Following his death at HMP Garth on 12th September 2019 an investigation was commenced in respect of Imre Paul Thomas born on 3rd October 1973. The investigation concluded at the end of the inquest on 29th March 2021. The conclusion of the inquest jury was that the deceased died by misadventure of asphyxia due to aspiration as a result of tramadol and multiple drug toxicity.

Sometime prior to 2014 the deceased had fractured bones in his hand. At some point the area had become infected and the deceased was suffering increased levels of pain. In August 2017 the deceased attended a GP appointment at HMP Garth. Pain killing medication in the form of dihydrocodeine was prescribed and an appointment with a consultant orthopaedic surgeon was arranged for November of that year. The appointment was cancelled. In between August 2017 and the deceased’s death in September 2019 a total of nine orthopaedic appointments were cancelled, three by the hospital, two by the deceased and four by the prison because the prison was unable to arrange an escort. The deceased complained of increasing levels of pain which he claimed was not met by the prescribed dihydrocodeine. The deceased took to acquiring painkilling medication from other prisoners and his death on 12th September 2019 was as a result of an overdose of tramadol and other prescription medication illicitly obtained.

HMP Garth and HMP Wymott stand adjacent to each other on a site in Leyland Lancashire. Together they have a population of over two thousand prisoners. Each week between them they send approximately 35 prisoners out for hospital appointments thereby employing a minimum of seventy officers as escorts at a significant cost to the NHS. As was seen in the present inquest, hospital visits are cancelled for a variety of reasons including lack of officer escorts and hospital cancellations. Such cancellations carry with them a risk of harm to prisoner patients and the cumulative effect of cancellations could potentially give rise to serious untreated illness or death. There are several clinic rooms at the healthcare departments of both prisons which could be used for specialist clinics by visiting hospital consultants thereby avoiding cancellations to the benefit of both prisoner patients and hospitals saved from cancelled or late appointments together with cost savings in respect of prison officer escorts.