A coroner has raised concerns after the death of John Joseph Singleton
A coroner has raised concerns after a prisoner who had a 'history of depression' was found dead in his cell.
The coroner said this was partly down to his 'anxiety' over collecting his medication in person as well as 'periods of self-isolation'. The report stated that Mr Singleton 'was a reclusive loner' who battled with depression as a result of 'significant family bereavements'. The report stated that although 'aspects of the systems relating to medicines non-compliance and mental health referrals at HMP Risley were lacking', it did not cause or contribute to his death. Ms Ainge said: "During the course of the investigation my inquiries revealed matters giving rise to concern.
"Whilst Healthcare at the prison were aware of some of the periods of non-compliance and in fact a GP referral and action was taken to enable John to have weekly in-possession medication to support his compliance, other periods were not flagged or identified and it became clear that monitoring those prisoners who are not medication compliant, particularly if receiving weekly or monthly medication was challenging due to the SystmOne electronic patient system not being able to flag a warning...
"Such a system is less than ideal as it is both resource heavy, carries real risks of not being accurate and in the Coroners view, for prisoners in possession of medication, there is likely to be a much longer period before non-compliance is identified which carries real risks of fatalities. The inquest touched upon the SystmOne electronic record used across the Prison estates by Healthcare.
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