21 April 2021

Before HM Coroner Darren Stewart OBE
HM Coroner’s Court, Woking, Surrey

Opening date 15 March 2021
Closing date 15 April 2021

Following the critical inquest findings into the death of Tariq Martin Dalton at HMP High Down, a coroner has heard evidence from the Interested Parties of the Ministry of Justice and the Central and North West London NHS Foundation Trust to determine whether a report on preventing future deaths is necessary.

On 19 November 2018, Tariq, 42, collapsed on the floor of his cell at HMP High Down, after reporting vomiting blood and internal bleeding. Shortly afterwards he was pronounced dead.  An inquest into Tariq’s death opened on 15 March, before HM Coroner for Surrey, Darren Stewart OBE and a jury. After four weeks of evidence, the inquest concluded the causes of death were an Upper gastrointestinal haemorrhage and bleeding duodenal ulcer, contributed to by a series of failures in healthcare at the prison.

Tariq lived in Sunbury-on-Thames in Surrey. He had a mixed ethnic background, with parents of Pakistani and Irish heritage. His sister told the inquest that Tariq and his siblings had a challenging childhood, having experienced abuse and spent time in and out of care.

She said Tariq was a homely person, who took pride in his looks and clothes.  He had a number of physical health needs which required care and treatment, and in the months leading up to his death his family were increasingly concerned about his behaviour and possible mental ill health. 

Just over a month before his death, on 17 October 2018 Tariq was remanded to HMP Highdown. At first he had been housed in an ordinary house block and then, on 14 November 2018, due to concerns for his mental health, prison staff had moved to the Healthcare Unit. He remained there until his death.

Tariq had presented with complex mental and physical health issues during his time at HMP Highdown. He had repeatedly raised concerns about his health with staff, and unusual behaviours had also been observed by other prisoners and prison staff. Many instances were recorded in his prison records.

Prison staff identified a need for Tariq to be seen by a GP. Despite this, there were four occasions, three of which were during Tariq’s time on the Healthcare Unit, where GPs did not assess Tariq in person. On two of those occasions, Tariq had been elsewhere in the prison, and on the other two occasions the GP had failed to attend Tariq’s cell.

Two days after arriving at the prison, Tariq attended a pain clinic at HMP Highdown. He was assessed by a GP who prescribed various medications including Meloxicam (an anti-inflammatory drug) for pain relief. The GP was unaware that, in late 2014, Tariq had experienced two incidents of haematemesis (vomiting blood). This had been recorded in Tariq’s community GP records, but prison medical staff had not obtained these. The GP who saw Tariq was therefore ignorant of this history.

Every prescribing clinician who gave evidence to the inquest stated they would not have prescribed Meloxicam to a patient with a known history of haematemesis. The jury found that Tariq was at high risk of experiencing gastro-intestinal irritation, which is a known possible side effect of Meloxicam which can lead to ulcers and internal bleeding. The inquest heard there were co-prescriptions and alternative options which could alleviate these side effects which were not used. Meloxicam was re-prescribed to Tariq several times during his time at HMP Highdown.

In such circumstances, co-prescription of a proton-pump inhibitor (‘PPI’) can alleviate irritation. A PPI is known to reduce the production of stomach acid, help prevent the formation of ulcers and also to assist with healing of such ulcers. However, this was not given to Tariq.

The inquest heard that Tariq made complaints of vomiting blood, blood in his faeces, and internal bleeding for around 36 hours before his death. He was reported by some witnesses to have looked very pale and unwell, with dark coloured matter on the floor of his cell, and fresh blood seen in the toilet on the morning of his death. Despite these incredibly alarming signs, he was not physically seen by a doctor, and did not receive medical attention.

The prison kept various internal record systems at that time. It also operated several methods of communications between teams and between individual staff members. Information on Tariq’s condition had not been effectively communicated between members of staff responsible for his care.

The inquest jury concluded that Tariq’s death was from an upper gastrointestinal haemorrhage and bleeding duodenal ulcer. They further found that:

  • On the balance of probabilities, the continued prescription of Meloxicam throughout Tariq’s time at HMP Highdown made a material contribution to his death.
  • It is possible that the failure to prescribe PPI may have contributed to his death.
  • The benefits of prescribing a PPI alongside a prescription of Meloxicam were well documented and well recognised.

The jury also concluded that the lack of effective communication between healthcare and prison staff had possibly been a contributing factor to his death. They found that Tariq’s behaviours and apparent mental health issues may have affected the care he received, which in turn, this may have contributed to his death.

In addition, the jury concluded that there had been missed opportunities for the GPs to assess Tariq’s condition. Consequently, and on the balance of probabilities, they found that the failure to have Tariq assessed in person by a GP during his time on the Healthcare Unit had made a material contribution to his death.

Sonya Dalton, Tariq’s sister, responded to the conclusions: “When I found out my brother had passed, I knew I required advice and support as I felt unsure of where to go. With the help of INQUEST and my legal team, I was guided through this whole ordeal.

 It has been a long drawn out two years and five months for Tariq's inquest to finally receive a conclusion that he so rightly deserves. Hearing the jury’s conclusions was overwhelming and emotional. 

My brother had a history of depression and other underlying physical and mental health issues. During the five weeks of the inquest we had listened to evidence about my brother which was painful and hard to hear.

During the short four weeks Tariq was on remand in HMP Highdown, he spent the first three weeks and two days on the normal house block. He was then moved to the Health Care Unit where you would assume him to be safe. In a matter of five days he was dead.

What hurts the most after hearing five weeks of evidence at the inquest was the lack of compassion and empathy you would expect a health professional employed within the prison to give a patient and fellow human being.

Just because a loved one is in an institution doesn't mean they are forgotten about. The standard of care they receive should, in fact, be higher as they depend more on the authorities to take care of their needs.”

Graeme Rothwell, on behalf of Duncan Lewis Solicitors, said: “It is disturbing to reflect on the established facts of this case; that a number of healthcare professionals had disregarded or overlooked the need to secure healthcare records and consider a patient’s medical history prior to prescribing such medication. The unusual behaviours exhibited by Tariq in his final days, ought to have been professionally investigated with cool heads. We hope that the jury’s critical findings will provide catharsis for Sonya and her family.”


For further information, interview requests and to note your interest, please contact Lucy McKay on 020 7263 1111 or [email protected]

The family is represented by INQUEST Lawyers Group members Graeme Rothwell and Jessica Smith of Duncan Lewis Solicitors and Angelina Nicolaou of One Pump Court Chambers.

Other Interested Persons represented are the Ministry of Justice, The Forward Trust, The Prison and Probation Ombudsman, Central and North Western London NHS Trust, the Nursing and Midwifery Council, Drs Ruse and Ransom, The Sunbury Group Practice, Nurses Sahadew and Panlaqui.