Guiseppe Tabone

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Independent investigation into
the death of Mr Guiseppe
Tabone, a prisoner at HMP/YOI
Lewes, on 28 June 2022
A report by the Prisons and Probation Ombudsman
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© Crown copyright, 2024
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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.
My office carries out investigations to understand what happened and identify how the
organisations whose actions we oversee can improve their work in the future.
Mr Tabone died of isotonitazene toxicity on 28 June at HMP Lewes. He was 58 years old. I
offer my condolences to Mr Tabone’s family and friends.
Mr Tabone was the first of two prisoners to die of isotonitazene (a synthetic opioid) toxicity
on the same day and on the same wing at Lewes.
Mr Tabone had a history of using illicit substances in prison and his death appears to have
been an accidental result of using drugs. When he arrived at Lewes, he was identified as
needing a drug detoxification programme. However, he declined any engagement with the
prison’s substance misuse service. Prison staff did not find Mr Tabone under the influence
of drugs during his time at Lewes and there were no changes in his behaviour or attitude in
the days prior to his death that would have suggested he was using drugs.
HMP Lewes has in place robust measures to try and reduce the number of illicit items
finding their way into the prison. However, the Governor should continue to identify and
address weaknesses in measures to prevent the supply of drugs into Lewes and revise the
substance misuse strategy in light of the findings.
My investigation also identified a continued culture at Lewes of prisoners covering their cell
observations panels at night, with little evidence of proactive action taken to address the
issue. Not only have I repeated my recommendations about this issue in this report, but I
have also sought the Governor’s reassurance that the advice promised to staff following
an earlier PPO recommendation has been issued.
I am also concerned that a member of staff failed to complete two required checks on 27
June.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Kimberley Bingham
Acting Prisons and Probation Ombudsman October 2023
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 6
Findings ......................................................................................................................... 10
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Summary
Events
1. On 21 October 2021, Mr Giuseppe Tabone was remanded to HMP/YOI Lewes
charged with conspiracy to supply Class A drugs. On 17 February 2022, he was
sentenced to five years imprisonment. Mr Tabone had been in prison before and
was known to staff at Lewes.
2. Mr Tabone was a known drug user and used illicit drugs in the community. On his
arrival at Lewes, healthcare staff prescribed medication to alleviate his withdrawal
symptoms and as a routine precaution, they observed him during the night between
21 – 25 October. Mr Tabone declined support from the prison’s Substance Misuse
Service (SMS).
3. Prison staff completed regular welfare checks on Mr Tabone and they did not raise
any concerns about him. Mr Tabone moved from A wing to L wing, primarily for
prisoners on an enhanced regime and who work across the prison in trusted
positions. He initially worked in the prison kitchen and later as an orderly in the Care
and Separation Unit (CSU).
4. On 27 June, Mr Tabone attended work in the CSU as usual. He returned to L wing
at around 6.00pm. At 7.00pm, Mr Tabone was locked in his cell for the night. This
appears to be the last time he was seen alive.
5. At 7.40pm, an Operational Support Grade (OSG) began his shift. He was required
to complete a routine roll check of each prisoner on the wing at the start of his shift
and again at 8.45pm, but he did not do so.
6. At approximately 5.06am on 28 June, the OSG started the morning roll check on L
wing. When he arrived at Mr Tabone’s cell, he saw that Mr Tabone had blocked the
observation panel on his cell door. The OSG raised his concern with a Custodial
Manager (CM). When they went into his cell, it was clear to them that he had been
dead for some time. While in the cell, staff found drug paraphernalia, which
suggested that his death was drug related.
7. A post-mortem examination concluded that Mr Tabone had died from isotonitazene
(a synthetic opioid) toxicity.
Findings
8. Mr Tabone was able to source and use illicit drugs while at Lewes, which caused
his death.
9. We are concerned that an OSG failed to complete two roll checks at 7.40pm and
8.45pm on 27 June as he should have done.
