Amy Cross

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Independent investigation into
the death of Ms Amy Cross,
a prisoner at HMP Eastwood
Park, on 10 June 2023
A report by the Prisons and Probation Ombudsman
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
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The Prisons and Probation Ombudsman aims to make a significant contribution to safer,
fairer custody and community supervision. One of the most important ways in which we
work towards that aim is by carrying out independent investigations into deaths, due to any
cause, of prisoners, young people in detention, residents of approved premises and
detainees in immigration centres.
If my office is to best assist His Majesty’s Prison and Probation Service (HMPPS) in
ensuring the standard of care received by those within service remit is appropriate, our
recommendations should be focused, evidenced and viable. This is especially the case if
there is evidence of systemic failure.
Ms Amy Cross died on 10 June 2023 at HMP Eastwood Park after she was found
unconscious in her cell. The post-mortem concluded that the cause of her death was the
consequences of chronic alcohol misuse with sudden cessation of alcohol consumption.
She was 31 years old. I offer my condolences to Ms Cross’ family and friends.
Ms Cross had only been at Eastwood Park for around three hours before she died. Upon
her arrest, Ms Cross was drowsy and intoxicated. Her care after this point was
complicated because she came into contact with three different healthcare providers
during her time in custody, who do not use the same systems to record clinical information.
Relevant medical information was not shared appropriately between the police, Serco, and
the healthcare team at HMP Eastwood Park. Had the digital Person Escort Record been
completed and shared as intended this would have resulted in a better continuity of
monitoring Ms Cross’ alcohol and drugs withdrawal symptoms.
However, Eastwood Park provided effective care for Ms Cross and did their best to meet
her needs and manage her withdrawal symptoms appropriately during her exceptionally
short time in their care.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Adrian Usher
Prisons and Probation Ombudsman July 2024
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 6
Findings ......................................................................................................................... 12
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Summary
Events
1. Ms Amy Cross was arrested on 9 June 2023 for possession of a controlled drug. In
police custody on the morning of 10 June, a healthcare practitioner assessed that
Ms Cross was withdrawing from drugs and alcohol and gave her detoxification
medication (to lessen her withdrawal symptoms).
2. Later that morning, Serco escort officers took Ms Cross to court for her hearing. The
digital Person Escort Record (PER) that travelled with her to court did not record
that she had been prescribed detoxification medication.
3. At court, Ms Cross was remanded to HMP Eastwood Park. Prior to her departure, at
the request of Serco, a healthcare practitioner employed by Aeromed assessed Ms
Cross, as she presented with withdrawal symptoms. The healthcare practitioner
identified that Ms Cross might be dehydrated (because she had been vomiting) but
considered that she displayed no signs that she was withdrawing. She gave Ms
Cross anti-sickness medication. The PER was not updated with this information.
4. Ms Cross arrived at Eastwood Park at 3.30pm. During her reception screening, the
GP diagnosed Ms Cross with opioid and alcohol dependency and prescribed her
methadone and alcohol detoxification medication. (Ms Cross was due to receive her
medication during the evening medication round, which started from around
5.30pm.)
5. At 6.49pm, when an officer went to unlock Ms Cross from her cell to collect her
detoxification medication, she found her unresponsive. She immediately alerted a
nurse and called the emergency alarm. Staff did cardio-pulmonary resuscitation
(CPR) until the paramedics arrived. The paramedics declared that Ms Cross had
died at 7.37pm.
6. The post-mortem concluded that the cause of Ms Cross’ death was the
consequences of chronic alcohol misuse with sudden cessation of alcohol
consumption.
Findings
7. When Ms Cross was seen by the Serco healthcare practitioner at court, they did not
adequately update the PER with the medical treatment that she received. This
meant that the medical information passed on to Eastwood Park was not as
accurate as it should have been.
8. Although Ms Cross had some risk factors for substance misuse when she arrived at
Eastwood Park, we consider that her needs were appropriately assessed, and she
was supported during her short time at the prison.
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Recommendation
• The Serco Contract Director for Prisoner Escort and Custody Services (PECS) must
ensure that information is recorded in a detainee’s PER after every significant
interaction, including any medical treatment given.
