Eral Morgan

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Independent investigation into
the death of Mr Eral Morgan,
a prisoner at HMP Oakwood,
on 17 February 2021
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
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© 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 to best 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 Eral Morgan died from the toxic effects of psychoactive substances (PS) on 17
February 2021 at HMP Oakwood. He was 25 years old. I offer my condolences to Mr
Morgan’s family and friends.
The investigation found that the care Mr Morgan received at Oakwood for his mental
health and substance misuse issues was equivalent to that which he could have expected
to receive in the community. However, the emergency response when Mr Morgan was
discovered unconscious was extremely poor. The prison investigated and took disciplinary
action against the staff involved and a nurse has been referred to the Nursing and
Midwifery Council.
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 August 2022
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 6
Findings ......................................................................................................................... 10
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Summary
Events
1. Mr Eral Morgan was recalled to prison on 29 September 2020. He was moved to
HMP Oakwood on 12 February 2021.
2. Mr Morgan had a long history of substance misuse. During his time in custody, he
engaged with substance misuse services and seemed motivated to address his
drug use. However, he frequently relapsed into taking drugs, usually psychoactive
substances (PS).
3. At around 8.45pm on 17 February, while completing a roll check, an officer saw Mr
Morgan lying on the floor of his cell. He fetched another officer who called the Night
Orderly Officer (the senior officer in charge of the prison at that time). She said she
would attend with healthcare staff. Staff did not enter the cell for 13 minutes and
then it took another six minutes before they started cardiopulmonary resuscitation
(CPR). Paramedics arrived at 9.20pm and continued resuscitation but at 10.12pm,
they declared that Mr Morgan had died.
4. The post-mortem report concluded that Mr Morgan died from the toxic effects of PS.
Findings
5. We are concerned Mr Morgan had access to PS. However, we are satisfied the
prison is taking steps to tackle drugs supply. It has a drugs strategy in place, which
was reviewed in August 2021.
6. Officers failed to call a medical emergency code when they saw Mr Morgan lying on
the floor of his cell, which resulted in a delay requesting an ambulance. There was
also an unacceptable delay before staff entered Mr Morgan’s cell. The prison
undertook disciplinary investigations into the actions of the staff involved. One
officer resigned and another was dismissed.
7. The clinical reviewer found that the resuscitation was handled very poorly, and the
care Mr Morgan received was not equivalent to the care he could have expected to
receive in the community. Practice Plus Group, the healthcare provider, conducted
an investigation, which found that while the nurse and healthcare assistant involved
had had immediate life support training through their employing agency, it was not
accredited by the Resuscitation Council. Attempts to engage the nurse in a
supervised development plan failed, and she has since been referred to the Nursing
and Midwifery Council.
8. The clinical reviewer concluded that the care Mr Morgan received for his mental
health and substance misuse issues was equivalent to that which he could have
expected to receive in the community.
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Recommendations
• Practice Plus Group and NHS England and Improvement should undertake further
enquiries to ensure that healthcare agencies which provide staff to prisons are
appropriately trained, competent and are practising safely, and Practice Plus Group
should:
• undertake a clinical audit examining the effectiveness of learning following
any significant incident and governance managers need to assure
themselves that this learning has been embedded; and
• undertake a clinical audit of records made following an emergency response
(after Mr Morgan’s death) to assess the quality of record keeping.
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The Investigation Process
9. The investigator issued notices to staff and prisoners at HMP Oakwood informing
them of the investigation and asking anyone with relevant information to contact
her. No one responded.
10. The investigator obtained copies of relevant extracts from Mr Morgan’s prison and
medical records.
11. We suspended our investigation in March 2021, pending the outcome of a police
investigation. We resumed it in February 2022, when Staffordshire Police told us
that no criminal charges would be brought.
12. NHS England commissioned a clinical reviewer to review Mr Morgan’s clinical care
at the prison. The investigator, together with the clinical reviewer, interviewed five
senior managers, including the Director, on 17 February 2022. On 10 March they
interviewed the clinical lead in post at the time of Mr Morgan’s death.
