Garrick Pierson

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Independent investigation into
the death of Mr Garrick Pierson,
a prisoner at HMP Bullingdon,
on 23 September 2024
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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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 Garrick Pierson died in hospital on 23 September 2024, after taking an overdose of
verapamil (a prescription medication used to treat cluster headaches) at HMP Bullingdon.
He was 34 years old. I offer my condolences to Mr Pierson’s family and friends.
Mr Pierson arrived at Bullingdon on 4 June 2024 and was monitored under suicide and
self-harm procedures (known as ACCT) up to 30 July, due to his mental health history and
high risk of suicide. Despite this, he was allowed to keep verapamil, a highly toxic drug if
taken in excess, in his possession. He stockpiled it and took a fatal dose on 23
September.
The investigation found failings with the in-possession medication risk assessment
process and medication compliance checks. It also found that Mr Pierson had missed
several doses of his antidepressant medication due to unclear processes around the
administration of evening medication. The mental health support provided to Mr Pierson
was also inadequate.
The clinical reviewer concluded that the care Mr Pierson received did not meet accepted
clinical standards and was not equivalent to that which he could have expected to receive
in the community.
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 December 2025
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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 Garrick Pierson was remanded to HMP Bullingdon on 4 June 2024, charged with
sexual offences. It was his first time in prison.
2. Due to Mr Pierson’s high risk of suicide, staff started suicide and self-harm
monitoring (known as ACCT) as soon as he arrived. ACCT monitoring continued
until 30 July (apart from three days in June when it was stopped and restarted).
3. On 20 August, a mental health nurse tried to see Mr Pierson for a mental health
assessment but he was at work. The nurse noted that she would rebook to see him
the following week but this did not happen. No one from the mental health team saw
Mr Pierson after his last ACCT review on 30 July.
4. On 17 September, Mr Pierson asked a GP to increase his antidepressant
medication (mirtazapine) due to constant low mood. The GP increased the dose
from 15mg to 30mg and changed the administration time from 4.00pm to 8.00pm.
Mr Pierson did not receive any mirtazapine on 20, 21 or 22 September and there
was no reason documented for the missed doses.
5. On 19 September, an officer recorded that he had called E Wing to let them know
that Mr Pierson was coming back from a legal visit and that he was tearful. An
officer on the wing spoke to Mr Pierson on his return but he did not document the
conversation.
6. Shortly after 1.00am on 23 September, Mr Pierson’s cellmate pressed the cell bell
to tell staff that Mr Pierson had taken 123 verapamil tablets. (Mr Pierson was
prescribed verapamil for cluster headaches and was allowed to keep the medication
in his possession.) According to his cellmate, Mr Pierson said he had done
something silly and that, “Now they will sort my meds out”.
7. Staff responded swiftly and healthcare staff contacted Toxbase for advice. They
were told it was a fatal dose and that Mr Pierson should immediately go to hospital.
Staff called for an ambulance at 1.23am and escorted Mr Pierson to reception to
wait for the ambulance. Mr Pierson was conscious and engaging with staff at that
time but he began to deteriorate in reception while waiting for the ambulance. The
ambulance arrived at 2.44am and took Mr Pierson to hospital. Mr Pierson died in
hospital at around 4.40am.
8. Staff later found some notes in Mr Pierson’s cell in which he indicated he would be
better off dead and apologised to the victims of his offence. The notes were not
dated.
Findings
9. We found that healthcare staff did not appropriately assess the risk associated with
Mr Pierson having verapamil, a highly toxic medication, in his possession.
Furthermore, the process for checking if prisoners were correctly taking their in-
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possession medication was inadequate. Mr Pierson must have been stockpiling his
verapamil medication since 12 August.
10. There was confusion about the process of administering medication in the evening,
during the prison’s night state, meaning that Mr Pierson did not receive his
antidepressant medication on three evenings. There was no record of why these
doses were missed and healthcare staff appeared to be unaware.