10. Mr Tabone had blocked the observation panel of his cell door. The blockage, and
lack of clear local policy to deal with such incidents, contributed to a delay of ten
minutes before Mr Tabone’s cell was unlocked and he was found dead. We are also
concerned that at the time of Mr Tabone’s death, Lewes still had not issued a local
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policy advising staff what to do in the event they find a cell observation panel
blocked in accordance with national policy.
11. Although Lewes has taken steps to address its drug supply issues, Mr Tabone’s
death is a reminder that more needs to be done to reduce the availability of drugs.
Mr Tabone was the first of two prisoners to die on the same day having used the
same illicit drug. The availability of illicit substances remains a problem across the
whole prison estate and should remain a priority for Lewes.
12. The clinical reviewer concluded that the healthcare and substance misuse care Mr
Tabone received at Lewes was not equivalent to that which he could have expected
to receive in the community. She was concerned about the lack of follow up
substance misuse and mental health care Mr Tabone received.
Recommendations
• The Governor should continue to identify and address weaknesses in measures
to prevent supply of drugs into Lewes and revise the substance misuse strategy
in light of the findings.
• The Governor should ensure that all staff understand the importance of
conducting roll checks and welfare checks at the prescribed times and record
the time the roll check was completed in the daily diary, in line with the Local
Security Strategy.
• The Governor should inform the PPO of the outcome of the disciplinary
investigation into the actions of the OSG on 27 June 2022.
• The Governor should ensure that:
• prisoners who block their observation panels are challenged, blockages
are removed, and frequent offenders receive appropriate disciplinary
action or support;
• staff are aware of national guidance and understand their
responsibilities when they find a cell observation panel obscured;
• they confirm with PPO that that a Safety Newsletter/handbook has been
issued and the date this was completed.
• The Head of Healthcare and the Head of the Substance Misuse Service should
ensure that healthcare staff:
• complete follow up COWS assessments and appointments for
prisoners who have previously displayed substance misuse withdrawal
symptoms, to ensure continuity of care; and
• record documentation relating to clinical rationale in the prisoners’
medical records.
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The Investigation Process
13. The investigator issued notices to staff and prisoners at HMP/YOI Lewes informing
them of the investigation and asking anyone with relevant information to contact
him. No one responded.
14. The investigator obtained copies of relevant extracts from Mr Tabone’s prison and
medical records.
15. The investigator interviewed seven members of staff at Lewes on 24 August and 27
September.
16. NHS England commissioned a clinical reviewer to review Mr Tabone’s clinical care
at the prison. The investigator and clinical reviewer jointly interviewed three
healthcare staff.
17. We informed HM Coroner for East Sussex of the investigation, who gave us the
results of the post-mortem examination. We have sent the Coroner a copy of this
report.
18. An inquest was concluded on 26 February 2024 and concluded that Mr Tabone
died as a result of misadventure by drug related overdose. This was caused by a
synthetic opioid namely isotonitazene. Due to the potency of the drug, 500 times
more powerful than Morphine, it is likely they became unconscious very quickly and
died.
19. The Ombudsman’s family liaison officer contacted Mr Tabone’s son, to explain the
investigation and to ask if he had any matters he wanted the investigation to
consider. Mr Tabone’s son asked the following questions:
• How were illicit drugs able to get into the prison?
• What is HMP/YOI Lewes doing to prevent the supply of illicit drugs?
We have addressed these questions in this report.
20. Mr Tabone’s family received a copy of our initial report but have not responded to
our findings or highlighted any factual inaccuracies.
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Background Information
HMP/YOI Lewes
21. HMP Lewes is a local prison serving the courts of East and West Sussex, holding
up to 624 men. Practice Plus Group (PPG) provides primary care services and
healthcare staff are on duty 24-hours a day.
HM Inspectorate of Prisons
22. The most recent unannounced inspection of HMP Lewes was in May 2022.
Inspectors found that the prison had identified and was responding to the key
threats that it faced, most notably the use of drugs and alcohol. A body scanner
used on all arriving prisoners had identified 96 illicit items in the previous 12
months. An ‘itemiser’ (a machine used to detect drugs in or on items such as paper)
was used on all incoming post.