13. We informed HM Coroner for Staffordshire South of the investigation. We have
sent the Coroner a copy of this report.
14. The PPO’s family liaison officer contacted Mr Morgan’s family to explain the
investigation and to ask if they had any matters they wanted us to consider. Mr
Morgan’s family wanted to know why he had a bruised face and cracked skull,
which they believed was as a result of an assault. This has been addressed in the
report.
15. Mr Morgan’s family received a copy of the initial report. They did not identify any
factual inaccuracies.
16. The prison also received a copy of the report and did not identify any factual
inaccuracies.
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Background Information
HMP Oakwood
17. HMP Oakwood is managed by G4S and is one of the largest prisons in England
and Wales, providing places for around 2,100 male prisoners. Practice Plus Group
(PPG) provides the healthcare services, which include a daily GP clinic, some
specialist services and out-of-hours GPs. Mental health and substance misuse
services are provided by the Midlands Partnership Foundation Trust (MPFT).
HM Inspectorate of Prisons
18. The most recent inspection of Oakwood was in May 2021. Inspectors reported that
prisoners were treated with respect and safety was good. Healthcare services were
found to be effective and well-led. Mental health and substance misuse services
were well integrated, although mental health support had been limited due to
COVID-19 restrictions.
19. Inspectors reported that when a concern was identified, a ‘keep safe’ referral was
made and shared with unit managers and the safer custody team, who liaised with
the security department. All referrals were discussed at the following keep safe
meeting, which was held twice a week. This multidisciplinary team decided what
violence reduction measures would be implemented.
20. Inspectors found there was a comprehensive drug strategy and good collaborative
work between the security department and drug use services, and action was
discussed at a well-attended monthly meeting. The prison had numerous measures
in place to tackle the availability of illicit drugs, including a drug recovery unit and a
robust approach to the use of the body scanner. However, inspectors noted the
availability of illicit substances was a concern.
Independent Monitoring Board
21. 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 most recent annual report for the year March 2021, the IMB
reported that the impact of a 23-hour lock-down regime, with limited exercise and
association, for some prisoners was traumatic and increased frustration and anxiety
but that levels of violence and the availability of illicit substances had decreased.
Previous deaths at HMP Oakwood
22. Mr Morgan was the 13th prisoner to die at Oakwood since February 2019. Of the
previous deaths, 11 were from natural causes and one was due to accidental burns.
Psychoactive substances (PS)
23. Psychoactive substances (PS - formerly known as ‘new psychoactive substances’
(NPS) or ‘legal highs’) are a serious problem across the prison estate. They are
difficult to detect and can affect people in a number of ways, including increasing
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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
PS to precipitate or exacerbate the deterioration of mental health, and they are
linked to suicide or self-harm.
24. In July 2015, we published a Learning Lessons Bulletin about the use of PS (still at
that time, NPS) 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.
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Key Events
25. In April 2018, Mr Eral Morgan (known as Jack) was sentenced to 52 months in
prison for burglary and dangerous driving. He was released on licence on 31 July
2020 but was recalled to prison on 29 September after committing further burglary
offences. He was taken to HMP Hewell.
HMP Hewell
26. Mr Morgan had attention deficit hyperactivity disorder (ADHD) and anxiety and
depression. He had a history of self-harm (food and fluid refusal, swallowing glass,
cutting) and a long history of substance misuse both in prison and the community.
Although at times he was motivated to address his substance misuse and worked
with addiction services, he often relapsed. He was supported in the community and
in prison by the mental health team.
27. Mr Morgan was supported using suicide and self-harm prevention measures
(known as ACCT) between 19 and 23 November after he cut his arm. He told staff
he had been using psychoactive substances (PS), had accrued drug debts and
wanted help. Staff referred Mr Morgan to the mental health team and supported
him using a Challenge, Support and Intervention Plan (CSIP – used to manage
perpetrators of violence and to support victims of violence).
28. On 29 November, a prison chaplain told Mr Morgan that his mother had died the
previous day of a drug overdose. Staff reopened the ACCT.
