Source · Prevention of Future Deaths

Harold Uzomechina

Ref: 2019-0351 Date: 21 Oct 2019 Coroner: Chinyere Inyama Area: London (West) Responses identified: 0 / 1 View PDF

Detainees on the substance misuse unit received differential and inadequate care at night, lacking dedicated prison officers and equivalent attention compared to those on formal ACCTs.

Date 21 Oct 2019
56-day deadline 17 Jan 2020 est.
Responses identified 0 of 1
Alcohol, drug and medication related deaths State Custody related deaths

Coroner's concerns

AI summary
Detainees on the substance misuse unit received differential and inadequate care at night, lacking dedicated prison officers and equivalent attention compared to those on formal ACCTs.
View full coroner's concerns
being: ~drug

_ There appeared to be differential treatment of detainees on the substance misuse unit at night compared to treatment they received during the specifically, detainees had the benefit of dedicated prison officers during the day time but not during the night:
2. The totality of the evidence given by staff suggests that the at-risk population of detainees on the substance misuse unit were not afforded the same level care and attention given to detainees who were formally on an ACCT. This needs to be addressed_

Report sections

Investigation and inquest
On 24th April 2016 an investigation was commenced into the death of Harold Chukwunedum Uzomechina then aged 34. The investigation concluded at the end of the inquest on 12th September 2019. The conclusion of the jury at the inquest was that Mr Uzomechina died a drug related death to which a failure to recognise signs of cardio respiratory depression contributed A factor preventing such recognition was an inadequate process of physical monitoring during the night state of Mr Uzomechina the medical cause of death 1a aspiration pneumonia 1b cardio respiratory depression Ic multi-C toxicity
Circumstances of the death
Mr Uzomechina was remanded to HMP Wormwood scrubs on 20h April 2016. At reception health screens, he reported physical and mental health problems as well as longstanding dependence on drugs and alcohol: prison GP prescribed methadone for management of heroin dependency and chlordiazepoxide for alcohol withdrawal and symptom relief medication: Mr Uzomechina was transferred to the substance misuse stabilisation unit for detoxification. Late at night on 23rd April, Mr Uzomechina's cell mate asked to move cells because he said Mr Uzomechina was snoring 50 loudly that it was keeping him awake: At 8.55 the following morning, 24th April, officers were unable to wake Mr Uzomechina and a nurse was called. Despite attempts at CPR Mr Uzomechina was confirmed dead at 9.32 am
Action should be taken
In my opinion action should be taken to prevent future deaths and believe you have the power to take such action.
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Report details

Reference
2019-0351
Date of report
21 October 2019
Coroner
Chinyere Inyama
Coroner area
London (West)

Responses identified

Responses identified 0 of 1
1 response not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 17 Jan 2020 (estimated).

Sent to

HMP Wormwood Scrubs

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