23. Inspectors also noted that in the previous six months, staff had submitted 3,278
intelligence reports, which was similar to the number at the time of the last
inspection. The prison had identified that reports were not coming from across the
prison, including areas where there were known to be issues, and were taking steps
to raise awareness of the reporting process.
24. Mandatory drug testing had been suspended at the beginning of the pandemic, only
consistently resuming in March 2022. Results suggested lower rates of drug use
than at the time of the previous inspection. In a survey carried out by the inspection
team, 37% of respondents said that it was easy to get drugs in the prison, which
was similar to the proportion at the time of the last inspection.
25. However, HM Inspectorate carried out a review of the progress being made at HMP
Lewes in February 2023. In their report they said that eight months on from the full
inspection, their latest visit found a worrying lack of overall progress at Lewes. Time
out of cell was among the worst they had seen outside pandemic restrictions, and
they were left concerned for prisoners’ well-being. The report said that it was
notable that the number of calls to the Samaritans was escalating. The report
concluded that without significant further action to stabilise officer numbers, the
situation at Lewes was unlikely to improve.
Independent Monitoring Board
26. 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 January 2022, the IMB reported
that all prisoners should be safer now that everyone entering the prison was
searched. They thought this would reduce the amount of illicit substances entering
the prison, which were often linked to cases of bullying and violence.
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Previous deaths at HMP Lewes
27. Mr Tabone was the fourteenth prisoner to die at Lewes since March 2020. Of the
previous deaths, three were self-inflicted. Mr Tabone was one of two prisoners that
died on the same day from using the same drug.
28. In a previous investigation into the death of a prisoner at Lewes in May 2021, we
recommended that prisoners who blocked their observation panels were
challenged, blockages were removed, frequent offenders received appropriate
disciplinary action or support, and that staff were made aware of the national
guidance and understood their responsibilities when they found a cell observation
panel obscured. The prison accepted our recommendations and provided us with
an action plan which said that in February 2022, a Notice to Staff (NTS) was issued.
However, during the course of this investigation, the prison told us that the NTS was
not published because it was decided that something more robust was needed. At
the time of Mr Tabone’s death in June 2022, Lewes still had no local policy in place
advising staff what to do in the event they found an observation panel obscured. It
is concerning that we are raising the same issue again and repeating those
recommendations in this report.
Psychoactive Substances (PS)
29. PS (formerly known as ‘legal highs’) continue to be a serious problem across the
prison estate. They can be difficult to detect and can affect people in a number of
ways, including increasing heart rate, raising blood pressure, reducing blood supply
to the heart and vomiting. Prisoners under the influence of PS can present with
marked levels of disinhibition, heightened energy levels, a high tolerance of pain
and a potential for violence. Besides emerging evidence of such dangers to
physical health, the use of PS is associated with the deterioration of mental health,
suicide and self-harm. Testing for PS is in place in prisons as part of existing
mandatory drug testing arrangements.
30. Synthetic opioids such as isotonitazene are considered to be one of the fastest
growing groups of psychoactive substances. Isotonitazene has no accepted
medical use and is thought to be up to one thousand times more potent than
morphine. Due to this, even handling the substance is considered to be high risk.
While isotonitazene is fairly new to the illicit drug scene in the UK, in 2021 there
were 24 deaths attributed to its use.
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Key Events
31. On 21 October 2021, Mr Giuseppe Tabone was remanded to HMP/YOI Lewes
charged with conspiracy to supply Class A drugs. Mr Tabone had been in prison
before and was known to staff at Lewes.
32. Mr Tabone had a history of illicit drug use since he was 17 years old. He took a
range of illicit substances, including ketamine and crack cocaine. Mr Tabone told
prison and probation staff that he had sold drugs to fund his illicit drug use and to
pay his bills. In a probation self-assessment questionnaire, he said that taking
drugs, being bored, being lonely, doing things on the spur of the moment, and
feeling depressed and stressed were problems for him.
