Four prison officers dismissed for lack of welfare checks as man died in his cell at HMP Leeds
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Prisoner Darren Horner died at the jail in Armley on September 22, 2018.
The 44-year-old, who was serving a 10-week prison sentence for failing to surrender at court, had a long history of substance misuse.
However, an internal prison investigation carried out after his death found that the prison officers responsible for completing roll checks and welfare checks upon him had not completed them as they should have done.
On September 21, Mr Horner saw his substance misuse keyworker and asked for an increase in his methadone dose to keep him stable. He denied using any illicit non-prescribed medication.
At approximately 4.40pm that day, a prison officer unlocked Mr Horner’s cell so he could collect his evening meal. Mr Horner did not leave his cell and he was locked up shortly afterwards.
This was the last time Mr Horner was seen alive, a report by the Prisons and Probations Ombudsman stated.
Prison staff did not complete roll checks correctly for the remainder of September 21 and the roll check at 7am on September 22 was not completed.
At approximately 9.50am on September 22, a prison officer unlocked Mr Horner’s cell but did not check his wellbeing.
A prisoner went into Mr Horner’s cell and found him unresponsive on the cell floor. He called for assistance and the prison officer returned to Mr Horner’s cell.
Mr Horner did not display any signs of life. Paramedics arrived at approximately 10.03am and pronounced Mr Horner dead at 10.14am.
A post-mortem concluded that Mr Horner had died from methadone toxicity with aspiration.
The failures to complete roll checks and welfare checks resulted in disciplinary action and the subsequent dismissal of four prison officers.
The Ombudsman's report stated: "The primary purpose of a roll check is to confirm that all prisoners are present and correctly accounted for. Not completing a roll check is, therefore, a serious breach of security.
"However, roll checks are also an opportunity to check on prisoners’ well-being and to identify any obvious signs that a prisoner may be ill or dead.
"When Mr Horner was discovered dead in his cell, he was lying on his back on the cell floor. If he had been seen in this position during a roll check, we would have expected officers to be concerned for his well-being and to try to get a response from him and to raise the alarm if they could not."
The officer who found Mr Horner unresponsive in his cell did not call a medical emergency code immediately because he was not carrying a radio.
Since Mr Horner’s death, all residential wing staff are now required to carry a radio.
A clinical reviewer who contributed to the report found that Mr Horner received a good standard of clinical and substance misuse care at Leeds, equivalent to that which he could have expected to receive in the community.
She considered that Mr Horner’s substance misuse care was of a good standard.
"He was regularly monitored and appropriately assessed using the clinical opiate withdrawal score", the report stated.
The Ombudsman did not make any recommendations.
The report concluded: "We are satisfied that since Mr Horner’s death, Leeds provides specific training to prison staff to emphasise the vital importance of completing roll checks and welfare checks in accordance with their local security strategy."
Prior to Mr Horner’s death, HM Inspectorate of Prisons carried out an inspection at Leeds in October and November 2017.
They found that the prison’s drug supply reduction strategy was reasonable, and some positive action had been taken to reduce supply.
However, 63 per cent of prisoners they surveyed said it was easy to get illegal drugs and about a third of prisoners tested positive for drugs during random mandatory drug tests.
The most recent full inspection of Leeds was in November and December 2019.
Inspectors found that since the previous inspection, there had been substantial work to reduce the availability of illicit substances, including the installation of a body scanner, an itemiser to detect drugs on prisoners’ mail, and netting over all exercise yards to stop packages from being thrown over.
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