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The Investigation Process
9. The PPO was notified of Ms Amy Cross’ death on 12 June 2023. The investigator
issued notices to staff and prisoners at HMP Eastwood Park informing them of the
investigation and asking anyone with relevant information to contact him. No one
responded.
10. The investigator obtained copies of relevant extracts from Ms Cross’ prison and
medical records, CCTV and body worn video camera (BWVC) footage. He also
obtained the HMPPS Early Learning Review, Serco’s internal investigation report,
police custody records and Southwestern Ambulance Service records.
11. The investigator interviewed seven members of staff at Eastwood Park in August
2023. He also interviewed two members of staff by telephone and video conference
in September and October 2023.
12. NHS England commissioned a clinical reviewer to review Ms Cross’ clinical care at
the prison. The clinical reviewer and investigator jointly interviewed staff.
13. We informed HM Coroner for Avon of the investigation. The Coroner gave us the
results of the post-mortem examination. We have sent the Coroner a copy of this
report.
14. We contacted Ms Cross’ mother to explain the investigation and to ask if she had
any matters that she wanted us to consider. Ms Cross’ mother asked about the
circumstances that led to her daughter’s death.
15. Ms Cross’ mother received a copy of the initial report. She pointed out two factual
inaccuracies. This report has been amended accordingly.
16. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS pointed out five factual inaccuracies, and this report has been amended
accordingly.
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Background Information
HMP Eastwood Park
17. HMP Eastwood Park is in Gloucestershire and holds adult women. It has ten
residential wings, two of which provide specialist substance misuse services.
Healthcare services at Eastwood Park are provided by Practice Plus Group (PPG)
who partnered with Avon and Wiltshire Mental Health Partnership NHS Trust, who
provide psychosocial and mental health services.
HM Inspectorate of Prisons
18. The most recent inspection of HMP Eastwood Park was in October 2022.
Inspectors noted that 83% of women reported that they suffered from mental health
difficulties, and that many were caught in a cycle of homelessness, drug or alcohol
misuse and offending. This made for a challenging environment which required
highly skilled professionals to provide support for those in their care. The effect of
staff shortages however, meant that the already curtailed regime was often further
restricted and some of the consistency of provision and support that was essential
in providing for this population, was not in place. Inspectors noted that women’s
prisons thrive when staff had time to build strong, professional relationships with the
prisoners. The staff shortages meant that this was sometimes just not possible.
19. Inspectors found that health services were generally well led. Women arriving at the
prison with a substance misuse concern were seen promptly by the psychosocial
substance misuse team for a full assessment, and their care was reviewed by a
doctor within 24 hours so opiate substitution therapy (OST) could be administered
where appropriate.
Independent Monitoring Board
20. Each prison has an Independent Monitoring Board (IMB) of unpaid volunteers from
the local community who help to ensure that prisoners are treated fairly and
decently. In its latest annual report, for the year to October 2023, the IMB reported
that the reception area staff were extremely helpful, calm and professional to those
coming in and time was taken to carefully explain all stages of the reception process
and to make sure it had all been understood. The complexity of prisoners’
respective needs was prioritised. The majority of women entering the prison were
tested for drugs. Mandatory drug testing (MDT) targets were met. However, a
variety of illicit drugs appeared to be available on some wings.
Prisoner Escort and Custody Services
21. The Prisoner Escort and Custody Services (PECS) is part of HMPPS and contract
Serco to provide court custody and escort services. This includes transportation
between police custody, courts and prisons. Serco contract Aeromed Medical
professionals to provide healthcare services within courts.
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Previous deaths at HMP Eastwood Park
22. Ms Cross was the fifth prisoner to die at Eastwood Park since July 2020. Of the
previous deaths, two were self-inflicted and two were due to natural causes. There
are no similarities between these deaths and that of Ms Cross.
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Key Events
9 June 2023
Police custody
23. At around 2.00pm on 9 June 2023, police arrested Ms Amy Cross on suspicion of
possession of a controlled drug (they found a small amount in her possession at
arrest). They took her into police custody at Torquay Police Station. At the time, she
also had two outstanding warrants for her arrest. Ms Cross was described as
intoxicated and drowsy. Police fully searched Ms Cross but found nothing further.