33. When he arrived at Lewes, prison staff conducted his first night interview. They
noted that he was withdrawing from drugs and that he was keen to see a nurse and
get his diabetic medication. Mr Tabone said that he had no history of self-harm or
attempted suicide and denied any current thoughts or intent to self-harm.
34. Later that evening, a nurse completed his initial health screen. Mr Tabone told the
nurse that he had been using crack cocaine and heroin and that he had depression
and diabetes. The nurse referred him to the primary Intensive Home Based
Treatment (IHBT) Service, part of the prison’s Mental Health Service.
35. A substance misuse nurse completed Mr Tabone’s drug screening. She recorded
that Mr Tabone had been remanded to prison and was due to appear in court the
following month for sentencing. Mr Tabone told her that he had been smoking
around £20 - £40 worth of heroin per day, and while in police custody he had been
prescribed withdrawal medication. She recorded that there were no obvious signs of
withdrawal at that time, but urine sample results were positive for cocaine and
opiates. She prescribed Mr Tabone symptomatic withdrawal medication.
36. On 22 October, a nurse from SMS completed an assessment with Mr Tabone,
using a Clinical Opiate Withdrawal Scale (COWS) score (used by registered
practitioners to measure the severity of a patient's opioid withdrawal symptoms).
The result indicated that Mr Tabone was experiencing mild withdrawal symptoms.
She offered him methadone to help reduce his withdrawal symptoms but recorded
that Mr Tabone had said that he did not want to be prescribed methadone. She
reassured him that he would continue to receive symptomatic relief until his
withdrawal symptoms had subsided. He was also observed during the night
between 21-25 October as part of the routine withdrawal observations, and staff did
not raise any concerns during this time. Mr Tabone declined any further help from
SMS, he said that he intended to remain drug free while in prison, and so he was
not added to their caseload.
37. On 28 October, Mr Tabone attended a mental health triage appointment with a
nurse. Mr Tabone said that he was struggling with low mood and suicidal thoughts
but had no current thoughts of harming himself. He said that he was frustrated
because he had not received his medication for his depression and to help with his
sleeping, and that he had been prescribed mirtazapine in the community. She
prescribed him an alternative medication.
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38. Prison staff completed regular welfare checks on Mr Tabone. They recorded that he
displayed a positive attitude and behaviour, they had no concerns about him and
that he did not raise any concerns with staff. He moved from A wing to L wing and
got a job in the prison kitchen.
39. On 6 December, a nurse completed a mental health review and welfare check with
Mr Tabone. Mr Tabone said that he was unhappy with his current medication, and
that since being on different medication his sleep was poor. Mr Tabone told her that
he was due to appear in court on 23 December, and that he no thoughts of suicide
or self-harm.
40. Prison staff continued to record positive entries about Mr Tabone’s behaviour. They
did not raise any concerns about him. Mr Tabone also worked as the orderly in the
Care and Separation Unit (CSU), which was considered to be a trusted position.
41. On 7 February 2022, a mental health and SMS practitioner visited Mr Tabone. She
told us that at that time she was working on Guided Self Help (GSH) materials with
prisoners on behalf of the mental health team. She said that there were three GSH
workbooks which prisoners completed themselves and that she guided them
through this process. She recorded that Mr Tabone was keeping himself busy and
was receiving support from his son and daughter, whom he telephoned twice a
week.
42. On 17 February, Mr Tabone was sentenced to five years imprisonment for
conspiracy to supply class A drugs. Staff spoke with Mr Tabone when he returned
from court to check on his well-being. Mr Tabone did not raise any concerns.
43. On 27 February, Mr Tabone went to work in the CSU. When he arrived, prison staff
completed a routine search. They asked him to empty his pockets and when he did
so, he had a medication bag with another prisoner’s name on it, which contained a
single Ibuprofen tablet. Staff asked him about the tablet and where it came from. He
said that another prisoner had given it to him the night before because he was in
pain. Prison staff sent Mr Tabone back to L wing and placed him on report. The
next day, Mr Tabone attended a prison disciplinary hearing (known as an
adjudication). He pleaded guilty to having medication belonging to another prisoner.
