Benjamin Harrison

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Independent investigation into
the death of Benjamin Harrison,
a prisoner at HMP Rochester,
on 10 May 2022
A report by the Prisons and Probation Ombudsman
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Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
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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.
My office carries out investigations to understand what happened and identify how the
organisations whose actions we oversee can improve their work in the future.
Mr Benjamin Harrison died of fentanyl (pain relief) toxicity on 10 May 2022 at HMP
Rochester, five days after he was transferred from HMP Elmley. He was 42 years old. I
offer my condolences to Mr Harrison’s family and friends.
The clinical reviewer found that the clinical care Mr Harrison received was of a reasonable
standard and therefore equivalent to what he could have expected to receive in the
community. However, she identified some issues with the management of Mr Harrison’s
medication and clinical care at Elmley and in the regional policy at Oxleas NHS
Foundation Trust. The healthcare team at Elmley were concerned about the combination
of medications that Mr Harrison had been prescribed in the community. However, they
made little progress in addressing this issue during the two months that he spent there.
HMP Rochester did make some progress in the short period that Mr Harrison was
accommodated there and we commend the prison’s proactive approach. Sadly, Mr
Harrison died before the process could be completed. The clinical reviewer also
considered that Elmley should have referred Mr Harrison to a neurology service to explore
his potential epilepsy.
No detailed clinical handover was provided for Mr Harrison when he transferred from
Elmley to Rochester. Although this is not a policy requirement, we consider that this would
have been good practice for someone with Mr Harrison’s complex medication, to ensure
continuity of care.
The clinical reviewer found that the healthcare provider at Elmley and Rochester do not
have a formal policy in place for the use of fentanyl patches in secure settings. She noted
that national guidelines advise stringent governance around the prescribing, administration
and monitoring of fentanyl patches using a safety checklist. We recommend that this
checklist is incorporated into Oxleas policy going forward.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Kimberley Bingham
Acting Prisons and Probation Ombudsman November 2023
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 6
Findings ......................................................................................................................... 11
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Summary
Events
1. Mr Benjamin Harrison had a long offending history and substance misuse issues.
Mr Harrison had some physical health problems, including an unconfirmed
diagnosis of epilepsy and chronic leg pain, for which he was prescribed medication.
2. Mr Harrison was released from HMP Elmley on 6 January 2021 and recalled on 8
March 2022. At his initial screenings, staff found that he had arrived with several
prescription medications, including fentanyl patches for pain relief, which were due
to be supplied every three days. Healthcare staff added Mr Harrison to the chronic
pain multidisciplinary team (MDT) meeting caseload, but the next meeting was
cancelled, so they referred to the local hospital for advice. They did not receive a
response.
3. On 5 May, Mr Harrison was transferred to HMP Rochester and placed in a shared
cell. Although no formal clinical handover took place between Elmley and
Rochester, a GP quickly highlighted that Mr Harrison was being prescribed a
significant amount of medication which should be reviewed.
4. At around 4.00pm on 9 May, healthcare staff at the medication hatch administered
Mr Harrison a new fentanyl patch. Mr Harrison used a vape pen to smoke the patch
and did so in the toilet/shower area of his cell, to conceal what he was doing from
prison staff.
5. At around 8.35pm, the night patrol officer carried out the evening roll check of
prisoners on Mr Harrison’s wing and thought she could detect a faint odour of
burning paper coming from his cell. She checked in on Mr Harrison on a few
occasions but raised no concerns.
6. At around 11.55am, Mr Harrison’s cell mate pressed the cell bell. He appeared
distressed and said he thought there might be something wrong with Mr Harrison.
The night patrol officer attended the cell and quickly called a medical emergency
‘code blue’, indicating a life-threatening situation. Officers responded and began
cardiopulmonary resuscitation (CPR). An ambulance crew arrived on site at
12.20am but were unable to revive Mr Harrison. Paramedics confirmed that Mr
Harrison had died at 12.41am.
Findings
7. The clinical reviewer found that the clinical care received by Mr Harrison was of a
reasonable standard and therefore equivalent to that which he could have expected
to receive in the community.