24. A nurse assessed Ms Cross and noted she had a history of alcohol and drug
misuse, was dependant on and currently prescribed methadone. The nurse noted
that Ms Cross had drunk alcohol in the last 24 hours. They requested that police
staff collect Ms Cross’ methadone from her nominated pharmacy, and noted that
she required food, fluids and rest. Ms Cross was placed on 30-minute checks. The
nurse did not prescribe any medication for alcohol withdrawal.
25. Police records noted that at around 3.43pm, two police officers visited Ms Cross’
nominated pharmacy to collect her methadone. However, they were informed that
Ms Cross had been banned from the shop some time ago, for shoplifting, and they
therefore would not provide any medication for her.
26. At 4.46pm, the police told Ms Cross that she would not face any charges for
possession of a controlled drug (due to the small amount found on her person when
arrested). However, because she had two outstanding warrants (for possession of
an offensive weapon and drug offences), she would still have to attend court.
27. The healthcare provider at Torquay Police Station does not provide a 24-hour
service. As Ms Cross required checks because of her medical risk due to alcohol
and heroin dependency, she was transferred to Exeter Police Station at 4.47pm,
where this service is provided.
10 June 2023
28. On 10 June around 7.00am, Ms Cross said that she had vomited and felt unwell. A
paramedic, using a Glasgow Modified Alcohol Withdrawal Scale (GMAWS)
assessment tool, noted that Ms Cross had moderate alcohol withdrawal symptoms.
A Clinical Opiate Withdrawal Scale (COWS) assessment was also completed and
indicated that Ms Cross had moderate opioid withdrawal symptoms. The paramedic
noted that Ms Cross was withdrawing from drugs and alcohol and prescribed
dihydrocodeine (for opiate withdrawal symptoms) and diazepam (for alcohol
withdrawal symptoms). A care plan created instructed that Ms Cross should be
monitored for ongoing withdrawal symptoms.
Exeter Magistrates Court
29. To aid communication of prisoners’ risks between criminal justice agencies, a digital
Person Escort Record (PER) is completed for every prisoner who is securely
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transported between police stations, courts, and prisons. The police will generate
the PER for prisoners in their custody. Relevant staff access the PER on handheld
devices (like a large mobile telephone). Serco escort staff access the PER on a
device known as a VERA (Vehicle Escorting Recording Application), and court staff
access the document on a device known as a CORA (Court Observations
Recording Application).
30. At around 9.13am, the police handed over Ms Cross to Serco’s care. Serco
transported Ms Cross from Exeter Police Station to Exeter Combined Court, arriving
at 9.26am. The PER that travelled with her to court (completed in police custody)
noted that Ms Cross had a history of concealing drugs and was dependant on drugs
(heroin) and was prescribed methadone. Staff added that Ms Cross was ‘not taking
methadone as not allowed script’. It also noted that a healthcare professional had
seen Ms Cross while in police custody on 9 June. The PER did not mention that Ms
Cross was dependant on alcohol and no details were recorded of the medications
that Ms Cross had been given in police custody.
31. Serco provided the investigator with their investigation report following Ms Cross’
death. The report noted that during the journey from the police station to court,
CCTV (from the escort vehicle) showed that Ms Cross vomited. Ms Cross told
Serco custody officers that she had stomach pains due to alcohol withdrawal. This
information was handed over to the Court Custody Manager (CCM) upon arrival.
32. Although the time is unknown, the CCM contacted Aeromed, the medical advisory
service contracted by Serco, and asked them to assess Ms Cross as she appeared
unwell, was withdrawing, looked thin and drained of energy. The CCM did not
update the PER with this information.
33. At 11.57am, Ms Cross appeared in court and was remanded to HMP Eastwood
Park to return to court later that month. Serco escort officers took Ms Cross back to
a court holding cell to await transportation to Eastwood Park.
34. At approximately 1.30pm, according to the Serco records (Part B Prisoner Activity
Log’ document held on the VERA electronic system), the Aeromed healthcare
practitioner arrived at court. The nurse assessed Ms Cross in the holding cell with
two Serco officer’s standing in the doorway. At interview, the nurse told us that she
had been informed that Ms Cross was withdrawing (from an unspecified substance)
but was not given any further information, including that Ms Cross had been seen
by a healthcare professional in police custody that morning, and given medication to
assist with opiate and alcohol withdrawal symptoms.
