Andrew Craig died at HMP Guys Marsh prison after prescription medicine overdose

Andrew Craig, 30, died at HMP Guys Marsh prison in September 2016, while serving a four-year jail sentence for robbery.

An investigation by the acting prisons and probation ombudsman has found that at on the day of his death, a prison officer unlocked Craig's cell at 7.45am and assumed he was asleep after seeing him lying on his bed. The same officer unlocked the cell again at 11.15am and saw that Craig's position had not changed, but was "not alarmed."

Prisoners raised the alarm shortly after and officers attended the cell but did not call a "code blue" – which would call an ambulance to the scene and alert a nurse to attend. Instead, officers called a prison manager, who instructed them to call it immediately.

A nurse attended but chose not to perform CPR, and Craig was pronounced dead by paramedics at 11.40am.

Rachael Griffin, senior coroner for Dorset, recorded a conclusion of death by misadventure following an inquest into Craig's death in June last year. He died of buprenorphine and diazepam toxicity, the inquest found.

Mrs Griffin filed a report after the inquest which raised concern over the "ongoing problem" with the use of prescription and illicit drugs at the prison, and said urgent action should be taken to prevent future deaths.

Elizabeth Moody, acting prisons and probation ombudsman who carried out an investigation into Mr Craig's death, said there was "a wealth of intelligence" suggesting Mr Craig was involved in drugs at the prison, but that "there is no evidence of any pro-active investigation". She said: "Healthcare staff did not share information with security staff. Prison staff most certainly did by filing numerous intelligence reports, but there is no evidence that the security department sought to look into the matter further.

"From what we have seen of the prison’s drug policies there seems to be a gap in this stage of the process," Ms Moody said.

She added that staff "made efforts" to manage Craig's mental health and substance misuse but "some referrals to the mental health team went astray." However, generally, "the care Mr Craig received in terms of his mental health and substance misuse was good", according to a clinical reviewer.

Several recommendations have been made following the investigation.

Ms Moody has urged the prison's head of healthcare to ensure a system is in place to guarantee mental health referrals are effectively scheduled and that all staff know how to process intelligence reports.

The prison has also been told to make sure staff are familiar with its drug policy and emergency code procedure, and that the policy regarding unlocking cells is "in line with national guidelines". A "hot debrief" meeting should be held after a death in custody, the ombudsman said, which did not happen after Craig's death.