29. On 2 December, staff placed Mr Morgan on a disciplinary charge after he climbed
onto the security netting. Mr Morgan said he wanted to move wings as he was
being tempted by drugs on the wing. Staff moved Mr Morgan to a different wing.
30. The chaplaincy continued to support Mr Morgan until after his mother’s funeral,
which was held on 24 December. This was a public health funeral, arranged by the
local authority, which meant there was no ceremony, but Mr Morgan attended the
chapel to light a candle. He was told that the prison chaplain who had been
supporting him had sadly died, but the chaplaincy team continued to offer him their
support.
31. On 29 December, Mr Morgan cut his arm and inserted a screw into the wound. He
told staff that he was frustrated being locked up and only being allowed out from his
cell for 30 minutes a day. Staff closed his ACCT the next day. Staff continued to
support Mr Morgan using CSIP until 19 January 2021.
32. Mr Morgan was much more settled over the next few weeks. He started work and
was also helping other prisoners who were struggling.
HMP Oakwood
33. On 12 February 2021, Mr Morgan was moved to HMP Oakwood as part of his
sentence progression.
34. At the initial healthscreen, the reception nurse noted Mr Morgan’s extensive history
of drug use, specifically the use of PS, and that he had previously self-harmed. Mr
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Morgan declined to be referred to the substance misuse service but was referred to
the mental health team.
35. On 14 February, a nurse assessed Mr Morgan’s mental health. She did not identify
any immediate mental health needs but noted that Mr Morgan was concerned about
his safety at Oakwood because of historic drug debts. She added Mr Morgan for
discussion at the referrals meeting, to consider if he was appropriate to be added to
the integrated mental health services and she contacted the safer custody team to
alert them to the concerns about his debts.
36. On 15 February, Mr Morgan was discussed at the integrated mental health and
substance misuse team meeting, attended by the team leader, mental health
nurses, psychosocial and recovery workers. They concluded that because Mr
Morgan did not have a severe or enduring mental illness, he would not be added to
their caseload, but would continue to be supported by the prison doctor.
37. On 16 February at 10.46am, a First Line Manager (FLM) recorded in Mr Morgan’s
prison record that the safer custody team had flagged concerns about his safety
and possible debts. The FLM and a colleague spoke to Mr Morgan who said there
were other prisoners at Oakwood that he had stolen a substantial amount of money
from some years earlier, but he did not give any names. Mr Morgan told staff that
he felt safe on the induction unit but thought he would soon be recognised. The
FLM recorded that Mr Morgan had requested a transfer out of Oakwood and that he
had said if it was not considered his behaviour would potentially dictate it.
38. The FLM completed a keep safe referral which meant that Mr Morgan would be
considered for support using CSIP procedures, but there was no time to complete a
full assessment of his risks and needs or discussion at the keep safe meeting
before he died. This is the last entry in Mr Morgan’s prison record.
17 February
39. CCTV shows that at around 5.08pm on 17 February, a prisoner stopped outside Mr
Morgan’s cell and passed what appears to be a small piece of paper through the
cell door. At 5.49pm on 17 February, an officer locked Mr Morgan in his cell for the
night after he had collected his food. CCTV shows that at 7.11pm, a prisoner, who
was a wing cleaner, went to Mr Morgan’s cell and was then laughing and joking with
the occupant of the cell next door. He appeared to do an impression of Mr Morgan
lying back with his arms above his head. A few minutes later, another prisoner,
also a cleaner, arrived at Mr Morgan’s cell. He looked into the cell and then closed
the cell hatch.
40. Officer A started the roll check at 8.44pm and arrived at Mr Morgan’s cell just over a
minute later. He used a torch to look into the cell, then kicked the door and around
a minute later moved on to continue checking the other cells. At 8.48pm, he
returned to Mr Morgan’s cell with Officer B. Officer B radioed the FLM, the Night
Orderly Officer who was in charge of the prison at that time, and asked her to attend
the wing as soon as possible because Mr Morgan appeared to be unconscious. He
told her that Mr Morgan appeared to be unconscious on his cell floor and she told
him she was on her way with healthcare staff.