The adjudication manager reminded him of the prison rules but decided not to take
any further action, and because of Mr Tabone’s previous good behaviour, he was
allowed to keep his job in the CSU.
44. On 8 March, a prisoner asked Mr Tabone to pass an item to another prisoner who
was being held in the CSU. Mr Tabone refused. As a result, prisoners on the unit
verbally abused him, but CSU staff praised and commended him for his actions.
45. On 19 March, a SMS practitioner visited Mr Tabone in the CSU while he was
working. She recorded that he was happy and that he planned to return to Sicily on
his release from prison and intended to work with a family friend. He said that he
had no thoughts of self-harm and knew where to get support should he need it. On
2 April, she visited Mr Tabone again. Mr Tabone talked about plans after his release
and told her that he did not intend to return to illicit drug use after his release.
46. On the 10 April, Mr Tabone decided to stop taking his antidepressant medication
and on 13 April, IHBT discharged him from their services. The IHBT did not
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reassess his needs following his decision or refer him to a mental health nurse or
GP for review as they should have done.
Events of 27 and 28 June
47. On 27 June, Mr Tabone attended work in the CSU as usual. He returned to L wing
at around 6.00pm. CCTV showed Mr Tabone arriving back onto the wing; all other
prisoners were locked in their cells. Mr Tabone walked around the landing and
stopped at a couple of cells to speak to other prisoners through their cell door. He
then collected his meal and had a shower before staff locked him in his cell at
approximately 7.00pm.
48. At approximately 7.40pm, an OSG arrived on L wing to start the night shift. He said
that when he arrived on the wing, two members of staff that had been on the day
shift, provided a brief handover and indicated that there were no issues. He said
that he answered a number of cell bells and then checked prisoners subject to
suicide and self-harm monitoring.
49. The OSG said that as he went around the wing, he checked to ensure all the cell
doors were locked but he did not look into each cell as he did so. He told the
investigator that he knew that he should have completed a roll check, which
involves visually checking each prisoner, when he started his shift at 7.40pm and
again at 8.45pm, but that he had failed to do so. The roll reported/recorded by him
was therefore done without any check taking place. He had no reason to check on
Mr Tabone during the night.
50. At 5.06am on 28 June, the OSG began completing a morning roll check on L wing.
CCTV shows him arriving at Mr Tabone’s cell. The observation panel on the cell
door was blocked from inside so he did not have a clear view into the cell however,
he thought he could see Mr Tabone lying on the cell floor. He spent around three
minutes trying to get a response from Mr Tabone. At interview, he confirmed that Mr
Tabone did not respond. He continued along the landing to complete his roll check.
51. At 5.20am, once he had finished checking the rest of the wing, he went back to the
wing office and called a Custodial Manager (CM), the most senior officer in charge
at that time. He told her that he had been unable to get a response from Mr Tabone,
that his observation panel was partially covered, and that he thought Mr Tabone
was lying on the floor. She said that she would attend the cell with other staff. CCTV
showed an officer arrived at the cell. He and the OSG can be seen looking into Mr
Tabone’s cell through the observation panel, before walking away. They returned a
few minutes later with the CM and another officer.
52. The CM went into the cell followed by the other staff. They found Mr Tabone lying
face down on the cell floor. The CM said that due to Mr Tabone’s appearance
(obvious signs of rigor mortis), it was clear to her that Mr Tabone had been dead for
some time and that any attempts to resuscitate him would have been futile. She
radioed nursing staff to attend the cell. While in the cell, staff found drug
paraphernalia (burnt rolled up tin foil) and considered that Mr Tabone’s death might
have been drug related.
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53. At 5.30am, control room staff called an ambulance and at 5.48am, paramedics
arrived at the prison and attended Mr Tabone’s cell. After carrying out their own
observations, they confirmed that Mr Tabone had died.
