Before HM Assistant Coroner for Nottinghamshire Tanyka Rawden
10 to 17 September 2019
The inquest into the death of Anthony Solomon has today concluded with the jury finding that his death was caused by the toxic effects of synthetic cannabinoids. The jury returned a narrative conclusion highlighting a failure to answer the cell bell sooner and the prevalence of drugs in Nottingham prison at the time of this death. They added that the staffing on the wing was too low, describing the government staffing benchmarks, which left only one officer on the wing to perform a number of essential duties, as “inadequate”. 
Anthony, a black man from Nottingham, was 38 years old when he died on 27 September 2017. He was described by his family as being one of the most loving, caring men you could ever meet and completely devoted to his children. He was the third of five men to die at HMP Nottingham in a month from 13 September 2017.
The jury heard that “mamba”, a synthetic cannabinoid drug, was rife in Nottingham prison in September 2017. Anthony was known by staff to have previously taken the drug, having been seen under the influence several times over the four months he had been in HMP Nottingham. The inquest heard that none of the steps required by the prison policy to respond to this drug use had been taken. That failure was put down to staffing levels and, in particular, the fact the prison was operating on minimum staff levels as a result of benchmarking, which had been introduced by the government in 2010 and rolled out to the adult male estate in October 2013.
When Anthony took the drug on the 27 September, he looked unwell straight away. His cell mate told the inquest that he had dropped to his knees and appeared to be vomiting and incontinent. The cell mate immediately rang the emergency cell bell, but despite a requirement that cell bells be answered within five minutes, a period which also reflects the time in which someone can be revived following a cardiac arrest, it took 40 minutes to attend. The jury concluded that the delay in answering the cell bell ‘denied Anthony the opportunity to receive the timely medical attention he deserved’.
The jury heard that over the lunchtime period, when Anthony became unwell, there was only one officer on the wing for up to 220 men. This officer had to respond to cell bells and complete checks including for suicide and self-harm monitoring (known as ACCT procedures). The officer concerned had been in the job for only a few weeks and did not know he was lunch cover that day. He told the inquest that he started completing the checks as best he could when he saw no-one else was, but prioritised the ACCT monitoring over responding to the cell bells.
The jury heard that drugs levels in the prison at the time were such that some officers were also hospitalised with the effects of fumes, which they were encountering on entering cells. HMP Nottingham reports they have now taken steps to combat the drugs, including new searching equipment, action against corrupt staff and wider training.
Leanne Blakey, partner of Anthony said: “I have lost a partner, and five children have lost their father. I am aghast at what we have heard about the level of drugs in Nottingham at the time, and the response times on cell bell emergencies. Staff knew what was going on with Anthony. They even knew he had been assaulted over drugs. I am pleased at what we have heard about improvements at the prison, though I am worried about what will happen if central government attention is taken away again. My real concern is that the wrong people were answering questions. Newly appointed and young staff were not primarily responsible for what happened here. The ministers who culled the staff and failed to respond to the warnings were responsible. Who is holding them to account?”
Jo Eggleton of Deighton Pierce Glynn solicitors said: “As with the other deaths in HMP Nottingham around this time Anthony’s death was preventable. The steps that have been taken since to reduce the availability of drugs could and should have been taken sooner. It is vital that those in the care of the prison can summon and receive help in an emergency. There’s little point instructing staff to respond to emergency cell bells within 5 minutes if they can’t in fact do so. Steps need to be taken in this and other prisons to ensure bells are responded to as soon as possible so that further lives are not lost.”
Natasha Thompson, Caseworker at INQUEST said: “Serious failures in Nottingham prison resulted in Anthony being left to deteriorate in his cell when he was in need of urgent medical attention. This is not the first inquest that has found serious failures in responding to cell bells. Ultimately, responsibility for Anthony’s death rests with complacency and indifference to enacting potentially lifesaving recommendations emerging from previous inquests.
At a time when the government is promising more money for more prison places, our ongoing casework shows that expanding the prison system is not solution to preventing further deaths and harms. We must look beyond the use of prison and act upon what are clear solutions - tackling sentencing policy, reducing the prison population and redirecting resources to community health and welfare services.”



For further information please contact Sarah Uncles on 020 7263 1111 or [email protected]

The family is represented by INQUEST Lawyers Group members Jo Eggleton of Deighton Pierce Glynn and Nick Armstrong of Matrix Chambers. Other interested persons represented at the inquest are Nottinghamshire NHS Foundation Trust (who deliver healthcare to prisoners) and the Ministry of Justice.

Since Anthony’s death on 27 September 2017, there has been at least another nine deaths at Nottingham. Of these, six were self-inflicted, one was a homicide and two were non self-inflicted.
Recent inquest conclusions from deaths at HMP Nottingham:

  • Andrew Brown, 42, died a self-inflicted death in September 2017. The inquest concluded that a series of failings contributed to his death and the jury noted serious issues with the systems of governance at the prison over a two month period in 2017. His cell bell was not answered for 43 minutes. Media release, June 2019.
  • Shane Stroughton, 29, died a self-inflicted death on 13 September 2017. The jury at the inquest returned a critical conclusion finding a series of failings contributed to his death. Media release, June 2019.

In January 2018, HMIP issued a ‘Urgent Notification’ on HMP Nottingham. Media release. In May 2018, Prison Inspectors report found ‘tragic and appalling’ levels of self-inflicted deaths and self-harm at Nottingham Prison. Media release.
Inquests which have highlighted failings in responses to cell bells:

  • Tony Doherty was found hanging in 2012 in a segregation cell in Wormwood Scrubs prison. His cell bell was not responded to for over 2 and a half hours. Media Release.
  • Carl Foot died a self-inflicted death at HMP Pentonville in 2014. He pressed his cell bell four times after threatening to take his life. The last time was at 2.51pm and was not answered for 27 minutes. The jury found that had he been found sooner there would have been a greater chance of survival. Media Release.
  • Natasha Chin died in 2016 after being found unresponsive at Bronzefield prison. The jury heard that her cell bell went unanswered due to a problem with the cell bell system. Over three hours after she rang her cell bell, a prison officer and a nurse who entered her cell to deliver her medication found her unresponsive and she could not be saved. Media Release.