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41. At 8.55pm, Officer B (who was now wearing PPE), returned to Mr Morgan’s cell with
Officer C. They were joined by Officer A (also wearing PPE), and they remained
outside the cell; a short while later another officer joined them, then all four walked
away.
42. At 8.57pm, Officers A and B returned to Mr Morgan’s cell. A nurse and a healthcare
assistant (HCA) arrived soon after and looked through Mr Morgan’s observation
panel. At 8.58pm, the FLM arrived with Officer C, and they opened Mr Morgan’s
cell door. The FLM activated her body worn video camera (BWVC), which captured
events when they entered, and she requested an ambulance.
43. Mr Morgan was lying on his back, with blood and vomit around his mouth and was
described as cyanosed (a blueish tinge to skin caused by a lack of oxygen). Mr
Morgan was placed in the recovery position while the nurse tried to obtain a pulse
and she requested oxygen. Six minutes after staff entered the cell, they started
cardiopulmonary resuscitation (CPR).
44. The nurse started CPR, but the HCA took over after a short while and asked for the
defibrillator. (As officers had not called a medical emergency code blue indicating
the prisoner was unconscious, healthcare staff had not taken a defibrillator with
them.) The HCA stopped administering CPR for a few seconds while he told an
officer where he could find a defibrillator machine. A defibrillator was brought to the
cell about four minutes later but was placed on Mr Morgan’s bed and was never
used.
45. West Midlands Ambulance Service records show an ambulance was requested at
8.58pm. Paramedics arrived at Mr Morgan’s cell at 9.20pm; they questioned why
the defibrillator had not been used. Paramedics continued resuscitation attempts,
but, at 10.12pm, declared that Mr Morgan had died. Paramedics noted that on their
arrival, they observed CPR was ineffective, there was no airway inserted and
oxygen was not being used; they also recorded that the defibrillator in Mr Morgan’s
cell had not been attached.
46. When Mr Morgan’s cell was searched after his death, a broken vape pipe and white
paper were found in his bin, which later tested positive for PS.
Contact with Mr Morgan’s family
47. Oakwood appointed a family liaison officer (FLO) and a deputy. Under normal
circumstances next of kin should, wherever possible, be informed of a death in
person by a FLO. However, the guidance was changed during the COVID-19
pandemic to say that telephone contact could be made instead. The FLO therefore
informed Mr Morgan’s grandmother of his death by telephone. She offered her
condolences and ongoing support. In line with Prison Service instructions, the
prison contributed towards the costs of Mr Morgan’s funeral, which was held on 22
March.
Support for prisoners and staff
48. After Mr Morgan’s death a prison manager debriefed the staff involved in the
emergency response to ensure that they had the opportunity to discuss any
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immediate issues and to offer support. The staff care team also attended and
offered their support.
49. The prison posted notices informing prisoners of Mr Morgan’s death, and offering
support. Staff reviewed all prisoners assessed as at risk of suicide and self-harm in
case they had been adversely affected by Mr Morgan’s death.
Post-mortem report
50. Toxicology tests showed that Mr Morgan had used PS before he died, and the
pathologist gave the cause of death as synthetic cannabinoids (PS) toxicity.
51. Mr Morgan’s grandmother said that Mr Morgan had injuries to his head and face.
The post-mortem concluded there was no evidence of injury or assault
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Findings
Oakwood’s Drug Strategy
52. Mr Morgan died from the effects of PS. He had a history of misusing substances
but when he arrived at Oakwood, Mr Morgan declined to be referred to substance
misuse services.
53. Oakwood has a comprehensive Drug Strategy, which is reviewed and updated
annually. It sets out the objectives to prevent supply of, and reduce the demand for,
illicit substances. A drug supply reduction action plan is completed and reviewed
each month and sets out the targets for cell searches, visitor and staff searching
and the process for referring those found under the influence of illicit substances to
substance misuse services. Oakwood reviewed the strategy in August 2021. We
are satisfied that Oakwood keeps its Drug Strategy under regular review and we do
not make a recommendation.