Contact with Mr Tabone’s family
54. Following Mr Tabone’s death HMP Lewes appointed a family liaison officer (FLO).
At 10.00am on 28 June, the FLO, along with a prison chaplain, visited Mr Tabone’s
son at his home to inform him of his father’s death. The FLO remained in contact
with the family to help arrange the return of property and to offer continued support.
55. The prison contributed to the funeral expenses in line with national policy.
Support for prisoners and staff
56. After Mr Tabone’s death, a prison governor debriefed the staff involved in the
emergency response to ensure they had the opportunity to discuss any issues
arising, and to offer support. The staff care team also offered support.
57. The prison posted notices informing other prisoners of Mr Tabone’s 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 the death.
58. Prison staff acted on intelligence and carried out searches to identify further illicit
items on the wing. They also liaised with local police and Public Health England and
provided advice to prisoners on the dangers of using isotonitazene.
Post-mortem report
59. The post-mortem report gave Mr Tabone’s cause of death as isotonitazene toxicity.
Information received after Mr Tabone’s death
60. A substance misuse worker at Lewes told the investigator that she had not worked
directly with Mr Tabone, but that he was employed in the CSU with one of her
clients. She told us that she was aware through hearsay that Mr Tabone used illicit
substances throughout his previous sentences. She said that every now and again
when she did see Mr Tabone, she got the impression from his presentation that he
had ‘used something’ (illicit drugs) and described him as a ‘functioning’ addict.
However, this was only her personal view and not based on any evidence and she
did not raise her views with anyone else. No one else interviewed as part of this
investigation shared any knowledge or concerns that Mr Tabone had used drugs
during his most recent sentence.
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Findings
Assessment of Mr Tabone’s risk and substance misuse
61. Mr Tabone had been in prison before and was known to staff at Lewes. He had
been convicted of supplying heroin and cocaine, was a known drug user and had
been taking illicit drugs since the age of 17.
62. When he arrived at Lewes in October 2021, he was identified as withdrawing from
illicit substances and was placed on a methadone detoxification programme.
However, Mr Tabone declined any further involvement with SMS and said that he
intended to remain drug free. Staff did not raise any concerns about Mr Tabone
being under the influence of illicit substances, and there was no intelligence
information to indicate that he had been involved in the supply or use of illicit
substances during his time at Lewes.
63. On 27 February 2022, during a routine search at work, Mr Tabone was found with
an ibuprofen tablet that belonged to another prisoner. Staff placed him on report for
breaching the prison rules, but staff did not raise any other issues or concerns
about his conduct or behaviour again. We do not consider that this one isolated
incident was sufficient to have indicated that Mr Tabone was involved in drug use or
supply at Lewes. In the absence of any clear indications that he was using drugs,
we do not think that staff could reasonably have taken any action. We make no
recommendation.
Drug strategy at HMP Lewes
64. It is troubling that Mr Tabone was the first of two prisoners to die on the same day
from using the same rare synthetic opioid at Lewes. The use of synthetic opioids is
a concern across the prison estate and has a profoundly negative impact on the
physical and mental health of prisoners, as well as being associated with debt and
bullying. Mr Tabone’s death is an example of the dangers of illicit drugs and
illustrates why prisons must do all they can to eradicate its use.
65. In April 2019, HM Prison and Probation Service (HMPPS) issued a national
instruction that all prisons should review their drug strategies. The Head of Security
and Intelligence spoke to us about the steps Lewes was taking to reduce the supply
of illicit substances. She told us that most of the local intelligence received about
drugs had been around cannabis, fermenting liquid, and known types of PS, namely
‘Spice’ – a synthetic cannabinoid. She said that intelligence information was
reviewed regularly at a tactical meeting held between herself and the Governor and
was shared more widely at security committee meetings.
66. The Head of Security and Intelligence also said that there were a number of
initiatives to try and reduce the supply of illicit items into the prison, including
enhanced gate security, which is aimed at targeting those (including staff and
visitors) trying to bring illicit items into the prison. All post was searched, including
with drug dogs. She also authorised intelligence led monitoring if information was
obtained from phone calls or through mobile phone detection. She explained that
mobile phone detection could be linked with conveyance of items or payment, so
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regular monitoring of bank accounts was completed to ensure that there was
nothing suspicious that could be linked to the illicit drug economy.
