Josh Tarrant (3): Prevention of future deaths report

The investigation concluded on 11 December 2025 at the end of an inquest conducted by me (sitting with a jury). The jury concluded that:
“Josh Yemi Tarrant died as a result of Cocaine toxicity following a lengthy and challenging restraint. Josh was experiencing an acute behavioural disturbance which was not recognized by Healthcare staff. Healthcare’s failure to provide sufficient medical treatment at the earliest appropriate opportunity by calling an Ambulance by 23:29 was probably a significant contributing factor in Josh’s death. Josh’s death was contributed to by neglect.”

The medical cause of death was:
Ia.     Cocaine intoxication
II.       Cardiac Hypertrophy and Exertion during Restraint

The Officer Staff Grade (“OSG”) supervising Houseblock 1 during the night spoke to Mr Tarrant at about 10.30 pm when he remained calm and lucid. About an hour later his demeanour had completely changed. Mr Tarrant asked the OSG for help and said that he was hearing voices. He had taken his shirt off and was bare chested. He had probably ingested cocaine in the preceding hour. The OSG called for assistance and the Prison’s ‘Oscar 1’ (the most senior member of staff on site) attended with other officers. They entered Mr Tarrant’s cell to speak to him. He was standing up and looking out of the cell window. He did not respond and was speaking incoherently and repetitively, saying “help me, help me, help me” repeatedly. Mr Tarrant suddenly knocked a TV in his cell to the floor and ran out of his cell. He was restrained on the floor by a number of officers using Control and Restraint techniques. Mr Tarrant displayed unusual strength during this struggle and at one point lifted several officers off the ground as he got to his feet.

The Oscar 1 called for the attendance of ‘Hotel 1’ (the nurse on duty at the Prison overnight) who attended after a short delay caused by the fact that she had no key to open locked gates. On arrival the Hotel 1 made little or no assessment of Mr Tarrant and, despite thinking he was having a psychotic episode, she did not declare a medical emergency (code blue) which would have triggered a 999 to the South East Coast Ambulance Service (“SECAmb”).

The Oscar 1 decided that Mr Tarrant should be taken to the Prison’s healthcare unit where he could be kept under observation. The healthcare unit was aa short distance from Houseblock 1 and the journey on foot would normally take no more than a few minutes. However, Mr Tarrant was agitated and non- compliant and so the transfer took place under restraint
During the next half an hour or so the officers were engaged in a extremely physically challenging transfer. Mr Tarrant was struggling throughout, allowing his body weight to drop and the officers had to stop form time to time to catch their breath and rotate staff. Throughout this episode Mr Tarrant was shouting incoherently and repetitively. He did not appear to know where he was (he kept asking for his mother) and displayed signs of severe distress.

Officers finally managed to get Mr Tarrant into a observation cell in the healthcare unit. Once the door was locked he continued to be extremely distressed. He was shouting repeatedly and incoherently. He became violent and smashed the gate of his cell with his legs, arms and even his head. The force  with  which  he  did  these  things  shocked  some  of the  officers who witnessed it. Mr Tarrant also seemed to be oblivious to the pain that that he must have been experiencing.

After about an hour, during which time Mr Tarrant did not seem to tire, he made a ligature out of his clothing material and put it around his neck and suspended himself. Officers entered the cell and removed the ligature. When closing the cell door, Mr Tarrant’s thumb was accidentally trapped between the metal gate and the door frame. Although this must have caused extreme pain, he did not seem to notice it.

Mr Tarrant continued to be violent and the force of his blows eventually smashed the Perspex door cover. There were sharp pieces of broken Perspex both inside and outside the cell which officers were worried that Mr Tarrant might use to harm himself. They therefore relocated him into the next-door cell under restraint. Once again, Mr Tarrant struggled and the relocation was very physically challenging and took about 7/8 minutes to transport him no more than a few metres away.

The officers exited the cell in a controlled way until there was one officer left. Whan the last officer made to exit the cell he sensed that something was wrong. He immediately re-entered the cell and saw that Mr Tarrant was unresponsive. He was not breathing and did not have a pulse. A Code Blue was called and an ambulance summoned at around 1.27 am on 1 November 2023. CPR was started immediately. Healthcare staff made a number of basic errors in providing CPR (failing to use the correct equipment, inserting an i-Gel in Mr Tarrant’s airway the wrong way around which blocked his airway). Although none of these failings ultimately caused or contributed to Mr Tarrant’s death the failures were shocking. In contrast, the Prison officers acquitted themselves very well and performed CPR to a high standard which was later complimented by paramedics.

Paramedics arrived at the scene at 1.44 am and took over the management of Mr Tarrant’s airway form healthcare staff. They immediately noticed that the i- Gel  had  been  placed  incorrectly  and  rectified  it.  CPR  was  ultimately unsuccessful and Mr Tarrant was pronounced dead at 2.13 am on 1 November 2023.

