On 13/07/2016 commenced an investigation into the death of Michalla Jane SWEETING. The investigation concluded at the end of the inquest The medical cause of death was: la) Aspiration of gastric content in association with methadone toxicity The conclusion of the jury inquest was a narrative which read as follows: "Michalla's death was contributed to by inadequate carrying out and response to prison officer ACCT checks, unsatisfactory handover quality between shifts, inappropriate process of assessment at the medicine dispense hatch inadequate communication between healthcare and prison staff. There was neglect due to combination of the following gross failures: Nurse to act on handover by HCA a5 noted on systm one 18 June 2016 at 14.50 by physically assessing Michalla and making plan and by still administering Methadone at 17.56 Nurse failed to check and update Michalla's records and contact a doctor and formulate a care plan after witnessing Michalla being sick at 22.14 1* June 2016 Nurse performed woefully inadequate clinical observations from 1st June 2016 at 22.14 onwards, including 2"d June 2016 at 03.21" Telephone 01275 461920 Email AvonCoronersTeam@bristol gOv.uk Website www.avon-coroner.com The Coroner's Court; Old Weston Road, Flax Bourton, BS48 1UL Avon and

detoxification programme and was on an ACCT: Deceased was a prisoner: She was undergoing a that she was over concerns raised by number of people including a healthcare assistant There were Michalla was not physically assessed and she was still given sedated this was reported to 2 nurses; her Methadone after this concern was raised. was handed over from the day to the night It appears unlikely that Michalla's over sedated appearance clinical staff: who Michalla unwell in her cell, he did not check Later that day she was seen by Nurse Mark Smith saw he did not his entry in the records which included a reference to her being over sedated that day; her out observations or make a plan and the one records until after Michalla's death; he did not carry woefully inadequate by the oecervation he did carry out at 03.Zlhrs on 2" June 2016 was described a5 expert found unresponsive in her cell at 07.OOhrs on 2"4 June 2016. Sadly Michalla was Her cause of death is described above

In my opinion action should be taken to prevent future deaths and believe you have the power to take such action:

"Michalla's death was contributed to by inadequate carrying out and response to prison officer ACCT checks, unsatisfactory handover quality between shifts, inappropriate process of assessment at the medicine dispense hatch inadequate communication between healthcare and prison staff. There was neglect due to combination of the following gross failures: Nurse to act on handover by HCA a5 noted on systm one 18 June 2016 at 14.50 by physically assessing Michalla and making plan and by still administering Methadone at 17.56 Nurse failed to check and update Michalla's records and contact a doctor and formulate a care plan after witnessing Michalla being sick at 22.14 1* June 2016 Nurse performed woefully inadequate clinical observations from 1st June 2016 at 22.14 onwards, including 2"d June 2016 at 03.21" Telephone 01275 461920 Email AvonCoronersTeam@bristol gOv.uk Website www.avon-coroner.com The Coroner's Court; Old Weston Road, Flax Bourton, BS48 1UL Avon and