8. Healthcare staff at Elmley identified that Mr Harrison’s medications presented
certain health risks and should be reduced or changed. Although there was no
quick solution, we are concerned that they did not make any progress during the
two months that Mr Harrison spent at the prison. The healthcare team referred to
the local hospital for advice but did not chase up a response. The clinical reviewer
suggests that staff at Elmley could and should have done more within that time, to
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reduce or change Mr Harrison’s prescribed medications. When Mr Harrison arrived
at HMP Rochester, a GP quickly highlighted that he was being prescribed a
significant amount of medication which should be reviewed. We are pleased that
progress to reduce Mr Harrison’s medication was underway at Rochester and
commend the prison’s proactive approach. Sadly, Mr Harrison died before the
process could be completed. The clinical reviewer also identifies that Elmley did
not take any action to confirm Mr Harrison’s epilepsy diagnosis and the
appropriateness of his medications for it.
9. We consider that it would have been good practice to conduct for Elmley to provide
a more detailed clinical handover for Mr Harrison, considering his complex needs,
to ensure the transfer was safe and to enable continuity of risk management and
care.
10. The clinical reviewer noted that Oxleas, the healthcare provider to Elmley and
Rochester, do not have a formal policy in place on the governance arrangements
for the use of fentanyl patches in a secure setting. The clinical reviewer noted that
the prescribing of fentanyl patches as a controlled drug is not recommended in
secure settings in accordance with national policy. However, in the exceptional
event they are prescribed, The Care Quality Commission (CQC) and NHSE
recommend that there should be stringent governance around the prescribing,
administration and monitoring of this drug by utilising a safety checklist.
11. PSI 04/2017 states that, “In those establishments where it is authorised for use,
BWVC must be deployed and set to record during a response to any reportable
incident”. Although some officers involved in the emergency response on Mr
Harrison were wearing body-worn video cameras (BWVC), none were turned on.
We have recommended that they do so in future reportable incidents.
Recommendations
• The Head of Healthcare at HMP Elmley should ensure that handovers take place
for complex patients who present clinical risks and are due to be transferred, to
ensure continuity of care.
• The Head of Healthcare at HMP Elmley should ensure that when new prisoners
enter the establishment on high risk and complex medication, staff complete a
prompt review of medication to manage any risks.
• The Head of Healthcare at HMP Elmley should ensure that when there is a query
regarding a prisoner’s diagnosis, the relevant referral is made to ensure it can be
confirmed or other options explored.
• The Lead Pharmacist at Oxleas Trust should create clear guidelines on the safe
prescription, administration and governance of Fentanyl patch prescriptions in
secure settings, in accordance with the RCGP ‘safer prescribing in prisons’ (2019)
and the guidance and checklist contained within the CQC and NHSE guidance for
the ‘safer use of controlled drugs’ (2016).
• The Governor of HMP Rochester should remind staff to switch on their body-worn
cameras during reportable incidents and that control room operators prompt staff to
do so during an incident.
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The Investigation Process
12. The investigator issued notices to staff and prisoners at HMP Rochester informing
them of the investigation and asking anyone with relevant information to contact
him. No one responded.
13. The investigator obtained copies of relevant extracts from Mr Harrison’s prison and
medical records.
14. The investigator interviewed five members of staff via video-link on 12 October
2022.
15. NHS England commissioned a clinical reviewer to review Mr Harrison’s clinical care
at the prison.
16. We informed HM Coroner for Mid Kent and Medway of the investigation. The
Coroner gave us the results of Mr Harrison’s post-mortem examination and
toxicology screen. We have sent the Coroner a copy of this report.
17. The Ombudsman’s family liaison officer contacted Mr Harrison’s sister to explain
the investigation and to ask if she had any matters she wanted us to consider. She
asked us to find out about the prescriptions Mr Harrison received at Rochester.
She also asked if we had spoken to Mr Harrison’s cell mate or any other prisoners,
if there was a delay in entering the cell during the emergency response, and why Mr
Harrison’s mother learned of her son’s death indirectly through someone known to
her family. We have addressed these questions in our report.
