20 January 2023

Before HM Coroner Andrew Harris
London Inner South Coroner’s Court
9 – 19 January 2023

Nathan Forrester was 36 years old when he died at HMP Thameside in South London on 2 July 2019. He died just one day after arriving in the prison on recall, with the cause relating to drug toxicity.

The coroner has issued two Prevention of Future Death Report to NHS England and the Ministry of Justice. The coroner raised his concerns about the level of training in resuscitation received by nurses across the prison estate, as well as the lack of training provided to prisoner staff in moving prisoners off the top bunk in emergency situations to start basic life support.

Nathan was described by his family as an outgoing, sociable and friendly person who was the life and soul of the party. Religion was an important aspect of his life, growing up Catholic and later converting to Islam in his 20s.

Nathan was from East London and learnt Bengali at school, engaging with the large Bengali community in his area. He studied travel and tourism at college, but at that time was introduced to drugs. He was drug dependent for much of his adult life, causing serious concern for his family who remained close and supportive.

Nathan spent time living in a hostel and served short sentences in prison between 2017 and 2019, including at HMP Thameside. The offences related to funding his drug habits. He had engaged with treatment and rehab over the years, including whilst on probation, but sadly this had not yet had a sustained effect.

On 1 July 2019, Nathan was recalled to HMP Thameside. On arrival, staff noted that he seemed drowsy and withdrawing from drugs. A prison GP assessed Nathan but decided not to prescribe methadone that evening as his pulse rate was too low.

The next day, Nathan had several health assessments. He received a dose of methadone just before 11.45am and was locked in his cell. A few hours later, Nathan’s cell mate found him in his bed not breathing and with a blue arm. He called for help.

When the first three officers arrived, they failed to move Nathan from the top bunk or begin resuscitation despite finding him unresponsive. At 3.10pm, a code blue was called and an ambulance requested.

Healthcare staff began resuscitation attempts until paramedics arrived at 3.24pm. The inquest heard how the resuscitation attempts were of extremely poor quality and attending paramedics had severe clinical concerns.

Nathan did not regain consciousness and died shortly after.

A clinical review found that there was a lack of leadership and that staff involved did not have the confidence, or level of expertise to deliver effective life support.

The inquest concluded that Nathan’s death was caused by acute toxic effects of heroin, cocaine and methadone.

Tara Mulcair of Birnberg Pierce solicitors, said: “Nathan’s family are relieved that the inquest process has come to an end, almost 4 years since Nathan’s death. The family are reassured by coroner’s decision to issue two national Prevention of Future Death reports. NHS England and the Ministry of Justice must now take urgent action to ensure that lessons are learned from Nathan’s death.”

A spokesperson from INQUEST, said: “This inquest has identified crucial lessons for prisons and their staff. Whilst we welcome the Coroner’s decision to issue two Prevention of Future Death reports, INQUEST repeatedly sees the fatal consequences of inadequate healthcare provision across the prison estate with little change.

 

If future deaths are truly to be prevented, resources must be redirected away from the criminal justice system and into welfare, health, housing, education and social care to ensure people like Nathan receive the support they need.”

. Whilst we welcome the Coroner’s decision to issue two Prevention of Future Death reports, INQUEST repeatedly sees the fatal consequences of inadequate healthcare provision across the prison estate with little change.

If future deaths are truly to be prevented, resources must be redirected away from the criminal justice system and into welfare, health, housing, education and social care to ensure people like Nathan receive the support they need.”

ENDS

NOTES TO EDITORS
For further information please contact Leila Hagmann on [email protected].

The family are represented by INQUEST Lawyers Group members Tara Mulcair and Rebecca Pelekanou of Birnberg Pierce solicitors and Tom Stoate of Doughty Street Chambers. The family are supported by INQUEST senior caseworker Luana D’Arco.

Other Interested persons represented are Serco, Oxleas NHS Foundation Trust and the Metropolitan Police Service.