An investigation has found that a man who died days after being released from prison was not offered a potentially life-saving medication. Andrew White was found unconscious at his friend's house three days after his release from Holme House Prison in Stockton.
His friend started CPR and called for an ambulance but, despite efforts, the 45-year-old was pronounced dead by paramedics 90 minutes later. The independent investigation, carried out by the Prisons and Probation Ombudsman, found that White, who had a history of drug misuse, was not offered naloxone prior to his release. The medication can rapidly reverse opioid overdose.
Post-mortem findings
A nine-page report outlines how a post mortem concluded that White died from cardiorespiratory failure, caused by the central nervous system depressant effects of morphine (heroin) and alcohol. White was sentenced to 18 weeks in prison for driving offences on January 14.
On arriving at HMP Holme House, he told the nurse he had a history of crack cocaine use, and a urine drug test was positive for benzodiazepines and cocaine. The report states how staff started withdrawal monitoring but White asked for it to be stopped the next day as he didn't feel he needed it. He declined to engage with the drug and alcohol recovery team and told them he would not use drugs while in prison.
Release and death
On his release, on March 5, he told his community offender manager he now wanted support with drug and alcohol use. His licence conditions included drugs testing and community substance misuse service engagement. White was homeless on release and said he intended to stay with family and friends while awaiting accommodation. He died three days later on March 8.
During the independent investigation, the prison's substance misuse service said the local policy was to offer naloxone only to prisoners who were engaging with the service. As White declined support, he had not been offered naloxone.
Investigation findings and recommendations
The report states: "We consider that Mr White would have been a suitable candidate for naloxone on release given his history of opiate use. We are concerned that the provision of naloxone to prison leavers with a history of drug use is inconsistent across the prison estate and should be routinely offered to all prisoners with a history of opiate use."
A recommendation was made to the head of healthcare, which is provided by Spectrum CIC. An action plan from the provider, attached to the report, states: "Spectrum will ensure that appropriate systems and processes are in place to identify and offer naloxone to prison leavers with a history of opiate use and other relevant risk factors. Recognising that practice currently varies across establishments, this review will provide an opportunity to align local processes with best practice and ensure that all eligible prisoner leavers are appropriately considered."
Teesside Live contacted Spectrum CIC for comment and had not received a response at the time of publication.
