King, Alun

Independent investigation into
the death of Mr Alun King,
a prisoner at HMP Winchester,
on 22 March 2022
A report by the Prisons and Probation Ombudsman
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
© Crown copyright, 2024
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The Prisons and Probation Ombudsman aims to make a significant contribution to safer,
fairer custody and community supervision. One of the most important ways in which we
work towards that aim is by carrying out independent investigations into deaths, due to any
cause, of prisoners, young people in detention, residents of approved premises and
detainees in immigration centres.
If my office is best to assist His Majesty’s Prison and Probation Service (HMPPS) in
ensuring the standard of care received by those within service remit is appropriate, our
recommendations should be focused, evidenced and viable. This is especially the case if
there is evidence of systemic failure.
Mr Alun King died of a duloxetine (an antidepressant) overdose on 22 March 2022, at
HMP Winchester. He was 45 years old. I offer my condolences to Mr King’s family and
friends.
Mr King was prescribed duloxetine, which he took twice daily under supervision. It is
unclear how he managed to take an excessive amount. It is possible he was not
swallowing his medication and saving it for later use, though there was no intelligence to
suggest he was doing so.
In their 2021/22 report, the Independent Monitoring Board said that although supervision of
medication rounds was effective, they were concerned that prisoners could still be
diverting medication. The Head of Security and Head of Healthcare may wish to review the
measures in place for preventing the diversion of medication.
Mr King was taken to hospital on 20 March when he became unwell. When he returned in
the early hours of 21 March after discharging himself, no one told healthcare staff. This
was a missed opportunity for healthcare staff to monitor Mr King and check for signs of
clinical deterioration.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Adrian Usher
Prisons and Probation Ombudsman November 2023
Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 5
Findings ........................................................................................................................... 8
Summary
Events
1. Mr Alun King was remanded to HMP Winchester on 12 March 2022, charged with
manslaughter.
2. Mr King had a history of drug use, chronic pain and depression. He was prescribed
methadone (an opiate drug, usually used as a heroin substitute but in this case for
pain relief), other pain relief medication and antidepressants, which he collected
from the wing medication hatch twice daily.
3. On 18 March, Mr King made cuts to his arms because he said he was angry about
not receiving items he had ordered from the prison shop. Staff took him to hospital
to have his wounds stitched and he returned to Winchester later that day. Staff
started suicide and self-harm prevention procedures (known as ACCT).
4. On the morning of 20 March, Mr King told healthcare staff at the medication hatch
that he felt dizzy. They noticed that his speech was slurred, and he had right-sided
weakness around his mouth. Healthcare staff examined him and found that his
clinical observations were normal.
5. Around two hours later, a nurse went to check on Mr King. Staff told him that Mr
King was out on the exercise yard, so the nurse assumed he was feeling better.
6. Later that day, Mr King felt unwell again with the same symptoms. A nurse found
that his blood oxygen level was low and sent him to hospital. That evening, a
hospital doctor called the prison to ask why Mr King had been sent to hospital and
whether he had taken any illicit substances. There is no record of what healthcare
staff at the prison told the doctor.
7. In the early hours of 21 March, Mr King discharged himself from hospital and staff
returned him to Winchester. Healthcare staff were not told straightaway that Mr King
had returned from hospital, but a nurse saw him later that morning and he said he
felt much better. There is no record that the nurse took clinical observations.
8. That night, during an ACCT check, a member of staff saw Mr King lying on the floor
of his cell with vomit by his head. She went to fetch a nurse and when she could not
find one, she called a medical emergency code.
9. Staff entered the cell and started CPR, which paramedics continued when they
arrived. However, resuscitation attempts were unsuccessful and at 12.25am on 22
March, paramedics declared that Mr King had died.
10. The post-mortem report concluded that Mr King died of a duloxetine (an
antidepressant) overdose. Mr King was prescribed duloxetine.
Findings
11. It is unclear how Mr King was able to take an excessive amount of duloxetine as he
was not allowed to administer it himself and collected it twice daily. It is possible
Prisons and Probation Ombudsman 1
that he was not swallowing his medication and storing it for later use, but there were
no suspicions that he was doing so. Mr King did not leave a note, and there was no
evidence to allow us to conclude he had intentionally overdosed on his medication.