18. The initial report was shared with HM Prison and Probation Service (HMPPS).
Healthcare at HMP Rochester and HMP Elmley. The clinical reviewer, made a slight
amendment to a recommendation in her Clinical Review in response to comments
made by Healthcare at HMP Elmley, however her overall findings remain
unaffected. We have provided clarification to the family by way of separate
correspondence to them. The final version of the clinical review is included as an
annex to this report.
19. Mr Harrison’s family received a copy of the draft report. The solicitor representing
the Harrison family raised several questions that do not impact on the factual
accuracy or findings of this report. We have provided clarification to the family by
way of separate correspondence to them.
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Background Information
HMP Rochester
18. HMP/YOI Rochester is a category C resettlement prison, holding up to 695 adult
and young male prisoners. Oxleas NHS Foundation Trust provides healthcare
services at the prison. Primary healthcare services are available onsite from
7.45am to 7.30pm Monday to Thursday, and 7.45am to 6.00pm from Friday to
Sunday. Healthcare services were therefore not available at the time of Mr
Harrison’s death.
HM Inspectorate of Prisons
19. The most recent inspection of HMP Rochester was in October 2021 and findings
were outlined in a report published in February 2022. Inspectors found that patients
who could not have medication in their possession attended an administration hatch
to receive their medicines.
20. Inspectors found that risk assessments for whether prisoners could hold and
administer their own medications were not routinely checked to ensure they were
up to date. Patients were not encouraged to have medicines in possession, which
did not support independent care.
21. Inspectors also reported that medication-related incidents were not reported
robustly and recommended that robust governance procedures, including
consistent incident reporting and investigation, should be implemented to ensure
that concerns affecting patient safety are promptly addressed.
Independent Monitoring Board
22. 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 March 2022 (published in
September 2022), the Board reported that there is nearly always a healthcare
staffing shortage at Rochester. However, core nursing responsibilities were
covered, with managers stepping in as necessary.
23. The Board noted that a new healthcare manager had been employed since April
2021, and improvements had been made in their first year in post. However, 85
healthcare related complaints had been received during the reporting year, up from
58 and 56 respectively from the previous two years. The overwhelming majority of
complaints related to medication issues or perceived delays in seeing the prison
GP. The Board described the increase in complaints as ‘concerning’ and stated
that they would continue to monitor the issue.
Previous deaths at HMP Rochester
24. Mr Harrison is the fourth death at Rochester since April 2018. Of the previous
deaths, two were self-inflicted and the one was from natural causes. There are no
similarities in our investigation findings for Mr Harrison and previous deaths.
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Assessment, Care in Custody and Teamwork
25. ACCT is the Prison Service care-planning system used to support prisoners at risk
of suicide or self-harm. The purpose of ACCT is to try to determine the level of risk,
how to reduce the risk and how best to monitor and supervise the prisoner. After an
initial assessment of the prisoner’s main concerns, levels of supervision and
interactions are set according to the perceived risk of harm. Checks should be
carried out at irregular intervals to prevent the prisoner anticipating when they will
occur. Regular multidisciplinary review meetings involving the prisoner should be
held.
26. As part of the process, a caremap (a plan of care, support and intervention) is put in
place. The ACCT plan should not be closed until all the actions of the caremap
have been completed. All decisions made as part of the ACCT process and any
relevant observations about the prisoner should be written in the ACCT booklet,
which accompanies the prisoner as they move around the prison. Guidance on
ACCT procedures is set out in Prison Service Instruction (PSI) 64/2011,
Management of prisons at risk of harm to self, to others and from others (Safer
Custody).
Psychoactive substances (PS)
27. Psychoactive substances (PS), previously known as ‘legal highs’, are an increasing
problem across the prison estate. They are difficult to detect and can affect people
in a number of ways including increasing heart rate, raising blood pressure,
reducing blood supply to the heart and vomiting. Prisoners under the influence of
PS can present with marked levels of disinhibition, heightened energy levels, a high
tolerance of pain and a potential for violence. Besides emerging evidence of such
dangers to physical health, there is potential for precipitating or exacerbating the
deterioration of mental health with links to suicide or self-harm.