67. In addition, the security department at Lewes carries out regular security briefings
on residential wings. They also monitor the visits lists to monitor those prisoners
who are subject to intelligence information and provide a briefing for staff prior to
visits. The Head of Security and Intelligence said that over weekends, security staff
brief other officers on monitoring cameras and those prisoners requiring closer
monitoring due to their possible involvement in the illicit economy. Staff were also
able to utilise closed visits as a deterrent, mandatory drug testing, intelligence
reports, and searching of communal areas with search dogs. Referrals to SMS and
the Safer Custody Team were also widely used to tackle the availability of drugs
and the illicit economy. She said that there was no intelligence linked to the
synthetic opioid that Mr Tabone took prior to his death.
68. The illicit economy is an ongoing issue facing the prison service and impacts on the
safety and well-being of all those that live and work in prisons. While there are
measures that can be taken to reduce the supply of illicit substances into secure
settings, we are realistic that those intent on supplying this will continue to find ways
of doing so. Despite the proactive steps being taken by Lewes, it is clear that Mr
Tabone and the other prisoner were able to obtain a synthetic opioid and died as a
result. We make the following recommendation:
The Governor should continue to identify and address weaknesses in
measures to prevent supply of drugs into Lewes and revise the substance
misuse strategy in light of the findings.
Roll checks
69. Roll checks are primarily a visual security check to count prisoners to ensure that
they are present in their cells, but they are also an opportunity for any concerns
about a prisoners’ safety to be identified and managed. HMPPS’ National Security
Framework expects welfare checks to take place at roll checks including that staff
are able to see the prisoner’s face and that they are alive and well.
70. The Local Security Strategy (LSS) at HMP Lewes which became effective from April
2022, sets out when prison staff should complete roll checks. It directs that roll
checks should take place at various times including 5.30pm, 7.30pm and 8.45pm.
71. On 27 June, prisoners on L wing were locked in their cells at 5.30pm. It appears
that this was the last roll check to be completed that day. The investigator found no
evidence that prison staff completed roll checks at 7.30pm or 8.45pm, as they
should have done. The OSG told the investigator that when he arrived for his duty,
there were a number of cell bells to respond to. He was also aware that there were
at least two prisoners who required additional welfare checks. He said that because
he was immediately busy with these tasks, it was not until the following morning, 28
June, that he realised that he had not completed the two evening roll checks as he
should have done. However, he would have had to sign for the roll at the start of his
shift to indicate that it was correct.
72. Because the OSG did not complete two roll checks, it would appear that Mr Tabone
was last seen alive at 7.00pm. We do not know whether the OSG conducting the
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two evening roll checks would have made any difference to the outcome for Mr
Tabone, but roll checks are important for both prisoner safety and security.
73. The Governor told us that he is conducting an internal disciplinary investigation into
the OSG’s actions on the evening of 27 and 28 June.
74. We make the following recommendations:
The Governor should ensure that all staff understand the importance of
conducting roll checks at the prescribed times and record the time the roll
check is completed in the daily diary, in line with the Local Security Strategy.
The Governor should inform the PPO of the outcome of the disciplinary
investigation into the actions of the OSG on 27 June 2022.
Cell observation panels
75. Lewes does not have a local policy advising staff what to do if they find a cell
observation panel obscured. A HMPPS Safety Briefing on observation panels,
issued in February 2018, states that when staff discover that a panel has been
blocked, and the prisoner does not comply with instructions to remove the blockage,
they must take immediate action to remove the obstruction and check on the
prisoner’s welfare. In such circumstances, we would usually expect staff who
cannot see or speak to a prisoner to radio for help from other staff and remain at the
cell door. If they believe the prisoner may be at risk, they should assess the risk of
opening the cell door before help arrives.