The MATTERS OF CONCERN are as follows:
From about 11.30 pm on 31 October 2023 until moments before his death Mr Tarrant was displaying classic signs of Acute Behavioural Disturbance (“ABD”), which was formerly referred to as ‘Excited Delirium’.

ABD is a well-known condition throughout the World. People suffering ABD can display a number of symptoms including apparent psychosis, repetitive shouting, random violence against people or objects, they tend to disrobe, be impervious to pain, demonstrate abnormal strength. They engage in bizarre behaviour and cannot be reasoned with.

Expert evidence was given by Dr [REDACTED], a Consultant in Emergency Medicine and an acknowledged expert on restrain and ABD (who has been engaged by both eh Scottish Prison Service and HMPPS to advise in relation to these matters).

Dr [REDACTED] stated that Mr Tarrant’s presentation made it obvious that he was suffering ABD and that anybody who had been trained to spot the signs of it would have come to that conclusion within minutes of seeing him.
People in a state of ABD are at risk of physiological collapse and death. It is believed that they become exhausted, acidotic, hyperthermic, hyperkaliaemic and  hypoxic  to  the  point  at  which  they  are  unable  to  compensate  by hyperventilating.

The risk of death is particularly acute where a person suffering ABD is subjected to  prolonged  restraint  because  it  increases  their  level  of  exertion  (thereby exacerbating  acidosis  and  hypoxia)  and  restricts  the  airway,  chest  and/or diaphragmatic movement.

Dr [REDACTED] expressed dismay that, in 2023, neither healthcare staff nor Prison staff had any training in respect of ABD and, as a result, appeared to have no idea that Mr Tarrant might be suffering from it.

This is despite the fact that Prison Service Order 1600 (2005), written nearly two decades before, states in section 3 that:
3. MEDICAL PROCEDURES
All staff who may be involved in the use of force (or in supervising it) are aware of the signs that a prisoner may be experiencing medical difficulties.
3.1     It is extremely important that staff involved in applying restraints or using force of any kind are aware off the signs and symptoms that may indicate that a prisoner is in medical distress. Such an incident will need to be treated as a medical emergency rather than a control and restraint incident.
3.2     The  onset  of serious  medical  condition  following the application of  physical  or mechanical restraints is extremely rare – however it has been known to occur, and prisoners in both prison and police custody have died as a result of being restrained.
3.3     Further information can be found in Annex D about the following medical conditions
that are relevant to the use of force on a prisoner:
·           Positional Asphyxia,
·         Excited Delirium,
·         Sickle Cell Disease,
·           Psychosis.
…
ANNEX D
MEDICAL CONDITIONS
Excited Delirium
Excited delirium is both a mental state and physiological arousal.
Excited delirium can be caused by drug intoxication (including alcohol) or psychiatric illness or a combination of both. Cocaine is a well-known cause of drug induced excited delirium.
Differentiating someone in excited delirium from someone who is simply violent is often difficult. People suffering excited delirium may:
·         Have unexpected strength and endurance, apparently without fatigue · Show an abnormal tolerance of pain
·         Feel hot to touch
·         Be agitated
·         Sweat profusely
·         Be hostile
·         Exhibit bizarre behaviour and speech

It may only become apparent that a prisoner is suffering from excited delirium when they suddenly collapse: beware of sudden tranquillity after frenzied activity which may be caused by severe exhaustion, asphyxia or drug related cardiopulmonary problems (problems with the heart and lungs).
The operator of primary healthcare at the Prison, Oxleas MHS Foundation Trust, acknowledged that their clinical staff received no training in relation to ABD prior to Mr Tarrant’s death. That has now been rectified and the Trust is rolling out a training programme at a local level.

Dr [REDACTED] explained that ABD is a well-recognised condition. Indeed, SECAmb witnesses provided evidence in this inquest that, if their call handlers are told that a person is displaying signs of ABD whilst under restraint, the response would be upgraded to aa Category 1 response and the immediate despatch of a Critical Care Paramedic (“CCP”).

Dr [REDACTED] also stated that:
(1) Mr Tarrant was displaying ‘textbook’ signs of ABD which would have been
apparent to a properly trained person within a matter of minutes;
(2) It was clearly a medical emergency that required the attendance of a CCP
who would have provided sedation and other treatments;
(3) Had treatment been initiated at any time before 1 am Mr Tarrant probably
would have survived.

I am concerned that:
(a) No training is provided to prison healthcare staff in relation to ABD
(despite the clear advice of PSO 1600).
(b) If prison nurses remain unaware of ABD and the need to treat it as a
medical emergency, then further deaths are likely in future.

Accordingly, this situation should be reviewed and consideration given as to whether any steps should be taken to reduce the risk of death by from ABD. In particular, training of prison clinicians should be carefully reviewed at a national level.

Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed.

I am under a duty to send the Chief Coroner a copy of your response. 

The Chief Coroner may publish either or both in a complete or redacted or summary form. She may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.