35. Ms Cross told the nurse that she had been sick twice and had smoked heroin the
previous day. The nurse completed Ms Cross’ clinical observations which were all
within the normal range. She told us that she thought that Ms Cross may have been
slightly dehydrated because she had vomited but she displayed no visible signs that
she was withdrawing from any substances. She completed a COWS assessment
that indicated that Ms Cross presented with medium to low withdrawal symptoms.
She did not conduct an alcohol withdrawal scale assessment. She told us that she
asked Ms Cross about her alcohol use, and she denied any issues. She prescribed
Ms Cross cyclizine (an anti-sickness medication) and omeprazole (used to treat
indigestion, heartburn, and acid reflux) for her stomach upset. She told us that she
did not have any immediate acute clinical concerns about Ms Cross.
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36. While information about the nurse’s clinical assessment and the medications she
had prescribed were recorded on the Serco Part B Prisoner Activity Log, the PER
was not updated with this information.
37. After Ms Cross was seen by the nurse, Serco escort staff agreed to wait (for around
30 – 40 minutes) for her medication to start working, before taking her to Eastwood
Park.
HMP Eastwood Park
38. At 2.00pm, Serco escort officers transported Ms Cross to Eastwood Park, arriving at
3.30pm. Serco’s prison custody officer (PCO) told us that he told the prison
reception staff that Ms Cross had been sick, was withdrawing and had been seen
by a medical professional at court and given medicine to help with her sickness. He
said Ms Cross had slept most of the journey to Eastwood Park. Ms Cross had been
given a drink of water but declined any food.
39. The PER that travelled with Ms Cross recorded that she had alcohol and drug
dependency and was a heroin and methadone user. It said that Ms Cross was seen
by a healthcare professional in Exeter Police Custody on 9 June. No further details
about this were recorded.
40. An officer recorded on the prison case management system that she interviewed
Ms Cross in reception. She noted that Ms Cross was showing signs of withdrawal
and described the interview process as difficult, although Ms Cross tried her best to
answer all questions. Ms Cross said that she felt like “shit” because she was
withdrawing. She denied any history of attempted suicide or self-harm and said she
had no thoughts to harm herself. Ms Cross was offered a cup of tea, food and
issued some vapes. She was offered a phone call but refused.
41. A paramedic completed Ms Cross’ initial healthcare reception screen. Using the
recognised withdrawal assessment tools, she noted that Ms Cross had mild alcohol
withdrawal symptoms, had a dependence on alcohol and had mild withdrawal
symptoms from opiates. Ms Cross told the paramedic that she had last used heroin
the day before she came into custody. Ms Cross tested positive for opiates, cocaine
and benzodiazepines. Ms Cross told the paramedic that she felt unwell due to
having withdrawal symptoms, and that she had been sick prior to her arrival to
Eastwood Park. She said that she took methadone in the community. When the
paramedic contacted the community pharmacy to check this, they told her that Ms
Cross’ methadone prescription had not been administered to her since April 2023,
because she had been banned from the pharmacy. During the review, Ms Cross did
not disclose any significant medical history and denied that she had any thoughts of
suicide or self-harm. The paramedic referred Ms Cross to the GP to review what
medication she required due to her opiate and alcohol withdrawal symptoms.
42. At 4.33pm, CCTV shows Ms Cross was located on Kinnon Unit, which is a
dedicated induction and detoxification unit (sometimes referred to as Residential
Unit 8). Staff gave her a sick bowl because she continued to state that she felt sick.
In his police statement, an officer said that he had known Ms Cross from previous
stays in custody at Eastwood Park. He said she looked unwell when he saw her and
was carrying a sick bowl in her hand.
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43. On Kinnon Unit, healthcare observations are completed twice a day (typically in the
morning and evening) or more frequently, for five days, dependent on the severity of
a patient’s symptoms or clinical presentation. Ms Cross was not due to have any
further withdrawal observations until the next day.
44. At 4.34pm, a Healthcare Assistant (HCA) collected Ms Cross from her cell and
escorted her to her video appointment with the GP. Ms Cross walked unaided to the
clinic room holding the sick bowl.