11. The mental health support provided to Mr Pierson was inadequate. Although he
was on the mental health team’s caseload, he was only seen by the mental health
nurse during ACCT reviews and there was no structured care plan in place. Once
Mr Pierson was no longer being monitored under ACCT procedures, he did not
receive any formal support from the mental health team and staff failed to follow up
a missed mental health assessment on 20 August.
12. Although the officer on E Wing did not document his conversation with Mr Pierson
on 19 September after his legal visit, we are satisfied that he considered whether
ACCT monitoring was required and concluded it was not.
Recommendations
• The Head of Healthcare should review:
• The in-possession medication risk assessment process, to include consideration
of whether the medication is high-risk.
• In-possession medication compliance checks, to include consideration of
focusing checks on those at greater risk.
• Ensure that a robust audit process is in place to check in-possession medication
risk assessments are being completed correctly and that medication compliance
checks are undertaken.
• The Head of Healthcare should develop an agreed local policy for medication
management during night state, which should set out:
• responsibilities for the prescriber, pharmacy, Head of Healthcare, the night
healthcare team and where applicable, night prison staff;
• how evening medications are to be accessed and administered;
• what action to take in the event of missed medication, including incident
reporting (i.e. Datix) and advising the prescribing clinician or team; and
• the audit process to ensure compliance.
• The Head of Healthcare should review the mental health process to ensure that
prisoners are not lost to follow-up and that upcoming important dates are
highlighted and appropriately escalated.
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The Investigation Process
13. HMPPS notified us of Mr Pierson’s death on 23 September 2024.
14. The investigator issued notices to staff and prisoners at HMP Bullingdon informing
them of the investigation and asking anyone with relevant information to contact
her. No one responded.
15. The investigator obtained copies of relevant extracts from Mr Pierson’s prison and
medical records.
16. NHS England commissioned two independent clinical reviewers to review Mr
Pierson’s clinical care at the prison.
17. The investigator and the clinical reviewers interviewed eight members of staff and
one prisoner between October and December 2024.
18. We informed HM Coroner for Oxfordshire 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 office contacted Mr Pierson’s father to explain the investigation
and to ask if the family had any matters they wanted us to consider. Mr Pierson’s
father wanted to know how his son had managed to store so much medication and
why it had taken the ambulance so long to arrive. We have addressed these issues
in this report and the clinical review.
20. We shared our initial report with HMPPS and the prison’s healthcare provider,
Practice Plus Group. They found no factual inaccuracies. Following representations
from Practice Plus Group, we removed the fourth recommendation. Practice Plus
Group provided an action plan which is annexed to this report.
21. We sent a copy of our initial report to Mr Pierson’s father. He did not notify us of any
factual inaccuracies.
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Background Information
HMP Bullingdon
22. HMP Bullingdon is a local and resettlement prison, serving the courts of
Oxfordshire, Berkshire, Buckinghamshire and Wiltshire. Practice Plus Group
provides healthcare services. (Cotswold Medicare Ltd provided GP services up to
June 2025.)
HM Inspectorate of Prisons
23. The most recent inspection of HMP Bullingdon was in November 2022. Inspectors
reported that, while prisoners subject to ACCT said they felt well-supported, the
quality of the ACCT documents was inconsistent. They noted that a new quality
assurance process had started to improve the quality of ACCT documents but was
not yet embedded.
24. Provision of mental health support was prompt and reasonable, although inspectors
noted there was scope to improve the range of psychological interventions on offer.
Prisoners were effectively screened at reception and referred to mental health
services promptly. A duty staff member was available to respond to urgent matters
and attend initial ACCT reviews.
25. Inspectors noted that the in-house pharmacy was well managed with in-possession
risk assessments completed on arrival. However, they noted that these
assessments were not always reviewed at appropriate levels and reasons for any
changes was not always recorded. There were limited provisions for midday or
night-time administrations, and some medicines were not prescribed in accordance
with therapeutic efficacy.
