report Concerning Edward James Hands

We write in response to your Prevention of Future Deaths Regulation 28 (‘Report’) dated 17 February 2026 concerning the death of Edward James Hands on 16 February
2024. Before responding to the matters of concern you have included within your Report, I would like to express my condolences to Mr Hand’s family and loved ones. From your Report, we understand that you have concerns about the arrangements in place within Bedford Prison to manage those suspected to be ‘under the influence of illicit substances’. Specifically, you are concerned that the healthcare and prison teams are working to difference policies/procedures; that there is a lack of awareness of roles, responsibilities, and processes that should be followed in such circumstances; and that any Trust-wide policy/procedures we have in place should be clear on what happens when individual institutions have their own local protocols. You have asked The Trust to either provide details of action taken, or proposed to be taken, or to explain why no action is proposed. Please find below our response to your concerns detailing the actions being taken.

Cont’d/…

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Trust Headquarters: St. Mary’s Hospital, London Road, Kettering, NN15 7PW

Our common protocol for managing those suspected to be Under the Influence

We have worked with the Prison Governor and Head of Safety to agree and implement a common, local protocol for managing those suspected to be under the influence of illicit substances (UTI) at HMP Bedford. I have enclosed a copy of the protocol with this letter for your information.

The protocol clearly articulates the roles, responsibilities, and expectations of both healthcare and prison staff in the identification, assessment, and management of those suspected to be UTI.

The protocol makes it clear when prison staff should escalate to healthcare staff. It states that healthcare staff are responsible for taking the lead on UTI cases in which medical intervention is required. We have included a flowchart as an appendix to the UTI protocol to ensure this is clearly understood by both healthcare and prison service team members.

Ensuring prison and healthcare staff are aware of their roles and responsibilities

The healthcare and prison service leadership teams circulated the UTI protocol and an amended UTI recording log to staff late last year. Mandatory training for healthcare staff on UTI detection and management is being facilitated by the Trust’s Resuscitation Lead and is part of our induction programme. An ‘Airways Champion’ has also been identified. The Airways Champion supports our leadership team in maintaining competence in airway management and suction machine use. They will also help deliver future UTI simulation training sessions.

A new monthly meeting between prison and healthcare leaders

We have established a new, monthly meeting between the Head of Healthcare and Prison Governor focused on operational matters of healthcare and prison service integration. This new meeting complements our existing Partnership Delivery Board, which serves as the primary mechanism for shared tactical oversight and decision- making on matters within the agreed terms of reference. These strengthened arrangements will help us to maintain aligned and effective working relationships between healthcare and prison service teams, learn lessons from any issues that may arise, and capitalise on opportunities for innovation and improvement.

Cont’d/…

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Trust Headquarters: St. Mary’s Hospital, London Road, Kettering, NN15 7PW

I hope the content of this letter fully addresses the concerns you raised in your Report and provides assurance on the steps we have taken.

Please contact me if you have any questions about this letter or require further information.

HM Prison Probation Service Central Government

6 May 2026 PDF

Action Taken

• HMP Bedford and NHFT carried out a joint review of the UTI policies and protocols in place, resulting in the removal of any previous conflicting guidance and implementation of a single UTI protocol. • The updated protocol has been issued to all prison and healthcare staff through structured briefings, written notices, daily meeting updates, and daily checks. • A newly appointed substance misuse lead carries out daily assurance and visits all suspected UTI cases, ensuring consistency between operational and healthcare colleagues and consistent adherence to the UTI protocol. (AI summary)

View full response

Dear Ms Patel,

Thank you for your Regulation 28 report of 17 February 2026 following the inquest into the death of Mr Edward James Hands at HMP Bedford on 16 February 2024. I am responding on behalf of His Majesty’s Prison and Probation Service (HMPPS) as the Director General of Operations.

I know that you will share a copy of this response with Mr Hands’ family, and I would first like to express my condolences for their loss. Every death in custody is a tragedy and the safety of those in our care is my absolute priority.

You have expressed concerns regarding consistency between HMPPS staff and Northamptonshire Healthcare Foundation Trust (NHFT) Under the Influence (UTI) policies and protocols.