45. During the consultation, Ms Cross told a prison GP that she had been arrested the
previous day and had had no medication in custody. Ms Cross provided no medical
history. The GP identified that Ms Cross looked unwell and was retching. She
completed a withdrawal assessment that indicated that Ms Cross presented with
moderate withdrawal symptoms. The GP diagnosed Mis Cross with opioid and
alcohol dependency and prescribed her an increasing titration dose of methadone,
and a seven-day alcohol detoxification regime. (Ms Cross would receive her
medication during the evening medication round, which commenced from around
5.30pm.)
46. At 4.42pm, an officer escorted Ms Cross back to her cell. In his police statement,
the officer said that Ms Cross’ medication was not ready yet and she would be able
to collect it later from the hatch. At 4.59pm, CCTV shows movement in Ms Cross’
cell through her observation panel.
47. A Custodial Manager (CM) arrived for duty on Kinnon Unit at 5.00pm. She told us
that she received a handover from the officer who told her that Ms Cross had
recently arrived, was located in cell K2-35 and that her medication was not yet
ready. She told us that it was not unusual for the medication for a new prisoner to
not be ready immediately to be collected and staff would sometimes wait until the
end of the medication round to collect that individual to attend the medication hatch.
48. As part of her cleaning job, Prisoner A handed out hot water (for tea) to prisoners on
the unit. At 5.25pm, she knocked on Ms Cross’ cell door and looked through the
observation panel and asked her if she wanted any hot water. In her police
statement, she said that Ms Cross was lying on her bed, facing the opposite wall,
where the TV was located, but did not respond.
49. At 5.30pm, the medication rounds began. Staff knocked on each prisoner’s cell door
to ask them if they were due to collect medication. Prisoners who needed
medication were then unlocked so that they could collect it from the medication
hatch.
50. At 6.09pm, Prisoner A again went to Ms Cross’ cell and asked her if she wanted any
hot water through the observation panel. Ms Cross did not respond. The prisoner
noted that Ms Cross had changed position on her bed and was no longer facing the
opposite wall, but the wall to the side of her bed.
51. Around 6.42pm, a nurse told an officer that Ms Cross had not received her
medication yet and she should be brought to the medication hatch to collect it.
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Emergency response
52. At 6.49pm, the officer went to Ms Cross’ cell. When she looked through the
observation hatch, she noticed that Ms Cross was on her bed with her arms
propped over her head. Although she thought Ms Cross was breathing lightly, she
did not look well and was unresponsive when called. The officer was concerned
about Ms Cross’ welfare and ran across the corridor to the healthcare team’s office
(approximately seven metres away) to request assistance. (Healthcare staff are
permanently situated on Kinnon Unit).
53. An HCA attended in seconds, unlocked and entered Ms Cross’ cell. When he
checked Ms Cross, she was unresponsive, not breathing and grey/purple in colour.
She had also vomited on the floor. The HCA immediately left the cell to obtain
further healthcare support and medical equipment. He told us that he told the officer
to call a code blue emergency (indicating that a prisoner was having difficulty or had
stopped breathing). The officer radioed a code blue. Control room staff recorded
that this happened at 6.50pm and telephoned for an ambulance immediately.
54. The HCA and a nurse returned to Ms Cross’ cell in less than 20 seconds with an
emergency medical bag and started cardiopulmonary resuscitation (CPR) with the
use of a medical airway and defibrillator. Two officers also responded to the
emergency alarm and assisted healthcare staff by rotating CPR. At 7.06pm,
ambulance paramedics arrived, and staff moved Ms Cross into the corridor to gain
better access to treat her. The paramedics took over the care of Ms Cross. At
7.37pm, paramedics confirmed that Ms Cross had died.
Contact with Ms Cross’ family
55. When Ms Cross arrived at Eastwood Park, she did not provide any details of her
next of kin. After extensive searching, Eastwood Park found Ms Cross’ mother’s
telephone number. A Senior Officer (SO) (who had been appointed as the family
liaison officer) attempted to call Ms Cross’ mother several times throughout that
afternoon and evening, without success. After several attempts, she left a voicemail
message that requested that Ms Cross’ mother contact the prison.