28. In July 2015, we published a Learning Lessons Bulletin about the use of PS and its
dangers, including its close association with debt, bullying and violence. The
bulletin identified the need for better awareness among staff and prisoners of the
dangers of PS; the need for more effective drug supply reduction strategies; better
monitoring by drug treatment services; and effective violence reduction strategies.
Fentanyl
29. Fentanyl is an opioid based painkiller. It is used to treat severe and long-lasting
pain, for example during or after an operation or a serious injury, or pain from
cancer.
30. It is possible to become addicted to fentanyl, but the prescribing doctor will explain
to patients how to reduce the risks of becoming addicted.
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Key Events
Background
31. Mr Benjamin Harrison had a long offending history dating back to 1996. He had
significant substance and alcohol misuse issues which were linked to his offending.
32. Mr Harrison also had a history of anxiety, depression and self-harm. In March 2018
at HMP Elmley, he placed a ligature around his neck in a protest about his
medication. He also reopened wounds from an earlier self-harm incident. In June
2019, Mr Harrison made a ligature to suspend himself before staff entered his cell
and cut him down. Afterwards, he told staff he was frustrated about not getting the
medication he needed. Staff monitored Mr Harrison under prison service suicide
and self-harm prevention measures (ACCT) on several occasions, most recently in
April 2022.
33. Mr Harrison was prescribed medication to treat epilepsy, although a formal
diagnosis had not been confirmed. Prison staff requested emergency support on
several occasions when he appeared to be experiencing seizures relating to the
condition. Mr Harrison also had Hepatitis C (a viral infection affecting the liver),
Deep Vein Thrombosis (a condition caused by blood clotting), self-reported Chronic
Obstructive Pulmonary Disease (a lung condition), and fractured shin bones after
jumping from height in 2019, for which he was awaiting an operation.
34. Mr Harrison was thought to be tampering with and diverting his prescribed
medication in prison. In May 2020, while at HMP Elmley, he was found diverting
prescribed Fentanyl patches and tampering with them (by trying to exchange a fake
patch for a new one), which led to his prescription being stopped.
HMP Elmley (2022)
35. Mr Harrison was released from HMP Elmley on 6 January 2021. On 8 March 2022,
he was recalled due to his lack of engagement, for not residing in accommodation
as directed, and an increase in risk due to substance misuse.
36. At his initial health screenings, staff noted the high volume of medications Mr
Harrison had been prescribed by a community GP. The healthcare team added Mr
Harrison to the chronic pain multidisciplinary team (MDT) meeting caseload, to
ensure there was opportunity to discuss this. At the time of Mr Harrison’s death, he
was prescribed the following medications: one 50mcg fentanyl transdermal patch
every three days (fast acting pain relief given as a patch that absorbs into the skin),
clonazepam and pregabalin (to treat epilepsy), co-codamol (codeine and
paracetamol-based pain relief), lansoprazole (to reduce stomach acid), mirtazapine
(for depression), quinine sulphate (for treatment of leg cramps), and amoxicillin (an
antibiotic).
37. On 30 March, a nurse noticed that Mr Harrison had been recorded as having
epilepsy but that the diagnosis was not confirmed. She noted that Mr Harrison had
last seen neurologist in May 2019. She also noted that he was taking medication
for his epilepsy that had not been reviewed by neurology specialists.
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38. Later that day, the scheduled chronic pain multidisciplinary team (MDT) meeting
had to be cancelled because no GP was available to attend. Healthcare emailed
the orthopaedic team at Kings College Hospital requesting advice about Mr
Harrison’s prescribed medication in relation to his upcoming operation on his shin
bone (which was due to take place in June). The email stated that Mr Harrison had
a long history of drug-seeking behaviour, and that he had previously been weaned
off all his medications but “unfortunately had them reinstated”. The email concluded
“Given the extremely high doses of opiates he is currently taking; we would be
happy to support a reduction if you feel this will improve the likelihood of a positive
outcome from surgery”. From the evidence we have reviewed, it does not appear
that Elmley received a response to the email.
