A coroner has determined that prison staff failed to identify clear signs of a medical emergency, leading to the death of a 34-year-old inmate at HMP Elmley. Josh Tarrant, a father-of-five, died from cocaine toxicity following a prolonged and difficult restraint incident in the early hours of November 1, 2023.
Inquest Findings on Medical Neglect
Assistant coroner Scott Matthewson concluded that Mr Tarrant was experiencing acute behavioural disturbance, a condition that healthcare personnel at the prison did not recognise. This failure to provide timely medical intervention was identified as a probable significant factor in his death.
Events Leading to the Tragedy
Mr Tarrant had been charged with robbery, actual bodily harm, and criminal damage after crashing a vehicle in Sittingbourne on October 28, 2023. He spent three days in police custody before being remanded to HMP Elmley on the Isle of Sheppey on October 31.
Despite undergoing a search, he managed to smuggle cocaine into the facility. Initially calm, his behaviour deteriorated during a phone call with his mother, where he reported hearing voices and mentioned suicide. His mother alerted prison authorities about her concerns.
Escalation and Restraint
Around 11:30 PM, after likely ingesting cocaine, staff visited his cell. Mr Tarrant was found bare-chested, speaking incoherently and repeating "help me" while looking out the window. He suddenly knocked a television to the floor and attempted to flee, leading to physical restraint.
During the restraint, he exhibited unusual strength, lifting several officers off the ground. A nurse was called but made minimal assessment, failing to declare a medical emergency that would have prompted an ambulance call. Instead, she decided to move him to the healthcare wing for observation.
Critical Delays and Errors
The transfer, which should have taken five minutes, extended to thirty minutes. In the new cell, Mr Tarrant remained violent, damaging the cell with such force that officers were shocked by his apparent insensitivity to pain. After being moved to another cell, he became unresponsive.
When an officer re-entered, Mr Tarrant was not breathing and had no pulse. A Code Blue was activated, summoning medically trained staff and an ambulance. However, healthcare staff made basic errors during CPR, including incorrect use of equipment and improperly inserting an airway device, which blocked his airway.
Coroner's Prevention of Future Death Report
Paramedics arrived at 1:44 AM and took over, but resuscitation efforts failed. Mr Tarrant was pronounced dead at 2:13 AM. Mr Matthewson has issued a Prevention of Future Death report, noting that from 11:30 PM until just before his death, Mr Tarrant displayed classic symptoms of acute behavioural disturbance.
These symptoms include apparent psychosis, repetitive shouting, random violence, and imperviousness to pain. The report states that anyone trained to recognise these signs would have identified the condition quickly. At the time, neither healthcare nor prison staff had received any training on acute behavioural disturbance.
Systemic Failures and Responses
The coroner expressed concerns that without training for prison healthcare staff on this condition and its treatment as a medical emergency, similar deaths are likely to occur. The report indicates that if treatment had been initiated before 1:00 AM, Mr Tarrant would probably have survived.
The prison service has until April 6 to respond to these concerns. A Prison Service spokesperson stated that healthcare in prisons is the responsibility of the NHS, but they will carefully consider the coroner's findings and respond accordingly. Oxleas NHS Foundation Trust, which serves HMP Elmley, has been approached for comment.