12. In its last report for 2021/22, the Independent Monitoring Board said that the
supervision of the medication rounds was generally effective, but they were still
concerned that prisoners were able to divert their medication. The Head of Security
and the Head of Healthcare may wish to consider how they could strengthen
measures to prevent the storing and diversion of medication.
13. The clinical reviewer found that aspects of Mr King’s care were not equivalent to
that which he could have expected to receive in the community. When Mr King
returned from hospital on 21 March, no one told healthcare staff. The Head of
Healthcare told us that they would have monitored Mr King had they known that he
had arrived back at the prison.
Recommendations
• The Governor should ensure that healthcare staff are told promptly when a prisoner
returns from hospital, regardless of the time of day or night.
2 Prisons and Probation Ombudsman
The Investigation Process
14. HMPPS notified us of Mr King’s death on 22 March 2022.
15. The investigator issued notices to staff and prisoners at HMP Winchester informing
them of the investigation and asking anyone with relevant information to contact
her. No one responded.
16. The investigator obtained copies of relevant extracts from Mr King’s prison and
medical records.
17. NHS England commissioned an independent clinical reviewer to review Mr King’s
clinical care at the prison. The clinical reviewer and investigator jointly interviewed
eight members of staff in June and July 2022. Another investigator interviewed the
Head of Security on 27 June 2023.
18. We informed HM Coroner for Portsmouth and Southeast Hampshire of the
investigation. The Coroner gave us the results of the post-mortem examination. We
have sent the Coroner a copy of this report.
19. The Ombudsman’s family liaison officer contacted Mr King’s wife to explain the
investigation and to ask if she had any matters she wanted us to consider. She did
not respond.
20. We shared our initial report with HMPPS. They found no factual inaccuracies.
Prisons and Probation Ombudsman 3
Background Information
HMP Winchester
21. HMP Winchester is a local prison that holds up to 690 men. It has a local category
B unit for young and adult men and a separate category C unit for adult men.
Practice Plus Group Health and Rehabilitation Services Limited has provided health
services at the prison since July 2020.
HM Inspectorate of Prisons
22. The most recent inspection of HMP Winchester was in February 2022. Winchester
had struggled to recruit and retain enough staff and this problem was affecting the
day-to-day running of the prison, where at times, there were simply not enough
officers to ensure even the most basic regime for prisoners.
23. The identification and management of patients with long term health conditions had
improved. Care plans had been updated. A long term conditions nurse carried out
prompt medicine reviews and annual health checks. Staff worked together to
discuss patient care and address immediate health care needs.
Independent Monitoring Board
24. Each prison has an Independent Monitoring Board (IMB) of unpaid volunteers from
the local community who help to ensure that prisoners are treated fairly and
decently. In its latest annual report, for the year to 31 May 2022, the IMB reported
that the high l turnover of prisoners made the provision of healthcare services
challenging, particularly when the prisoners’ healthcare needs were complex.
Prisoners with long-term conditions were provided with care plans. Supervision of
medicines rounds was generally effective, but the IMB had concerns that prisoners
were able to divert medication.
Previous deaths at HMP Winchester
25. Mr King was the fifteenth prisoner to die at Winchester since March 2019. Of the
previous deaths, ten were from natural causes and four were self-inflicted. There
are no similarities between the findings from our investigation into Mr King’s death
and our findings from the previous investigations.
4 Prisons and Probation Ombudsman
Key Events
26. On 12 March 2022, Mr Alun King was remanded in prison, charged with
manslaughter, and sent to HMP Winchester. It was not his first time at Winchester.
27. Mr King had a history of substance misuse, mental health issues and chronic pain.
The reception nurse recorded that he had a history of self-harm but no current
thoughts of suicide or self-harm. He said he had last attempted suicide in 2007.
28. Mr King was using buprenorphine (also known as Subutex, an opioid drug) patches
for pain relief. However, the substance misuse nurse told him that he could not
have these patches in his possession while in prison. Instead, the nurse prescribed
methadone (another opioid drug, usually used as a heroin substitute but in this case
prescribed as pain relief). He had been on methadone previously as part of a drug
detoxification programme but not for a few years. He was prescribed a range of
other medications for pain, depression and physical conditions (including asthma).