56. On 11 June, Ms Cross’ mother contacted the prison and explained that she was on
holiday abroad and that was why she had not responded. The next day, the
Governor managed to speak to Ms Cross’ mother and broke the news of her
daughter’s death. Eastwood Park contributed to Ms Cross’ funeral costs in line with
national instructions.
Support for prisoners and staff
57. The prison posted notices informing other prisoners of Ms Cross’ death and offering
support. Staff reviewed all prisoners assessed as being at risk of suicide or self-
harm in case they had been adversely affected by her death.
58. After Ms Cross’ death, the staff involved in the incident were given the opportunity
to discuss any issues arising and were also offered support by the staff care team.
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Post-mortem report
59. The post-mortem concluded that the cause of Ms Cross’ death was the
consequences of chronic alcohol misuse with sudden cessation of alcohol
consumption.
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Findings
Clinical care
60. The clinical reviewer noted that the healthcare Ms Cross received at Eastwood Park
was of a reasonable standard and therefore equivalent to what she would have
received in the community. She noted that the clinical management of Ms Cross’
alcohol withdrawal in Eastwood Park was in accordance with PPG’s standard
operating procedure for ‘assessment and management of alcohol dependence’
(2021). However, the clinical reviewer raised concerns about the lack of
communication between police custody staff, Aeromed, Serco and healthcare staff
at Eastwood Park.
Identification and assessment management of withdrawal symptoms
61. When the Aeromed nurse examined Ms Cross at court, she was not aware of her
medical history or that she had recently been given medication in police custody.
62. The Aeromed nurse told us that there was currently no formal process in place to
ensure Aeromed clinicians knew that a person had been given treatment by another
agency, unless Serco escort staff verbally handed this information over to her. The
nurse told us that she did not have access to the PER, although on this occasion,
we note that even if she had, it had not been completed sufficiently in police
custody, and there was no information about the medication Ms Cross had been
given. The lack of a formal process for sharing clinical information poses a
significant risk because Aeromed healthcare professionals are making clinical
decisions without obtaining relevant past and recent medical history.
63. Furthermore, the Aeromed nurse told us that Aeromed assessments are recorded
on an electronic (medical) database which Serco staff do not have access to. As a
result, the treating clinician must give a verbal handover to Serco staff on the
medical treatment or advice provided to a prisoner. The clinical reviewer noted that
this also posed a clinical risk because the handing over of clinical information to
non-clinical staff meant information could inadvertently be misunderstood. This was
evidenced by the documentation that Serco completed which indicated that the
Aeromed nurse had given Ms Cross medication for “withdrawal”. However, this was
not the case, as the medication was prescribed to simply treat the nausea and
vomiting that Ms Cross said she had been experiencing.
64. The Royal College of Psychiatrists (RCPSYCH) guidance for ‘detainees with
substance use disorders in police custody: guidelines for clinical management’
(2020) recognises that transitions to, from, and between, criminal justice settings
such as police custody to courts and to prisons can create a potential for
interruption of medication. It highlights the importance of ensuring there are
effective channels of communication between all agencies within the criminal justice
system. It states that if a detainee is transferred to court, and subsequently to
prison, a copy of the medical record form should be sent with them. Any medication
prescribed should be entered on the form with confirmation of the time the
medication was dispensed to the detainee. This did not happen in Ms Cross’ case
on the PER.
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65. The Deputy Head of PECS told us that the healthcare contract Serco have with their
healthcare provider states that “There may be healthcare information contained
within the Person Escort Record (PER) which may be relevant to the Prisoner’s
care whilst in court detention which should be given due regard. Healthcare staff will
contribute to the accurate completion of risk documentation and records including
the PER, to provide details of assessment and any interventions provided.”
66. Clearly this did not happen in Ms Cross’ care. The Deputy Head told us that Serco
are currently working towards giving Aeromed nurses access to the PER. We make
the following recommendation:
The Serco Contract Director for Prisoner Escort and Custody Services (PECS)
must ensure that information is recorded in a detainee’s PER after every
significant interaction, including any medical treatment given.