Independent Monitoring Board
26. 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 30 June 2024, the IMB reported
that healthcare provision was generally good. However, they noted that services
had been placed under strain due to shortages of both healthcare and operational
staff. In a survey conducted in May 2024, 68% of prisoners who responded said
that it was very difficult or quite difficult to speak to someone in healthcare, and 59%
said that it was very difficult or quite difficult to get support for mental health and
wellbeing. The results showed some improvement from the previous survey in
September 2023 when figures were 75% and 77% respectively.
Previous deaths at HMP Bullingdon
27. Mr Pierson was the eleventh prisoner to die at Bullingdon since September 2021.
Of the previous deaths, one was self-inflicted, eight were from natural causes, and
in one the cause was unascertained. Up to the end of September 2025, there have
been two further deaths, one self-inflicted and one from natural causes. There are
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no similarities between the findings from our investigation into Mr Pierson’s death
and the findings from our investigations into the previous deaths.
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Key Events
28. On 16 May 2024, Mr Garrick Pierson was arrested for sexual offences. He was due
to be bailed the next day but was transferred to a psychiatric hospital after he
reported suicidal thoughts. He was discharged back into police custody on 3 June.
29. On 4 June, Mr Pierson was remanded to HMP Bullingdon. It was his first time in
prison. Staff immediately started suicide and self-harm prevention procedures
(known as ACCT). Mr Pierson said he had anxiety, depression, and cluster
headaches, but he had no medication with him. Staff moved him to the healthcare
unit and checked on him hourly throughout the night. Mr Pierson was subsequently
prescribed antidepressants and verapamil for his cluster headaches, along with
other pain relief and medication to treat high cholesterol and stomach acid.
30. On 5 June, staff held Mr Pierson’s first ACCT review. Nurse A, a mental health
nurse, attended. Mr Pierson told staff that he had been charged with multiple rapes
and expected to receive between five and ten years in prison. He said he had
planned to kill himself before he was arrested and was struggling with being in
prison. He said that his relationships with family and friends had broken down and
that previous coping mechanisms were no longer working for him. Nurse A noted
that Mr Pierson said he had constant thoughts of self-harm and while he had no
active thoughts of taking his life, he said he would do so if given the opportunity.
Staff considered he was at high risk of suicide and self-harm. Staff moved Mr
Pierson to the induction wing and placed him under constant supervision.
31. On 6 June, Mr Pierson was accepted onto the mental health team’s caseload and
allocated to Nurse A.
32. By the time of his ACCT review on 8 June, Mr Pierson reported feeling better in
himself and said that he was adjusting to the prison regime. He said he felt
supported by staff on the induction wing and had also spoken to his father. Staff
reduced checks to three an hour.
33. On 11 June, staff moved Mr Pierson to the vulnerable prisoners unit (E Wing). At
his ACCT review, Mr Pierson said he was happy with the regime but continued to
have anxiety and insomnia. He told staff that he previously used cannabis in the
community to help him sleep. Staff referred him for support from the substance
misuse team.
34. Due to Mr Pierson’s risk of self-harm, staff decided that he could only have some of
his medication in his possession. This included verapamil. He collected three
verapamil tablets from the pharmacy each day.
35. On 24 June, staff agreed to stop ACCT monitoring. They referred Mr Pierson to a
Managing Emotions group and agreed that Nurse A would check in with him after
his court appearance on 2 July.
36. On 27 June, Mr Pierson had a meeting with his legal team who told him he could be
facing 15 to 20 years in prison. Mr Pierson reported feeling overwhelmed and he
self-harmed by scratching his arms. Staff restarted ACCT monitoring and set
checks at one an hour.
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37. On 2 July, Mr Pierson attended court by video link and pleaded guilty to the
offences. Video link staff noted that he was tearful and said he expected to get a
sentence of 12 to 15 years. He said he had a supportive cellmate and was currently
supported by the ACCT process. He said he had no current thoughts of suicide or
self-harm.