39. On 8 April, staff observed that Mr Harrison seemed to be under the influence of
drugs or alcohol in his cell. An officer recorded that Mr Harrison was “lying on his
bed moaning and unable to speak, in a zombie-like fashion”.
40. On 24 April, Mr Harrison made superficial cuts to his left arm which were dressed
by a nurse. He told staff that that he made the cuts in response to not being given a
fentanyl patch earlier in the day, after his other one had allegedly fallen off in the
shower.
41. Staff began monitoring him under ACCT procedures. They closed it two days later
when they were satisfied that the risks had reduced.
42. On 3 May, a nurse assessed Mr Harrison after staff observed that he appeared to
be under the influence of drugs or alcohol. Mr Harrison told staff that he had
smoked psychoactive substances (PS) earlier that day.
43. On 4 May, Mr Harrison was observed to be under the influence of drugs or alcohol
for the third time and a nurse went to assess him. No concerns were raised, but the
nurse asked officers to complete hourly rousing observations to ensure that he was
conscious. Officers completed the checks, and no concerns were raised.
HMP Rochester
44. On 5 May, Mr Harrison was transferred to HMP Rochester and placed in a shared
cell with another prisoner. Mr Harrison arrived wearing a fentanyl patch, which he
had been given at Elmley two days earlier.
45. The reception nurse completed Mr Harrison’s initial health screening. He noted Mr
Harrison’s substance misuse history and referred him to the substance misuse
team for a triage assessment. The same day, a prison GP reviewed Mr Harrison’s
medications and recorded that he was a complicated patient. The GP noted that
the chronic pain team at Elmley recommended that the extremely high dosage of
opioids needed to be reduced slowly, however no formal clinical handover took
place between Elmley and Rochester. He agreed that Mr Harrison’s medication
should be reduced and that an appointment should be made to discuss the
approach. Healthcare staff invited Mr Harrison to a Complex Case Review meeting
(a multidisciplinary meeting between prison and healthcare staff to discuss complex
patients) planned for 18 May.
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46. On 6 May, a nurse completed Mr Harrison’s second reception screening
assessment. Mr Harrison told the nurse that he had been sectioned under the
Mental Health Act five years prior. He also said that a bipolar diagnosis was being
explored for him and that he wanted to see the mental health team. She referred
Mr Harrison to the mental health team for further assessment.
47. That same day, Mr Harrison should have been given a new fentanyl patch to
replace the one he arrived with. However, Rochester did not have any in stock at
the prison’s pharmacy and had to order it in. (We have found no evidence to
suggest that this delay had an adverse impact on Mr Harrison.)
48. On the evening of 8 May, Mr Harrison’s cellmate told the police that he had
observed Mr Harrison become excited because he was due to be prescribed a new
fentanyl patch.
9 May
49. At around 2.00pm, the mental health team completed a paper-based triage for Mr
Harrison, in response to the referral made on 6 May. After the assessment, a nurse
planned to write to Mr Harrison to request further details about the exploration of a
bipolar disorder diagnosis in the community.
50. At 3.58pm, healthcare staff at the medication hatch administered Mr Harrison a new
fentanyl patch (the only one he received at Rochester). According to the cellmate,
Mr Harrison returned to the cell, removed the patch and began to dismantle his
vape pen. He said that Mr Harrison had placed the patch on to the heating element
of the vape pen and, using scrunched up tissue paper, heated this to cause the
paper to ignite. This then caused the patch to heat up and release the fumes and
chemicals from the patch. The cellmate told police that he saw Mr Harrison inhaling
the fumes that were being produced from the patch, which influenced his behaviour,
and he became intoxicated. (We requested an interview with the cellmate, but the
prison was unable to facilitate this.)
