Source · Prevention of Future Deaths

Daniel Stokes

Ref: 2018-0346 Date: 5 Nov 2018 Coroner: Neil Cameron Area: South Yorkshire (East) Responses identified: 0 / 1 View PDF

Prison healthcare staff possessed diazepam but were not trained or authorised to administer it, potentially hindering response to drug abuse incidents.

Date 5 Nov 2018
56-day deadline 7 Jun 2019 est.
Responses identified 0 of 1
Hospital Death (Clinical Procedures and medical management) related deaths State Custody related deaths

Coroner's concerns

AI summary
Prison healthcare staff possessed diazepam but were not trained or authorised to administer it, potentially hindering response to drug abuse incidents.
View full coroner's concerns
(1) Part of the evidence in this case related to the attendance of prison healthcare staff who were in the possession of diazapam, but not trainedlauthorised t0 administer it. Whilst there be good reason for this (ie s0 that pam is available at the scene of an incident if someone attends who is s0 trainedlauthorised) nonetheless, the jury which considered the case clearly considered that this amounts t0 a failure to have proper systems in place. therefore adopt their view as a matter of concern, such that | consider consideration should be given to the practicality of requiring healthcare staff working within prisons to be trainedlauthorised to administer diazapam in circumstances where prisoner may be suffering from the effect of abuse of controlled drugs. Coroner's Court and Office, Doncaster Crown Court; College Road; Doncaster; DNI 3HS Tel 01302 737135 Fax 01302 736365 and 30th from belng may diazar

Report sections

Investigation and inquest
On 4th December 2015 commenced an investigation into the death of Daniel Paul Mark Stokes;
34. The investigation concluded at the end of the inquest on Znd November 2018, The conclusion of the inquest was Misadventure.
Circumstances of the death
Daniel Paul Mark Stokes was an inmate at HM Prison, Lindholme, Doncaster. On November 2015 , it is reported by another prisoner that the deceased had described taking an amount of MDMA and was acting erratically: The deceased showed features of physical agitation, culminating in cardiac arrest; Despite assistance prison and paramedic staff; Mr Stokes could not be revived, declared deceased on the same day at 20.05 hours on the 30th November 2015.
Action should be taken
In my opinion action should be taken to prevent future deaths and believe to take such action: you have the power

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Report details

Reference
2018-0346
Date of report
5 November 2018
Coroner
Neil Cameron
Coroner area
South Yorkshire (East)

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: 7 Jun 2019 (estimated).

Sent to

NHS England

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