38. On 4 July, Mr Pierson attended an assessment with a member of the substance
misuse service. He said he had been a regular user of cannabis from the age of
ten. He said he would like to complete in-cell workbooks around cannabis and
emotions, as well as attending specific workshops including enhancing self-esteem,
managing emotions, relapse prevention, and mindfulness.
39. Staff continued to monitor Mr Pierson under ACCT procedures. At his ACCT review
on 30 July, staff noted that he had made good progress and had obtained a job as
an industrial cleaner. Mr Pierson was happy about this and said he was looking
forward to having something to do. Staff agreed to stop ACCT monitoring and set a
post-closure review date of 6 August. However, this review did not take place.
40. On 5 August, Mr Pierson had his first key worker session with Officer A. Officer A
noted that Mr Pierson was keen to have contact with his son and to get enhanced
prisoner status. Mr Pierson complained that he was not getting enough positive
behaviour points to progress to enhanced status. He also told Officer A that he
needed a change to his antidepressant medication.
41. On 20 August, Nurse A tried to see Mr Pierson to carry out a mental health
assessment but he was at work. At interview, Nurse A confirmed that she had not
seen Mr Pierson as his care coordinator, other than during ACCT reviews. She
therefore had not seen him since his last ACCT review on 30 July, but she said she
was not concerned about him as she knew he had a job and officers on the wing
had not reported any issues. Nurse A said that care coordinators were not expected
to see people on their caseload with specific regularity, stating that it varied
according to individual need. When she did not see Mr Pierson on 20 August, she
noted that she would re-book the mental health assessment for the following week
but this did not happen. She said that she had a period of annual leave around that
time and was unable to comment on why Mr Pierson’s appointment was not
followed up in her absence, other than to say that she was not concerned about
him.
42. On the same day, Mr Pierson had a review with the substance misuse team. He
told the substance misuse worker that he was doing well and was waiting for his
sentencing at court on 27 September. He said he was struggling with the in-cell
workbooks because of his dyslexia. The substance misuse worker offered to
arrange for a peer supporter to help him. Mr Pierson also said that he was
struggling with cravings and was getting angry at times. The substance misuse
worker encouraged him to use distraction packs and agreed to send him some.
43. On 21 August, Mr Pierson had a key worker session with Officer A. He reported that
he had received a positive behaviour point and was awaiting a medication review.
Officer A told him that he could not help him to have contact with his son as he was
not allowed to have contact with children or vulnerable adults. Mr Pierson did not
have any further key worker sessions.
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44. On 17 September, a GP saw Mr Pierson. Mr Pierson asked the GP to increase his
mirtazapine (an antidepressant) as he was experiencing constant low mood. The
GP increased the mirtazapine from 15mg to 30mg and changed the administration
time from 4.00pm to 8.00pm. Although he did not note the reasons for the change
of time in Mr Pierson’s medical record, the GP said at interview that this was to help
improve Mr Pierson’s sleep and to make him less drowsy during the day. He said at
interview that he did not know how the 8.00pm medication would be administered
and he believed this would be the responsibility of the pharmacist to ensure the
change took place as prescribed.
45. Records show that Mr Pierson did not receive any mirtazapine on 20, 21, or 22
September. We found no documented reason why this medication was not
administered and we found no evidence of any follow-up. Mr Pierson’s cellmate told
the investigator that Mr Pierson was frustrated that he had to constantly request his
medication before anyone gave it to him. He had even set an alarm for 8.00pm so
that he could press the cell bell to alert staff that he needed his medication. Mr
Pierson’s cellmate said that when staff attended they said they would chase it with
healthcare but it did not arrive. He alleged that staff told Mr Pierson that the night
nurse in charge said it was not their job to dispense his medication.
