21 May 2018

Before HM Coroner Jonathan Leach
Wakefield Coroner’s Court, Wakefield, West Yorkshire, WF1 3BS

1 May 2018 - 17 May 2018
Nicola Jayne Lawrence, from Creswell in Derbyshire, was 38 when she died from a combination of methadone toxicity and multi drug administration at HMP New Hall. The narrative conclusion returned by the jury at the inquest identified various missed opportunities that may have resulted in Nicola’s life being saved. She was one of 22 women to die in women’s prisons in 2016, the highest annual number of deaths on record.
Nicola, one of three siblings, was described by her mother as a very loving and caring daughter. Nicola was diagnosed with Multiple Sclerosis (MS) in her early twenties. She developed PTSD after the death of her partner. She suffered from anxiety and struggled with mental ill health. She also struggled with addiction to drugs. Despite her family desperately trying to access therapeutic support and help with drug rehabilitation, the right kind of support was never available to her.

In September 2016, Nicola was recalled to prison to serve a 28-day sentence. During an initial health screening on 9 September 2016, Nicola told the staff about her MS, an injury to wrist and dependence on drugs. The prison doctor prescribed medications to manage her various health needs. In addition to her usual medications, Nicola was prescribed methadone. This was the first time Nicola had received a prescription for methadone.

The inquest heard how there was no consideration given to the impact of methadone on the medication she was already prescribed for her MS. There was also a failure of communication with her MS specialist.

At 21.30 on the 23 September 2016, officers saw Nicola lying face down on the floor of her cell and snoring loudly. They say she raised her arm in response to requests for her to get on to her bed but otherwise remained on the floor. The staff decided to check on her at regular intervals, noting each time that she remained on the floor snoring.  At 23.30, they noticed that Nicola was no longer snoring and was unresponsive. They entered her cell and called for emergency assistance.

In their conclusion, the jury found:

  • The level of communication between health professionals and prison staff was lacking.
  • Prison officers lacked the training and information to recognise and deal appropriately with a prisoner on a Methadone programme exhibiting signs and symptoms of drug toxicity.
  • Had the prison staff acted on their concerns and contacted the health team between 9.30pm and 11.00pm, it is likely that Naloxone would have been administered - a drug which could have reversed the effect of methadone toxicity which could have saved Nicola’s life.

Christine Lawrence, Mother of Nicola said: “The fact that the jury have confirmed she might still be with us if the level and nature of observations had been different is painful to hear. I am still worried for other vulnerable prisoners, who like Nicola, might not be getting the correct treatment or support. I hope that lessons have been learnt and the prison and healthcare providers put changes in place which mean that Nicola’s life has not been lost in vain. I do not want another family to have to go through what we have been through.
I would like to take this opportunity to thank the jury members that sat patiently for nearly three weeks listening to the evidence and for their full and thought out conclusion.”
Deborah Coles, Executive Director of INQUEST said: “Nicola’s death could have and should have been prevented by those who owed her a duty of care. The prison service must address the serious failings in this case as a matter of urgency. Nicola should not have been sent to prison in the first place, but once she was there it is unforgivable that she had to lose her life in this way.”



For further information please contact Sarah Uncles on 020 7263 1111 or [email protected]
INQUEST has been working with Nicola’s family since October 2016. The family is represented by INQUEST Lawyers Group member Kulvinder Gill of Howells Solicitors and Maria Roche of Doughty Street Chambers.

The Ministry of Justice and Care UK were also separately represented at this inquest.

  • There have been 11 deaths in HMP New Hall in the past 10 years, 5 of which have been non self-inflicted.
  • The age range of these non self-inflicted deaths is between 24-54 years old. 
  • Poignantly, this week marked the 10-year anniversary of the death of Pauline Campbell, a formidable campaigner who fought to prevent the imprisonment of vulnerable women and to hold the state to account for preventable deaths. Her work was pivotal in the setting up of the Corston review after her daughter was one of the six women to die in Styal prison. She was a great advocate for INQUEST and she was dedicated to supporting other families.
  • INQUEST's recent report, Still Dying on the Inside, calls for urgent action to save the lives of women in prison. It highlights the lack of action from successive governments to prevent deaths and puts forward a series of recommendations to close women’s prisons by redirecting resources from criminal justice to community-based services.