His medications included pregabalin (to treat neuropathic pain but also widely
abused for its euphoric effects when taken alongside opioid drugs), duloxetine and
mirtazapine (both antidepressants). Mr King was not allowed to keep his medication
in his possession and collected it from the medication hatch on the wing twice a
day. Prison officers monitor the medication queue and are expected to check
prisoners’ mouths to ensure that they have swallowed their medication.
29. On 18 March, Mr King made cuts to his arms. He told staff he did it because he was
angry that he had not received his canteen (items ordered from the prison shop).
Staff took Mr King to hospital where his wounds were stitched. He was discharged
later that day. Staff started suicide and self-harm prevention procedures (known as
ACCT) and set observations at two an hour.
30. At his ACCT assessment interview the next day, Mr King said he was expecting a
long sentence and was worried about his mental health. He said he heard voices
which made him angry. He said the issue with his canteen had been resolved and
that he had the support of his wife, daughter and parents. Staff held a case review
the same day. They reduced observations to one an hour and scheduled the next
case review for 24 March.
20 March
31. At 11.30am, on 20 March, Mr King told healthcare staff at the medication hatch that
he felt dizzy. His speech was slurred, and he had right-sided weakness around his
mouth. A nurse took Mr King’s clinical observations, which were all normal, but he
called for the duty nurse to examine Mr King more closely.
32. The duty nurse examined Mr King and noted his slurred speech, dry lips, and
weakness. He took Mr King’s clinical observations again, which were normal. Mr
King said he had not taken any illicit drugs but had not been drinking enough fluids.
Staff gave him a glass of water and the nurse noted that he would check on him
again later.
33. At around 2.30pm, the duty nurse returned to the wing to review Mr King but was
told he was on the exercise yard. At interview, he said he had assumed this meant
Prisons and Probation Ombudsman 5
Mr King was feeling better and that he did not try to see Mr King as prisoners
generally did not like having their exercise time interrupted.
34. At around 5.45pm, an officer called for a nurse to see Mr King as he had appeared
dizzy and weak during an ACCT check. The duty nurse attended. He took Mr King’s
clinical observations and found that his blood oxygen level was low. He asked staff
to call for an ambulance, and Mr King was taken to hospital.
35. Later that evening, a hospital doctor called the prison to ask why Mr King was sent
to hospital, what his clinical observations were and whether he had taken any illicit
substances. The call is noted in Mr King’s medical record, but the entry does not
say what the doctor was told. When interviewed, the duty nurse said that when a
prisoner was sent to hospital, he would normally print off a summary from the
medical record and pass it to the escorting officers and he would have done this for
Mr King. However, there is no documentary evidence of this.
21-22 March
36. At around 2.10am on 21 March, Mr King discharged himself from hospital and staff
returned him to Winchester. Staff took him straight to his cell and did not tell
healthcare staff that he had returned from hospital.
37. Staff gave Mr King his methadone at around 8.40am. Around three hours later, a
nurse noted that she saw Mr King and he said that he felt much better. There is no
record that she took any clinical observations.
38. Later that day, healthcare staff called the hospital to request Mr King’s discharge
summary. According to the Head of Healthcare at Winchester, during the call the
hospital told a member of staff that Mr King had been given naloxone (a medicine
that reverses the effects of opioid overdose) at the hospital. This was not mentioned
on the discharge summary, which just said that Mr King had self-discharged prior to
assessment.
39. That afternoon, staff recorded in the ACCT ongoing record that Mr King had asked
about getting a wing job, that he had engaged with the regime and had no issues.
Later, at around 5.00pm, they recorded that he seemed to be in a low mood.
40. At 11.07pm, an operational support grade (OSG) carried out Mr King’s ACCT
check. She said that Mr King was watching television and confirmed that he was
well.
41. At 11.33pm, the OSG checked Mr King again. She saw Mr King on the floor with
vomit around his head. She went to get help from the healthcare office nearby, but
the nurse was not there, so she radioed a code blue (a medical emergency code
used when a prisoner is unconscious or having breathing difficulties). Two officers
arrived at the cell at 11.34pm, followed by healthcare staff. They went into the cell
and healthcare staff started CPR.
42. At 11.45pm, paramedics arrived and took over CPR. However, resuscitation
attempts were unsuccessful. At 12.25am on 22 March, paramedics declared that Mr
King had died.