46. During interviews, there was ambiguity about how medication should be
administered out of hours and what should happen if medication was missed. The
Head of Healthcare said that any night-time medication should be added to the
ledger of the night nurse in charge. The GP said at interview that he thought it was
the role of pharmacy staff to ensure night-time medication was administered. The
pharmacy technician said he was not aware of any specific process for 8.00pm
medication. He said he did not consider it was his role to add night-time medication
to the night nurse in charge’s ledger, although he would add missed medication (for
example for prisoners who were due to collect theirs at 4.00pm and were delayed in
doing so) to the ledger. During the investigation, we found no evidence that Mr
Pierson’s mirtazapine was on the ledger. Nurse B, the nurse who was in charge on
the night of 22 September, said that Mr Pierson’s medication was not on his ledger
that night.
Events of 23 September
47. Mr Pierson’s cellmate said he heard Mr Pierson being sick at around 1.00am and
when he asked what was wrong, Mr Pierson said “I’ve done something silly”. He
said he had taken 123 verapamil tablets and that he hoped staff would now sort out
his medication. His cellmate pressed the cell bell to alert staff and staff attended
immediately.
48. Nurse B did not assess Mr Pierson at that stage. He told the investigator he did not
want to waste time. He said that he immediately called Toxbase (poisons advice
centre) and when he told them that Mr Pierson had taken 123 verapamil tablets,
they said it was a fatal dose and he needed to go to hospital immediately. Nurse B
contacted the prison’s night orderly officer to request an ambulance for Mr Pierson.
He said he then went to complete the necessary paperwork for his escort to
hospital. Records show that the ambulance was requested at 1.23am.
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49. Nurse B said he considered whether he should administer activated charcoal to Mr
Pierson (which can reduce the effects of overdose if taken within an hour) but it was
not immediately available to him. He said it would have taken around eight minutes
for him to collect it from the out of hours storeroom on F Wing and he would have
needed a member of prison staff to escort him. Nurse B said, given what Toxbase
had told him about the serious nature of the overdose, he prioritised getting Mr
Pierson to hospital and preparing the necessary escort paperwork.
50. A senior healthcare assistant (HCA) escorted Mr Pierson from his cell to reception
to wait for the ambulance. She said that, while waiting for the ambulance, Mr
Pierson deteriorated. He was being sick and feeling dizzy. She took some physical
observations, tried to make him comfortable, and kept him talking. Despite having
been logged as a priority 1 emergency (meaning requiring an urgent response) by
the 999 operator and prison staff making further calls to find out why the ambulance
had not yet arrived, paramedics finally reached Bullingdon at 2.44am and took Mr
Pierson to hospital, where he died at around 4.00am.
51. Staff later found some notes in Mr Pierson’s cell in which he said he would be better
off dead and apologised to the victims of his offence. The notes were not dated.
Contact with Mr Pierson’s family
52. On 23 September, at around 11.15am, the prison’s appointed family liaison officers
attended the home address of Mr Pierson’s father to tell him that his son had died.
The prison service contributed to Mr Pierson’s funeral expenses in line with national
guidance.
Support for prisoners and staff
53. Postvention is a joint HMPPS and Samaritans initiative that aims to ensure a
consistent approach to providing staff and prisoner support following all deaths in
custody. Postvention procedures should be initiated immediately after every self-
inflicted death and on a case by case basis after all other types of death. Key
elements of postvention care include a hot debrief for staff involved in the
emergency response and engaging Listeners (prisoners trained by the Samaritans
to provide confidential peer-support) to identify prisoners most affected by the
death.
54. A prison manager 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.
55. The prison posted notices informing other prisoners of Mr Pierson’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 Pierson’s death.