76. After first identifying that Mr Tabone’s observation panel was blocked, not receiving
a response, and believing that he could see Mr Tabone lying on the cell floor, the
OSG continued his count of prisoners before returning to the wing office. He
telephoned the CM and asked her to come over and check on Mr Tabone. Mr
Tabone’s cell was only opened when the staff arrived, over 15 minutes after the
OSG had first discovered the blocked observation panel.
77. We consider that the OSG should have taken action to ensure that Mr Tabone’s cell
observation panel was clear, including calling the CM on his radio, opening the cell
to remove the blockage and check on Mr Tabone’s welfare and calling a medical
emergency if necessary. Although it is unlikely that earlier intervention would have
changed the outcome for Mr Tabone, such actions could prove crucial in similar
situations.
78. In a previous investigation into the death of a prisoner at Lewes in May 2021, prison
staff told us that it was not unusual for prisoners to block their observation panels at
night and up to 16 cells on the wing could have their panel blocked on any one
night. We observed that it appeared that the culture at Lewes, where prisoners
frequently block their observation panels with little consequence, contributed to
staff’s decision not to take more urgent action. We recommended that prisoners
who blocked their observation panels were challenged, blockages were removed,
and frequent offenders received appropriate disciplinary action or support, and that
staff were made aware of the national guidance and understood their
responsibilities when they found a cell observation panel obscured. The prison
accepted our recommendation and provided us with an action plan which said that
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in February 2022, a Notice to Staff (NTS) was issued. However, during the course
of this investigation, the prison told us that the NTS was not published because it
was decided that something more robust was needed. At the time of Mr Tabone’s
death in June 2022, Lewes still had no local policy in place.
79. The Head of Safety at Lewes told us that the Safety Committee wanted to ensure
that new starters and staff always had access to Safety information, and it was
decided that a Safety Newsletter/handbook would be designed and distributed. She
said that this had not happened when she took over the role in September 2022,
but that she had completed the document in October, and it was ready for issue.
We repeat our previous recommendation:
The Governor should ensure that:
• prisoners who block their observation panels are challenged,
blockages are removed, and frequent offenders receive appropriate
disciplinary action or support; and
• staff are aware of national guidance and understand their
responsibilities when they find a cell observation panel obscured.
• they confirm with the PPO that that the Safety Newsletter/handbook
has been issued and the date this was completed.
Clinical care
80. The clinical reviewer concluded that the clinical care Mr Tabone received at Lewes
was not equivalent to that which he could have expected to receive in the
community.
81. She was concerned about substance misuse and mental health care given to Mr
Tabone. On his arrival at Lewes on 21 October 2021, a SMS assessed his
substance misuse needs. She checked him for any withdrawal symptoms and, as
the Clinical Opiate Withdrawal Scale (COWS) score did not give any cause for
concern, this action plan was appropriate at the time. However, the clinical reviewer
found that there was no evidence that healthcare staff completed any follow up
COWS assessments or arranged any appointments with the prison’s Substance
Misuse Services. She considered that healthcare staff should have completed a
further needs assessment for continuation of care but that they failed to do so. We
recommend:
The Head of Healthcare and the Head of the Substance Misuse Service should
ensure that healthcare staff:
• complete follow up COWS assessments and appointments for
prisoners who have previously displayed substance misuse
withdrawal symptoms, to ensure continuity of care; and
• record documentation relating to clinical rationale in the prisoner’s
medical record.
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82. Mr Tabone was appropriately referred to IHBT. He was discharged from the service
on 13 April 2022. Medical records indicated that he completed the workbooks as
part of his treatment and support. However, he stopped taking his antidepressant
medication on 10 April. The clinical reviewer was concerned that, while there was
no evidence in Mr Tabone’s medical records that stopping his antidepressant
medication had any adverse effects on his mental health, IHBT did not offer a
further mental health assessment to assess his needs or arrange a follow up
appointment with a mental health nurse or GP as they should have done. The
clinical reviewer made two recommendations about these issues which we do not
repeat in this report, but which the Head of Healthcare and the Head of the Mental
Health Team will need to address.
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