51. At dinner time that day, the cellmate had to rouse Mr Harrison so that he could
collect his meals. He said that Mr Harrison used the patch on the vape pen
consistently throughout the day and inhaled the fumes in the toilet/shower area
most of the time, to conceal what he was doing from prison staff.
52. At around 8.35pm, an Operational Support Grade (OSG) carried out the evening roll
check of prisoners on Mr Harrison’s wing. She thought she could detect a faint
odour of burning paper coming from Mr Harrison and the cellmate’s cell. In
interview, she told us that she could see Mr Harrison lying on his bed, but the
cellmate told her that he was ok. She told the cellmate that she would come back
to check on them once she had finished her roll check.
53. At around 9.15pm, the OSG returned to the cell to check on Mr Harrison. The
cellmate asked her to turn off the cell night light. At this point, Mr Harrison jumped
up from his bed but, according to the OSG, looked a bit wobbly. He asked her if the
light could stay on for another 20 minutes, to which she agreed. She asked Mr
Harrison if he was ok, to which he replied that he was fine. As she was observing
another prisoner on an ACCT, she continued to check in on Mr Harrison at regular
intervals because she was suspicious that he might be under the influence. On at
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least two to three occasions, she saw him sitting on the edge of his bed talking to
his cellmate and raised no concerns.
54. At around 10.00pm, the cellmate pressed his cell bell and asked the OSG to dim
the lights in his cell. She looked across at Mr Harrison and noted he was lying on
his bed and appeared asleep. She asked the cellmate if Mr Harrison was ok, and
he said he was just asleep. She turned the night light off. However, the television
remained on as the cellmate had started watching a film.
55. At around 11.55am, the cellmate pressed the cell bell. He appeared distressed and
told the OSG that he thought there might be something wrong with Mr Harrison.
When she arrived at the cell, the cellmate told her he had finished watching his film
and was about to turn the television off when realised that Mr Harrison had not
moved for a while and was lying face down on the bed.
Emergency response
56. The OSG asked the cellmate to try and physically rouse Mr Harrison by shaking him
by the shoulder, which he did. He became distressed at this point because Mr
Harrison remained unresponsive. He told her that he thought Mr Harrison may
have been sick and said he felt cold to the touch.
57. At 11.58pm, the OSG called a medical emergency ‘code blue’, indicating a life-
threatening situation. She waited for the arrival of another officer before entering
the cell, having assessed the security risks. More staff arrived in around one to two
minutes and entered the cell straight away. They were closely followed by a
Custodial Manager (CM).
58. Officers began cardiopulmonary resuscitation (CPR) and used a defibrillator (a
device that can give a high energy shock to someone who is in cardiac arrest),
which indicated no shock was advised. An ambulance crew arrived on site at
12.20am and noted that prison staff were completing effective CPR, which they took
over.
59. At 12.41am, paramedics confirmed that Mr Harrison had died. After Mr Harrison’s
death, staff found drug paraphernalia including a vape pen in his cell.
Contact with Mr Harrison’s Family
60. At around 8.50am on 10 May 2022, Mr Harrison’s sister telephoned HMP Rochester
and said that her family had been made aware of her brother’s death via a family
relation. The relation was told by another prisoner on the same wing as Mr
Harrison. She spoke to the Head of Operations and Family Liaison Officer (FLO)
and asked if he could telephone again later that morning, once Mr Harrison’s
mother had joined her at her home.
61. At 10.00am, the FLO telephoned Mr Harrison’s mother (who was with his sister)
and told them that Mr Harrison had died. He told the family that he would have
preferred to tell them in person; however, as the news had already been shared
with them, it was important that he provided as much information as possible in
order not prevent any further distress.
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62. The FLO explained to the family that Kent Police had told the prison that they would
be going to the family home to deliver the news to Mr Harrison’s mother. He told us
that he was shocked to find out that they had not done so when the family called.
When he spoke to the police, they said the contact details for Mr Harrison’s Next of
Kin were incorrect and they had attended the wrong address. The FLO explained
that if the police had told prison staff that they had not been able to contact the
family as agreed, the prison would have made arrangements to visit the family
home themselves, as quickly as possible. He agreed that he and a colleague would
visit the home of Mr Harrison’s mother that afternoon, around 2.00pm.