Post-mortem report
56. The post-mortem report concluded that Mr Pierson had died from verapamil toxicity.
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Findings
Identifying the risk of suicide and self-harm
57. Prison Service Instruction (PSI) 64/2011, Management of prisoners at risk of harm
to self, to others and from others (Safer Custody), which was the policy in place at
the time of Mr Pierson’s death, set out the processes (known as ACCT) that staff
should follow if they identified that a prisoner was at risk of suicide or self-harm.
(The PSI has been superseded by the Prison Safety Policy Framework but the
ACCT process remains broadly the same.)
58. We found that staff appropriately started ACCT procedures when Mr Pierson
arrived at Bullingdon. ACCT reviews were multidisciplinary and attended by a
mental health nurse. Although staff briefly stopped ACCT monitoring on 24 June,
they reassessed Mr Pierson’s risk and restarted ACCT monitoring from 27 June to
offer him additional support in the weeks surrounding his court appearance on 2
July, when he pleaded guilty to the offences. This was good practice. Staff
continued ACCT monitoring until 30 July when they considered his risk had reduced
sufficiently. We consider this was a reasonable decision. However, we note that no
post-closure review was completed and this was not identified during quality
assurance. We consider that Mr Pierson was adequately supported by ACCT and
the lack of post-closure review had no impact on him. We are also aware that the
safer custody team have put plans in place to improve the ACCT quality assurance
process, so we make no recommendation.
59. When Mr Pierson became tearful after a legal visit on 19 September, an officer
spoke to him to try to assess if he was at risk of suicide or self-harm. He alerted an
officer on E Wing that Mr Pierson was returning from legal visits and had been
tearful and he noted this in his prison record. The officer said he did not think Mr
Pierson needed to be monitored under ACCT but he thought it would be better for
an officer who knew him better to speak to him and assess his risk.
60. An E Wing officer spoke to Mr Pierson on his return to the wing but he did not write
anything in his prison record to confirm what they had spoken about and whether he
considered Mr Pierson could be at risk of suicide or self-harm. We are satisfied that
the officer in legal visits considered starting ACCT monitoring again and concluded
it was not necessary. We consider his actions in alerting the E Wing officer were
appropriate in the circumstances and that it is likely that both members of staff did
not think ACCT monitoring was necessary. However, it is important that staff
document conversations and risk considerations. We bring this to the Governor’s
attention.
Clinical care
61. The clinical reviewer concluded that the healthcare Mr Pierson received at
Bullingdon was not equivalent to that which he could have expected to receive in
the community.
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In-possession verapamil
62. The clinical reviewer considered that letting Mr Pierson retain daily in-possession of
his verapamil may not have been a clinically safe decision. She noted that his
medication arrangements were inconsistent. Some medicines were issued weekly,
others daily, and some not at all. The system used to determine in-possession
eligibility did not appear to account for the relative toxicity or lethality of each drug in
overdose.
63. For example, Mr Pierson was not permitted daily in-possession of mirtazapine or
atorvastatin, both of which carry low overdose risk. He was also required to collect
naproxen twice daily, despite its similarly low toxicity. In contrast, verapamil, a drug
known to be highly dangerous in overdose, was supplied daily in-possession (three
tablets collected daily) without sufficient safeguards.
64. No checks were carried out to see if Mr Pierson was taking his medication as
prescribed and we now know he was stockpiling it. The clinical reviewer estimated
that to accumulate 120 tablets, he must have been stockpiling from no later than 12
August. We were told that random spot checks were carried out on ten prisoners
each month. We consider this insufficient and that consideration should be given to
checking on prisoners at high risk rather than selecting prisoners at random.
65. We recommend:
The Head of Healthcare should:
• Review the in-possession medication risk assessment process, to include
consideration of whether the medication is high-risk (i.e. highly toxic).
• Review the in-possession medication compliance checks, to include
consideration of focusing checks on those at greater risk.
• Ensure that a robust audit process is in place to check in-possession
medication risk assessments are being completed correctly and that
medication compliance checks are undertaken.