Withdrawal Management
67. The Aeromed nurse assessed that Ms Cross did not present with any withdrawal
symptoms for alcohol. However, she did not use a formal alcohol withdrawal clinical
assessment tool, such as a GMAWS, to aid her clinical decision making.
68. If the Aeromed nurse had known that Ms Cross had been given alcohol withdrawal
medication in police custody and had been made aware of the previous GMAWS,
this might have prompted her to use an alcohol assessment tool during her
consultation or at least ensured there was greater clinical justification recorded for
why further alcohol withdrawal medication was not given.
69. The British National Formulary (BNF) recommends a long-acting benzodiazepine
for alcohol withdrawal symptoms, including diazepam, which Ms Cross was given in
police custody at around 7.00am. It also recommends that further reducing doses
should be given over seven to ten days, but this is dependent on the person’s
presentation and severity of withdrawal symptoms. Treatment should only continue
as long as the person presents with withdrawal symptoms. As the Aeromed nurse
told us that she did not believe Ms Cross presented with alcohol withdrawal
symptoms, her decision not to give alcohol withdrawal related medication at this
time, was in line with prescribing guidance.
Medical risk management at Eastwood Park
70. Ms Cross was only at Eastwood Park for just over three hours before her death.
The PER provided to staff in reception did not give any detail about the assessment
and treatment she had received in police custody, nor the assessment and
treatment given to her while she was in court. (Prison staff do not have access to
the Serco Part B Prisoner Activity Log document held on the VERA electronic
system.)
71. Nonetheless, clinical observations completed for Ms Cross upon her arrival at
Eastwood Park were within a normal range. Given how Ms Cross presented during
the reception assessment and during the consultation she had with the GP, the
clinical reviewer had no concerns that her clinical observations were not repeated
during her short time in custody. Healthcare staff told us that clinical observations
can be taken at any time at the discretion of healthcare staff, but the clinical
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reviewer was satisfied that there was not an immediate clinical indication to take Ms
Cross’ clinical observations again outside of the planned times.
72. Furthermore, the GP who assessed of Ms Cross at around 4.30pm deemed that
she did not require medication immediately and prescribed it to be given to her
during the normal medication rounds on the Kinnon Unit (which typically started at
5.30pm). Staff went to collect Ms Cross at the end of the medication rounds at
6.49pm.
73. From interviews, we were told that healthcare and prison staff could request that a
prisoner was given their medication sooner if there were concerns about their
presentation. As none of the prison or healthcare staff had any additional concerns
about Ms Cross’ presentation, this did not happen. The clinical reviewer concludes
this was a reasonable decision in the circumstances.
Head of Healthcare to note
74. It was well documented that all the agencies that had come into contact with Ms
Cross had known that she had vomited a number of times, which is a symptom of
both alcohol and opiate withdrawal. When someone is vomiting due to alcohol
withdrawal there is a risk that they can become severely dehydrated, which can
then lead to further serious medical complications.
75. The clinical reviewer noted that while it may be more difficult to expect staff at
Eastwood Park to monitor a person’s fluid intake and output than in a hospital
environment, it would have been helpful for Eastwood Park to have increased Ms
Cross’ clinical assessment and monitoring of her levels of hydration. The Head of
Healthcare should consider including within their withdrawal observation policies, a
specific process to support and guide healthcare staff on how to assess and monitor
a patient’s level of hydration in the event of prolonged vomiting or diarrhoea due to
withdrawal.
Learning outside our remit: Police custody
76. Ms Cross’ period in police custody is not within the remit of this investigation. In
police custody on 10 June, a paramedic gave Ms Cross medication for both alcohol
and opiate withdrawal symptoms. When she was handed over to Serco, who
escorted her to court, the PER stated that she had been seen by a healthcare
professional in police custody but did not record any specific details of that
assessment, including the medication that she had been given. We consider that
the information passed from the police to Serco escort staff on the PER did not
adequately reflect Ms Cross’ risk due to her drug and alcohol dependency. We
passed on our concerns to the police, but they did not confirm whether they were
completing an investigation into Ms Cross’ care.
Inquest
77. An inquest was concluded on 29 September 2025, that the cause of Ms Cross’
death was from natural causes due to consequences of chronic alcohol misuse with
sudden cessation of alcohol consumption.
14 Prisons and Probation Ombudsman
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