63. At 2.00pm, the FLO visited Mr Harrison’s mother’s home to discuss what had
happened and answer any initial questions. Rochester contributed to the costs of
Mr Harrison’s funeral in line with Prison Service instructions.
Support for prisoners and staff
64. After Mr Harrison’s death, the 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.
65. The prison posted notices informing other prisoners of Mr Harrison’s death and
offering support.
Post-mortem report
66. The toxicology screening found an elevated level of fentanyl in Mr Harrison’s blood.
The post-mortem concluded that, on the balance of probability, Mr Harrison’s death
was due to fentanyl toxicity.
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Findings
Clinical care
67. The clinical reviewer found that the clinical care received by Mr Harrison was of a
reasonable standard and therefore equivalent to what he could have expected to
receive in the community.
Medication risk management
68. The clinical reviewer noted that when Mr Harrison arrived at HMP Elmley in March
2022 he had been prescribed several medications in the community that, when
combined, increased the risk of respiratory and central nervous system (CNS)
depression. She highlights that the combination of fentanyl, pregabalin, mirtazapine
and clonazepam must be prescribed with caution, particularly for those with
substance misuse problems. Mr Harrison’s medications had been prescribed by a
community GP, and it was not the first time he had been prescribed that
combination. During a previous period in prison, he had been successfully weaned
off the same combination. We are unable to comment on the actions of community-
based healthcare services, which are outside of the PPO’s remit.
69. We found that healthcare staff at Elmley identified the risks and the challenges
around reducing Mr Harrison’s medication in the prison environment. They
contacted the orthopaedic team at Kings College Hospital for support on how they
could approach it. Unfortunately, the prison did not make any progress on reducing
the medications during the period that Mr Harrison was at Elmley. The clinical
reviewer suggests that staff could and should have done more within that time, to
reduce or change his prescribed medications.
70. The clinical reviewer found that some of Mr Harrison’s medications were for
epilepsy, which had not been confirmed with a diagnosis. She highlights that
Elmley should have referred Mr Harrison to a neurology service to explore the
potential epilepsy and appropriateness of his medications for it.
71. We are pleased that when Mr Harrison arrived at Rochester, a GP quickly identified
that he was being prescribed a significant amount of medication which should be
reviewed. Mr Harrison was added to the Complex Case Review meeting agenda
for 18 May and invited to attend (this was the first meeting following his arrival).
We note that the meetings were attended by the Chronic Pain Management
Service, so would have been particularly helpful for Mr Harrison. The clinical
reviewer noted that the personalised approach was in line with the Royal College of
General Practitioners (RCGP) guidance for ‘safer prescribing in prisons’ (2019).
After the initial meeting, Mr Harrison’s care was due to be discussed every two
weeks. Sadly, Mr Harrison died before he could attend the first meeting.
72. Mr Harrison spent only five days at HMP Rochester, and they were unable to make
any further progress on reducing his medication and addressing his longer-term
care needs.
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Clinical handover
73. Mr Harrison had significant substance misuse needs. He was prescribed a range of
medications and was found under the influence and requiring intervention in the two
days before he transferred to Rochester on 5 May. His medication combination
presented specific health risks that were known to the healthcare team at Elmley.
While they flagged the high amount of opioid based medications Mr Harrison was
taking, they did not supply any further information. We consider that it would have
been good practice to conduct a more detailed clinical handover for Mr Harrison,
considering his needs, to ensure the transfer was safe and to enable continuity of
care planning. Rochester did not have any fentanyl patches in stock at the prison’s
pharmacy and had to order it in. A formal handover would have enabled Rochester
to order a patch in advance of Mr Harrison’s arrival.