Missed doses of mirtazapine
66. Mr Pierson had requested an increase in his antidepressant medication,
mirtazapine, due to continued low mood and difficulty sleeping. A GP increased the
dose from 15mg to 30mg and changed the administration time from 4.00pm to
8.00pm to help improve Mr Pierson’s mood and ability to sleep. Although Mr
Pierson received mirtazapine up to 19 September, he did not receive any on the
evenings of 20, 21 or 22 September.
67. The administration of medication at 8.00pm meant that it was taking place during
night state when there were minimal staff on duty. Healthcare staff need to be
escorted by prison staff to the prisoner’s cell to administer the medication. While we
appreciate that night-time medication administration may cause some challenges as
opposed to administering medication during the day, we consider that all staff
should be clear of their roles and responsibilities to ensure that prisoners receive
their medication as prescribed. Furthermore, if a prisoner’s medication is not
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administered, we would expect to see this clearly documented including the
reasons why it was missed. This did not happen for Mr Pierson.
68. From interviews and prison records, we consider that Mr Pierson was frustrated that
his medication was not being given to him at 8.00pm. He drew this to the attention
of staff and, given that this was medication to help with his mood and his sleep, it is
not surprising that he felt he was not being listened to. While we cannot be sure of
his reasons for taking an overdose of his verapamil medication, he allegedly
indicated to his cellmate that he hoped staff would listen to him and give him his
medication. While waiting for the ambulance, he also told healthcare staff that he
did not want to die. It is therefore possible that Mr Pierson took the overdose so that
healthcare staff would take notice of his plight, rather than as a deliberate attempt to
end his life. We make the following recommendation:
The Head of Healthcare should develop an agreed local policy for medication
management during night state, which should set out:
• responsibilities for the prescriber, pharmacy, Head of Healthcare, the night
healthcare team and where applicable, night prison staff;
• how evening medications are to be accessed and administered;
• what action to take in the event of missed medication, including incident
reporting (i.e. Datix) and advising the prescribing clinician or team; and
• the audit process to ensure compliance.
Mental health care
69. Mr Pierson was appropriately referred to the mental health team when he arrived at
Bullingdon. As he was immediately placed under ACCT monitoring, he was seen by
a member of the mental health team at each ACCT review. Given that Mr Pierson
was placed on Nurse A’s caseload from 6 June, we would expect to see evidence
of a formal care plan and some individual sessions with Mr Pierson outside of the
ACCT process but this did not happen.
70. When ACCT monitoring stopped on 30 July, Mr Pierson did not have any further
documented contact with Nurse A or anyone else from the mental health team.
Nurse A did, however, attempt to see him for a full mental health assessment on 20
August but he was not available due to being at work. It is not clear if he knew that
Nurse A was due to be assessing him. Nurse A noted that she would rebook the
assessment for the following week, but no follow-up had taken place by the time Mr
Pierson died. Furthermore, we found no evidence that the mental health team had
any plans in place to support Mr Pierson in the days surrounding his sentencing,
which was due to take place on 27 September. We consider that the support
received from the mental health team was inadequate and we make the following
recommendation:
The Head of Healthcare should review the mental health process to ensure
that prisoners are not lost to follow-up and that upcoming important dates are
highlighted and appropriately escalated.
12 Prisons and Probation Ombudsman
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Inquest
71. At the inquest, held from 22 to 26 June 2026, the jury reached a narrative
conclusion:
“Garrick Gerald Pierson died on 23rd September 2024 at the John Radcliffe
Hospital, Oxford from a self-inflicted act of taking verapamil. However, it is not
possible to safely discern his intent. It is probable that the inadequate process for
the management and monitoring of his medication contributed to his death. It is
possible that insufficient formal support to Garrick Gerald Pierson following his
solicitor’s visit on the 19th of September 2024 may have also contributed to his
death. Therefore, we have come to a narrative conclusion due to the conflicting and
unclear evidence of his intent.”
Prisons and Probation Ombudsman 13
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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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