Emergency response
54. We found the emergency response was extremely poor by both prison and
healthcare staff. Staff did not call a medical emergency code as they should have
done when they saw Mr Morgan unconscious on his cell floor. It then took staff 13
minutes to enter Mr Morgan’s cell and an ambulance was not called until the Night
Orderly Officer arrived.
55. The prison undertook disciplinary investigations into the actions of the four officers
who delayed going into Mr Morgan’s cell. Officer A resigned and Officer B was
dismissed on 4 May 2021. Officer C received a Written Warning on 25 May 2021
(which stays on his record for 12 months). No action was taken against the fourth
officer. As Oakwood has already taken disciplinary action, we do not make a
recommendation.
56. The Head of Safer Custody told us that staff had been reminded of the need to
enter a cell as soon as possible and to call the correct code in a medical
emergency. She said all staff now carry a card to remind them of how to respond in
a medical emergency and notices have been reissued. Given Oakwood has taken
steps to address these issues, we do not make a recommendation.
Resuscitation
57. Staff did not start CPR until over six minutes after the cell was opened. BWVC
footage shows the clinical assessment of Mr Morgan was poor and that CPR was
not delivered effectively, which was also noted by paramedics when they arrived.
There was no defibrillator in the emergency medical bag, as is required, and when
one was brought to the cell, it was never attached to Mr Morgan. The clinical notes
made by the nurse following Mr Morgan’s death were limited. The HCA did not
record his account in the medical records. The clinical reviewer found that the
resuscitation was handled poorly and was not equivalent to the care Mr Morgan
could have expected to receive in the community.
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Clinical investigation into emergency response
58. On 2 March 2021, Practice Plus Group (PPG), which provides healthcare services
at Oakwood in conjunction with Midlands Partnership NHS Trust, held a Clinical
Case Review because of the poor emergency response. The HCA attended the
meeting, but the nurse did not. The clinical reviewer is satisfied that the HCA has
completed necessary training, via his employing agency, as a result of this meeting.
59. The Director of Nursing & Quality for PPG told us that she had contacted the nurse
and the agency she worked for and invited them to work with PPG to develop a plan
for restricted and supervised practice until a decision had been made regarding
referral to the NMC. The initial agreement was that the nurse would work at a
different prison during this time but would not carry the emergency response radio
until additional training had been undertaken and competency assured. However,
the nurse did not engage with either PPG or the agency, so they were unable to
implement the support and risk mitigation plan.
60. PPG undertook a Patient Safety Incident Investigation and subsequently referred
the nurse to the Nursing and Midwifery Council (NMC - the regulator for nursing and
midwifery professions in the UK) who are investigating.
61. Given that PPG has already referred the nurse to the NMC, we do not make a
recommendation.
Practice Plus Group (healthcare provider)
62. The nurse and the HCA had completed Immediate Life Support (ILS) training
delivered by their agency, but this was not delivered by an accredited Resuscitation
Council UK instructor.
63. The clinical reviewer concluded that PPG did not ensure agency staff were trained
and competent to provide an emergency medical response, or that the agency have
the required clinical governance checks in place to ensure staff are competent and
practising safely. The investigation is limited to the care Mr Morgan received at
Oakwood and does not extend to the agency, so we make the following
recommendation:
Practice Plus Group and NHS England and Improvement should undertake
further enquiries to ensure that healthcare agencies who provide staff to
prisons are appropriately trained, competent and are practising safely, and
Practice Plus Group should:
• undertake a clinical audit examining the effectiveness of learning
following any significant incident and governance managers need to
assure themselves that this learning has been embedded; and
• undertake a clinical audit of records made following an emergency
response (after Mr Morgan’s death) to assess the quality of record
keeping.
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Clinical Care
64. The clinical reviewer found that the care Mr Morgan received for his mental health
and substance misuse issues was equivalent to that which he could have expected
to receive in the community.
Inquest
65. The inquest into Mr Morgan’s death concluded in December 2024. Mr Morgan’s
death was drug related (synthetic cannabinoids toxicity).
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