Fentanyl patches
74. Mr Harrison was prescribed fentanyl patches to help with his chronic leg pain. His
family told us that they were concerned he had been given more fentanyl patches
than he was prescribed. After a thorough review of the relevant documentation, we
found that staff at Elmley and Rochester gave fentanyl patches to Mr Harrison every
three days, in line with directed use. We have found no evidence to suggest that Mr
Harrison was given more than one patch every three days. At Rochester, Mr
Harrison only received one Fentanyl patch (on 9 May) due it being a controlled drug
and issues with stock.
75. The clinical reviewer found that Oxleas, the healthcare provider to Elmley and
Rochester, do not have a formal policy in place on the governance arrangements
for the use of fentanyl patches in a secure setting. At both Elmley and Rochester,
Mr Harrison had to hand over his old Fentanyl patch before he could be given a
new one. However, there was no formal policy in place for healthcare staff to
ensure the control measure was consistently followed. The clinical reviewer noted
that, on balance, there was no evidence to suggest this was not followed, but we
consider it important that there are clear guidelines for staff to refer to in these
circumstances, to reduce any risks.
76. The clinical reviewer noted that the prescribing of fentanyl patches as a controlled
drug is not recommended in secure settings in accordance with the RCGP (2019)
guidelines. However, in the exceptional event they are prescribed, The Care
Quality Commission (CQC) and NHSE recommend in their guidance for ‘safer use
of controlled drugs’ (2016) that there should be stringent governance around the
prescribing, administration and monitoring of this drug by utilising a safety checklist.
We recommend that this checklist is incorporated into Oxleas policy for secure
settings. We make the following recommendations:
The Head of Healthcare at HMP Elmley should ensure that handovers take
place for complex patients who present clinical risks and are due to be
transferred, to ensure continuity of care.
The Head of Healthcare at HMP Elmley should ensure that when new
prisoners enter the establishment on high risk and complex medication, staff
complete a prompt review of medication to manage any risks.
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The Head of Healthcare at HMP Elmley should ensure that when there is a
query about a prisoner’s diagnosis, the relevant referral is made to ensure it
can be confirmed or other options explored.
The Lead Pharmacist at Oxleas should create clear guidelines on the safe
prescription, administration, and governance of Fentanyl patch prescriptions
in secure settings, in accordance with the RCGP ‘safer prescribing in prisons’
(2019) and the guidance and checklist contained within the CQC and NHSE
guidance for the ‘safer use of controlled drugs’ (2016).
Emergency response
77. National policy guidance on entering cells during the night state is set out in
National Security Framework 24/2011. Paragraphs 5.17 and 5.18 state that in an
emergency, where there is or appears to be an immediate danger to life, a cell may
be unlocked without the authority of the Duty Manager and with only one officer
present. It also says that night staff should not take action that they feel would put
themselves or others in unnecessary danger.
78. In interview, the OSG told us that when she realised Mr Harrison was unresponsive,
she radioed a medical emergency code blue without hesitation. However, after
completing a dynamic risk assessment, she opted to wait for help from officers
before entering the cell because she was a lone female officer and could be
vulnerable in a cell accommodating two men. We are satisfied that this was a
reasonable assessment, in the circumstances. The assessment did not have a
significant impact on the timing of the emergency response for Mr Harrison. Other
officers arrived in around one to two minutes.
79. Overall, we consider that the emergency response by was prompt and appropriate.
Body-worn camera
80. PSI 04/2017 Use of Body Cameras states that, “In those establishments where it is
authorised for use, BWVC must be deployed and set to record during a response to
any reportable incident”.
81. We found that some of the officers involved in the emergency response for Mr
Harrison were wearing body-worn video cameras (BWVC) but none of the cameras
were turned on. Although we recognise why officers might forget to activate their
cameras in these difficult circumstances, BWVC footage is an important source of
evidence which helps the PPO and other bodies investigate deaths in custody and
identify learning that might prevent deaths in future. We make the following
recommendation:
The Governor of HMP Rochester should remind staff to switch on their body-
worn cameras during reportable incidents and that control room operators
prompt staff to do so during an incident.
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Inquest
82. The inquest into Mr Harrison’s death concluded on 7 June 2024, and found that Mr
Harrison died an accidental death after inhaling fumes from a transdermal fentanyl
patch.
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