Following the conclusion of the inquest HMP Bedford and NHFT carried out a joint review of the UTI policies and protocols in place. This review resulted in the removal of any previous conflicting guidance and implementation of a single UTI protocol with standardisation of responsibilities, including observation requirements, escalation routes, and handover expectations. This protocol has been agreed by both parties and is to be followed by both operational and healthcare staff at HMP Bedford.

The updated protocol has been issued to all prison and healthcare staff through structured briefings, written notices, daily meeting updates, and daily checks.

Furthermore, the following additional actions have been carried out to reinforce the updated protocol:

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• Staff have been given guidance on recognising signs of being UTI , initiating the protocol, completing observations, and ensuring follow up checks are undertaken.
• A newly appointed substance misuse lead carries out daily assurance and visits all suspected UTI cases, ensuring consistency between operational and healthcare colleagues and consistent adherence to the UTI protocol.
• Every UTI related incident is now logged and tracked to support monitoring and learning.
• Assurance of documentation and observations is completed to ensure compliance of timescales and escalation procedures. Where this identifies areas requiring improvement a record is made and the issue escalated to both prison and healthcare senior leaders to be addressed as appropriate.
• Learning is shared across teams and discussed in the monthly Healthcare Partnership Board, attended by senior leaders from both the prison and healthcare. This ensures that all parties have the opportunity to raise any issues and these can be addressed and monitored. I hope the measures outlined above taken by HMP Bedford, in partnership with NHFT, provide you with reassurance that learning and appropriate action has been taken from the circumstances of Mr Hands’ death.

HMP Bedford Prison / Probation

PDF

Action Taken

• HMP Bedford implemented a new local protocol for managing prisoners suspected of being under the influence of unknown substances. • The protocol outlines steps for staff, including activating body-worn video, notifying colleagues, and calling for medical assistance. • The protocol specifies guidance for healthcare staff on observation frequency and documentation for prisoners under the influence. (AI summary)

View full response

HMP BEDFORD LOCAL UNDER THE INFLUENCE PROTOCOL

We have seen a worrying increase in prisoners that are found to be under the influence (UTI) of unknown substances recently. It is important that we all know the correct processes to follow, to keep our prisoners, colleagues and ourselves, safe. Upon identifying a prisoner suspected to be UTI, you should:

- Activate your Body Worn Video Camera immediately and notify your colleagues for assistance
- Call Hotel 2 and or Hotel 1 to attend to the incident.
- The prisoner should be taken back to their cell if safe to do so
- If presenting with severe symptoms, consider if a Code Blue needs to be called and continue with first aid response.

Following assessment of the prisoner from Hotel 1/2, if confirmed as suspected of being UTI:

• Healthcare will advise you on the frequency, and for how long the welfare observations on the prisoner should occur for. This should be documented in the observation book along with the follow-on observations.

• If a prisoner appears to recover quickly, you should continue the observations, and the prisoner should remain as ‘resting in cell’ for this period. Staff must ensure that meals are taken to the prisoner in the cell during this time.

• When completing observations, you must ensure that the prisoner is alert, responds appropriately to your voice, and if they have deteriorated, assess the need to call Hotel 1/2 or Code Blue.

• If the prisoner appears to recover and wishes to attend their visit/activity or appointment, they should be reassessed to determine if they are fit to attend. This can be done by Hotel1/2, or a defensible decision should be made by Victor 1.

• The prisoner should be placed on report, under the charge “Disobeys or fails to comply with any rule or regulation applying to him” Prison Rule 51, paragraph 23, and basic for a 28-day period, with a 14-day review where this can be lessened, if there is engagement with supporting change. Those on Basic should be managed accordingly and every effort should be made to move the prisoner into a cell with another basic prisoner to allow for removal of TV.

• The UTI form needs to be completed. On the UTI form, the First on Scene Officer should document why they believe the prisoner to be UTI and there is a section for Hotel 1/2 to complete. This paperwork needs to be taken to the CASU as evidence ready for the adjudication.

• A cell search needs to be conducted, with any drug paraphernalia or unauthorized articles removed as evidence and the prisoner should be placed on report for them. A body scan should not be routine however it is to be used on suspicion or related intelligence, and approval must be sought from V1.