6 Prisons and Probation Ombudsman
Contact with Mr King’s family
43. On 22 March, the prison appointed a prison manager as the family liaison officer.
He and a colleague informed Mr King’s wife of his death in person, later that day.
44. Winchester offered to contribute to Mr King’s funeral costs in line with national
policy.
Support for prisoners and staff
45. After Mr King’s death, the duty governor debriefed the staff involved in the
emergency response to ensure they had the opportunity to discuss any issues
arising, and to offer support. The staff care team also offered support.
46. The prison posted notices informing other prisoners of Mr King’s death and offering
support. Staff reviewed all prisoners assessed as being at risk of suicide or self-
harm in case they had been adversely affected by Mr King’s death.
Post-mortem report
47. Toxicology results showed that Mr King had a raised level of duloxetine in his blood,
which could indicate overdose. He also had raised levels of pregabalin and
mirtazapine, but both were far below the levels associated with fatalities. The other
drugs detected were at levels consistent with therapeutic use.
48. The post-mortem report concluded that Mr King died from a duloxetine overdose.
There was also evidence of food aspiration (breathing food into the lungs) and
pneumonia that had contributed to death.
Prisons and Probation Ombudsman 7
Findings
Duloxetine overdose
49. Mr King’s post-mortem report concluded that he died from a duloxetine overdose.
He did not leave a note so there is no evidence that it was a deliberate overdose.
The fact that he reported to staff at the medication hatch that he was feeling unwell
would also suggest that his overdose was not intentional.
50. Mr King was prescribed duloxetine (60mg twice daily), which he collected from the
medication hatch on the wing. As Mr King did not keep his medication in his
possession, it is unclear how he was able to take an excessive amount. Prison
officers supervise the medication queue and are supposed to confirm that prisoners
have swallowed their medication by checking their mouth. However, prisoners can
still find ways to secrete medication. It is possible that Mr King did not swallow his
medication and stored it for use later, but there were no suspicions that Mr King
was storing or diverting his medication while at Winchester.
51. The IMB noted in their latest report for 2021/22 that although supervision of
medicines rounds was generally effective, they had concerns that prisoners were
able to divert medication. We do not make a recommendation, but the Head of
Security and Head of Healthcare may wish to consider how they could reduce
opportunities for prisoners to store and divert medication.
Clinical care
52. The clinical reviewer concluded that some aspects of Mr King’s clinical care were
not equivalent to that which he could have expected to receive in the community.
She noted that there was no documented handover to the hospital, including clinical
observations, when Mr King was sent to hospital on 20 March. She made some
recommendations in her clinical review which the Head of Healthcare will need to
address.
Communication between prison staff and healthcare staff on 21 March
53. When a prisoner returns from hospital out of hours, when the prison reception is
closed, it is good practice for prison staff to tell healthcare staff so that they can
ensure continuity of care.
54. At interview, the Head of Healthcare said that if her staff had been made aware that
Mr King had returned from hospital, they would have taken Mr King’s clinical
observations and closely monitored him, either on the wing or transferred him to the
prison’s inpatient unit if necessary. The nurse involved in the emergency response
also said in interview that he would have checked Mr King if he had known that he
had returned from hospital. This was potentially a missed opportunity to monitor Mr
King for any clinical deterioration (though it is noted that Mr King appeared to be
well during the day of 21 March and only seemed to deteriorate much later on that
evening).
8 Prisons and Probation Ombudsman
55. We recommend:
The Governor should ensure that healthcare staff are told promptly when a
prisoner returns from hospital, regardless of the time of day or night.
Inquest
56. The inquest concluded on 7 May 2024. The medical cause of death was found to
be:
1a Respiratory Depression
1b Central Nervous System Depression
1c Combined Use of Complex, Prescribed Medication, Exacerbating Pre-Existing
Chronic Lung Disease, due to Recurrent Aspiration Pneumonia and Chronic
Obstructive Pulmonary Disease
57. The inquest reached a narrative conclusion:
“Alun died as a result of natural causes, though his ability to manage his respiratory
challenges and his other co-morbidities was compromised by prescribed medication
treatment that was potentially administered outside of the optimal prescribed times
and a polymorphy review was due.”
Prisons and Probation Ombudsman 9
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk