HMP Leeds inmate died after taking ‘toxic combination’ of drugs mostly prescribed by the prison

Martin Brake, 55, was found dead in his cell in HMP Leeds on March 29, 2020. His death was ruled as accidental.

A post-mortem examination found he died from methadone, amitriptyline, mirtazapine, gabapentin, pregabalin and codeine toxicity.

Pneumonia and heart disease were also factors in his death.

A report into Mr Brake’s death by Prisons and Probation Ombudsman Sue McAllister found that all but two of the drugs had been prescribed by the prison.

Ms McAllister raised concerns that despite the risks of prescribing that combination of drugs, no one ever carried out a medical review.

Mr Brake was remanded in custody at the Armley prison in December 2018 and was later convicted of burglary, fraud and theft.

He had a history of substance misuse and was located on an incentivised substance-free living (ISFL) wing, where prisoners are given privileges in exchange for agreeing to stay drug-free.

Mr Brake suffered from a number of health conditions and had complained of pain in his back, arm and leg.

Prison GPs prescribed a range of pain relief medication and increased the dosage on a number of occasions.

Despite previously admitting to a prison GP that he had brought drugs from other prisoners, this was not passed on to the substance misuse team.

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In the report, Ms McAllister said: “Two of the prescription drugs found in Mr Brake’s system had not been prescribed to him so he must have obtained them illicitly.

“Although Mr Brake told a prison GP that he had been buying prescription drugs from other prisoners, the GP did not pass this information onto wing staff or the substance misuse team.”

The report identified a number of action points for the prison following Mr Brake’s death.

These include regular medication reviews for prisoners and better protocol for sharing information of illicit drug use.

HMP Leeds said it was implementing “safer prescribing clinics” to make sure reviews are carried out on a regular basis, as well as creating an information sharing protocol.

The Ombudsman accepted the prison’s response.