• Oscar 1 should be informed, and an incident report needs to be completed, along with the completion of an IR and NOMIS case note.

• All prisoners that have been UTI should be added to the priority key work list and discussed at the following SIM. 11

Additional information:

Below are some common signs to look out for if you suspect a prisoner is UTI which you can also include on the UTI form description is relevant. Please be mindful that this list is not exhaustive due to the ever-changing illicit substances entering the prison community.

Physical signs of being under the influence:
• Confusion/disorientation
• Aggression
• Sweating
• Red Eyes & Dilated or Constricted Pupils
• Anxiety or Paranoia
• Poor coordination
• Sudden change in mood
• Vomiting

Signs of Overdose:
• Breathing slowly or very shallow
• Unconsciousness
• Lips/nails blue
• Chest pain
• Nausea
• Stroke
• Seizures
• Gurgling or snoring sounds
• Tremors
• Hot/clammy skin
• Vomiting

Other signs to look out for:
• Changes in appetite
• Needle marks
• Loss of interest in hygiene or grooming habits
• Unusual smells
• Finding drug paraphernalia
• Changes in sleep patterns
• Noticeably different energy levels
• Drastic personality change
• Being dishonest or sneaky, hiding things, or needing increased privacy
• Debt
• Loss of memory
• New peer groups
• Missing work with no legitimate excuse

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Report sections

Investigation and inquest

On 20 February 2024, I commenced an investigation into the death of Edward James HANDS aged 42, who died on the 16 February 2024. The investigation concluded at the end of the inquest on 2 December 2025.

The family requested that I refer to the deceased Edward James Hands as Eddie and therefore I will reflect that in this report. The medical cause of death was: 1a Aspiration Pneumonitis 2 Methadone Use

The conclusion of the jury inquest was a Narrative Conclusion - After consuming methadone, the major contributing factor in Eddie's death was a lack of follow up care by both healthcare and prison staff. Overall, Eddie's death was contributed to by neglect. On the balance of probabilities, Eddie's death could have been prevented as there was a window of opportunity to intervene. The following factors contributed to the death in a more than minimal way: Insufficient training around the Under the Influence (UTI) protocol; A lack of awareness by prison and healthcare staff in identifying and managing the signs of a UTI case; The availability of staff on the day; High staff turnover, as well as inadequate onboarding of new staff; A lack of cooperation between healthcare and prison management; An omission of discussing the ongoing UTI case during afternoon briefings and/or handovers; An overall lack of accountability in taking ownership of handling the UTI case.

Circumstances of the death

1) Eddie died on the 16th February 2024 at 1724 in his cell A329, Alpha Wing, HMP Bedford. He died from Aspiration Pneumonitis following consumption of methadone. He was last seen at: 1449, when he was reported snoring in his cell.
2) Access to mental health support services did not contribute to the death. Access to substance misuse support, although broadly beneficial, would not have directly impacted the outcome.
3)There was an Under the Influence Protocol (Bedford Staff Community Notice 265/2023) in place at the time of the death. This protocol was not being used at the time, as evidenced by the number of noted UTI (Under the Influence) incidents (34 in January and 15 in February) and the lack of awareness and recording in the protocol by both prison officers and healthcare staff. Methadone administration at the prison was conducted by two members of staff (healthcare and/or prison staff). However, this was applied inconsistently.
4) Eddie was not prescribed methadone, and it is uncertain how he came to ingest it.

On 16th February 2024, Eddie's presenting condition was initially managed in line with the protocol with prison staff raising a Hotel 2 call. Healthcare staff responded to this call. The observations conducted by healthcare staff assessed that he was under the influence. At this point, the UTI protocol should have been started by prison staff and/or healthcare staff, and this did not happen. The lack of follow up visits or checks were a failure in his ongoing care. Thereafter, there was a failure by healthcare staff to carry out a follow up medical assessment or by prison staff as per the protocol. In responding to the 'Code Blue', there was not a full response by healthcare, in that only one of the designated staff members attended. Whilst the evidence does not establish that the following matters probably caused or contributed to Eddie's death, it was admitted that there was a failure of healthcare to use suction equipment to clear the airway at the time he was found unresponsive in his cell and in cardiac arrest with stomach contents in his mouth and throat.

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