Peter Campbell: Prevention of future deaths report

The medical cause of death was recorded as:
1a pneumonia and ischaemic hypoxic brain injury
1b cardiac arrest
1c toxic effects of [REDACTED]

The MATTERS OF CONCERN are as follows.
For HMPPS and Pentonville
In the narrative conclusion, the jury recorded a failure to prevent drugs from entering the prison. 
  
Every witness at inquest who expressed a view gave evidence that drugs are rife within Pentonville, as they are across the prison estate.  They enter attached to drones and in throw overs; via prison officers, visitors and prisoners; and, to a lesser extent these days, in the post.  [REDACTED], a drug  many  times  more  potent  and  dangerous  than  cannabis, [REDACTED].

It has infiltrated the prison population with enormous reach and with potentially devastating consequences for the prisoners themselves and for others – there is a risk of prisoners leaving prison in a worse state than when they went in, a state that may of course be reflected in violent reoffending. 
Initially, I was not going to include that failure within my prevention of future deaths report, because the availability of drugs in prison seems such a huge and intractable problem. However, on reflection it seems to me that it would be complacent to view the size of the problem as prohibitive. Perhaps the size of the problem dictates only the size of the solution required.   

At inquest, I heard about other aspects of the prison regime that were sub optimal, but it appeared that since Mr Campbell’s death, the staff at Pentonville had taken steps to address these.    

However,  the mass availability  of  drugs  apparently  persists  without abatement. This is not in any way peculiar to Pentonville, but Pentonville is an exemplar.  

For Phoenix and PPG
Mr Campbell collapsed in prison on 18 September 2024 as he had done before following the use of [REDACTED], and the prison and healthcare staff responded to this as an emergency code blue.  The ambulance service was called and he was immediately conveyed to hospital where he was resuscitated.   
The jury found a failure by the prison drug service to provide a meaningful interaction with Mr Campbell between the collapse on 18 September 2024 and the fatal collapse on 3 October 2024. This was partly because a visit was not arranged promptly, a systemic issue that since seems to have been addressed. 

However, I also heard evidence that, when the Phoenix recovery worker did go to see Mr Campbell on 1 October 2024 in an attempt to promote harm minimisation: 
·  She did not read any part of his medical records before she saw him,
and she did not know whether she was meant so to do.  She was. 
·  She spoke to him through the hatch in the cell door, with his cellmate present.  This was her normal practice, but she was not able to say why.  It should not have been. 
·  She did not have any meaningful discussion with him about his drug use, either the use that led to his collapse on 18 September 2024 or his use generally.  She should have. 
·  She gave him various pieces of harm minimisation guidance in keeping with her training, including the advice to avoid using drugs whilst alone. This advice was later confirmed as within policy by the Phoenix head of service. However, it does not seem to take account
of the fact that smoking a drug in a small cell with a cellmate puts the cellmate at risk. 
·  Mr Campbell told her that he was not under the influence at the time. The recovery worker was not wholly convinced, but she did not return later that day or the following day to see if better engagement was possible. She should have. 
·  She did not know whether her interaction with Mr Campbell was in accordance with her training. I was told that it was not. She had not received further training or changed her practice since his death. 
·  The drug recovery worker was the last healthcare worker to see Mr Campbell before his fatal collapse from drugs and did so just two days before that occurred.                                           
However, the gaps in her care of Mr Campbell were not identified by the investigation following his death by Phoenix and PPG (or by the Prisons and Probation Ombudsman).
·  She had not changed her practice since Mr Campbell’s death, but any gaps in her care of other prisoners had also not been identified in the following year and a half, either by routine supervision or by audit. I heard that audits are undertaken of the medical records only.
Therefore, the first time that Phoenix and PPG recognised a drug recovery worker’s failures to follow their procedures over at least a year and a half, was at the inquest. 

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. 

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 she 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.