Liam Turner died on 6th December 2021 at HMP Manchester. He had a long history of substance misuse and engaged in interventions offered to him whilst serving a custodial sentence.

Liam continued to use illicit substances alongside his prescribed medication, and this sadly led to his death.

On 29th January 2024, an Article 2 inquest took place at Manchester Coroner’s Court, which explored how and in what circumstances Liam came by his death.

The inquest explored Liam’s use of psychoactive substances and their availability at HMP Manchester, as well as the healthcare received around Liam’s use of psychoactive substances and the specific events on 6th December 2021 that caused his death.

When three officers found Liam unresponsive in his cell, they moved him from the bed to the floor in preparation to commence CPR. However, CPR was not commenced until the healthcare and paramedics arrived.

Evidence was heard that one witness received training in 2006 as part of his Emergency First Aid at Work but had not received any refresher training. The training certification expires after three years, and it is not mandatory for prison officers to receive refresher or additional training.

The Jury, having heard evidence from several witnesses, returned a conclusion that Liam died a drug-related death and recorded that:-

“It is admitted on behalf of the Ministry of Justice that on 6 December 2021, an officer did not immediately contact Healthcare upon forming the view that the deceased was under the influence of some form of illicit substance. That was a failing but not causative of the deceased’s death.

That on 6 December 2021, officers did not immediately call a Code Blue upon entering the deceased’s cell and finding him unresponsive. That was a failing but was not causative of the deceased’s death.”

As a result of the evidence heard around basic first aid training, the Coroner issued a Regulation 28 Report to HM Prison and Probation Service.

It is highlighted within that report that 48% of prison staff will have training certification (which includes CPR), which has expired.

The evidence admitted showed that the main reason for this is due to it not being mandatory for prison staff to have up-to-date training.

HMPPS are required to respond detailing what action or proposed action is to be taken by 1st April 2024. If they do not propose to take action, they must state why.

Kelly Darlington, Partner at Farleys Solicitors, said:

It is clear to see how concerning this issue is and the risk it potentially poses to the lives of many prisoners in an urgent, life-threatening situation. Whilst it could not have been said to have caused or contributed to this death, it obviously could prevent many other deaths from occurring in the future.

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