Josh Tarrant

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Independent investigation into
the death of Mr Josh Tarrant,
a prisoner at HMP Elmley,
on 1 November 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.
Mr Josh Tarrant, a black British man, died from cocaine toxicity on 1 November 2023 at
HMP Elmley. He was 34 years old. I offer my condolences to Mr Tarrant’s family and
friends.
Mr Tarrant had been at Elmley for just eight hours when he died. Two hours before his
death, he had been moved under restraint to the healthcare unit due to concerns about his
mental health. He was non-compliant and staff had to use force to move him. He was then
moved from one cell to another, again by force, after he damaged the first cell. He became
unresponsive straight after the second move.
While the post-mortem examination found that Mr Tarrant’s primary cause of death was
cocaine toxicity, it also revealed that Mr Tarrant had an underlying heart condition and
concluded that this, along with exertion during the restraint, was a contributory factor in his
death.
I am satisfied that the decision to move Mr Tarrant was a reasonable one in the
circumstances. However, some of the officers involved in the restraint used inappropriate
techniques, including kicking, and used bad language towards Mr Tarrant. The prison
carried out an investigation and took disciplinary action against the officers.
The clinical reviewer found it probable that a nurse at the prison inserted an airway
incorrectly during the attempt to resuscitate Mr Tarrant which resulted in him not getting
oxygen for over 16 minutes. He recommended more frequent Immediate Life Support
refresher training for healthcare staff at Elmley. He also recommended more training for
healthcare staff on assessing and managing prisoners who are under the influence of
drugs.
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 April 2025
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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 31 October 2023, Mr Josh Tarrant was remanded to HMP Elmley, charged with
robbery, actual bodily harm and criminal damage. He arrived at approximately
6.20pm. Mr Tarrant was searched and went through a body scanner as part of the
usual reception process. No illicit items were found. (CCTV footage from the van
transporting Mr Tarrant from court to the prison, viewed after Mr Tarrant’s death,
shows Mr Tarrant putting his hands down the back of his trousers and, at one point,
squatting down while his hands were behind him. Police suspect that he may have
been retrieving illicit items.)
2. Mr Tarrant told staff he had mental health problems and had been sectioned under
the Mental Health Act three months previously. He said that he had committed the
offences while having a mental health breakdown and that he had used cannabis at
the time. Mr Tarrant did not disclose use of any other drugs.
3. Staff took Mr Tarrant to a cell on the first night centre. During a call to his mother, he
told her he was hearing voices and that he was going to take his own life. She
contacted the prison to raise her concerns. Staff went to Mr Tarrant’s cell to check
on his wellbeing at around 11.30pm. While staff were trying to engage with him, Mr
Tarrant ran out of his cell resulting in staff having to restrain him on the landing. Due
to concerns about Mr Tarrant’s welfare, the night orderly officer (the senior officer in
charge), decided to move him, under restraint, to the healthcare inpatient
department (IPD) for observation. Mr Tarrant was highly distressed and non-
compliant so the journey to the IPD that should have taken less than five minutes
took around 30 minutes. During the move, two officers used inappropriate
techniques, including kicking Mr Tarrant, and one used bad language towards him.
4. Staff put Mr Tarrant in a constant supervision cell in the IPD shortly before midnight.
He remained distressed and began damaging the cell. Mr Tarrant tried to strangle
himself using the elastic from his boxer shorts. Due to his behaviour and the
damage to the cell, the night orderly officer decided to move him to a neighbouring
cell for his own safety. Mr Tarrant was non-compliant, so staff moved him the short
distance, again under restraint. However, as soon as they left the cell, staff realised
that Mr Tarrant appeared unresponsive and went back into the cell to check on him.
Mr Tarrant was not breathing and had no pulse so staff immediately started CPR
and called an ambulance. Paramedics arrived at around 1.44am on 1 November
and took over CPR. They were unable to resuscitate Mr Tarrant and pronounced life
extinct at 2.13am.
5. The post-mortem report concluded that Mr Tarrant died from cocaine toxicity. It
listed cardiac hypertrophy (a condition that causes the walls of the heart’s ventricles
to thicken) and exertion during restraint as contributory factors.
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Findings
6. The two moves under restraint were clearly traumatic for Mr Tarrant and while they
did not cause his death, they contributed to it. We accept that the night orderly
officer made this decision because she was concerned for Mr Tarrant’s welfare and
considered he could be monitored more closely in the IPD. She did not know at that
stage how difficult the move was going to be. We consider that the decision to move
Mr Tarrant to the IPD was a reasonable one in the circumstances.
7. The prison investigated the inappropriate behaviour of two officers during the
restraint and took disciplinary action against them.
8. Although Mr Tarrant was searched and went through a body scanner on reception,
it is likely that he brought cocaine into the prison. There were 12 other incidents
relating to cocaine within the prison in the weeks surrounding Mr Tarrant’s death (20
October to 20 November 2023). In their most recent inspection of Elmley, HM
Inspectorate of Prisons found that while targeted actions to address specific areas
of concern regarding drug supply were often successful, there was a lack of
coordinated strategy to address the issue in the long term. The Governor may wish
to consider requesting drug diagnostic support from HMPPS.
9. The clinical reviewer found that healthcare staff had presumed Mr Tarrant’s
presentation was due to his mental health without establishing whether there was a
physiological cause, such as drug intoxication. He considered that staff should have
more training on assessing and managing prisoners who are under the influence of
drugs.
10. The clinical reviewer concluded that there was a significant possibility that a nurse
had inserted an airway incorrectly during CPR, meaning that Mr Tarrant may not
have been receiving oxygen for 16 minutes or more. He noted that healthcare staff
at Elmley received Immediate Life Support (ILS) training every two years rather than
annually.
11. The clinical reviewer concluded that Mr Tarrant’s clinical care was not equivalent to
that which he could have expected to receive in the community.
Recommendations
• The Head of Healthcare should arrange supplementary training for healthcare staff
on the recognition of substance intoxication and its treatment.
• The Head of Healthcare should ensure that healthcare staff receive Immediate Life
Support (ILS) refresher training annually.
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The Investigation Process
12. HMPPS notified us of Mr Tarrant’s death on 1 November 2023.
13. The investigator issued notices to staff and prisoners at HMP Elmley informing them
of the investigation and asking anyone with relevant information to contact her. No
one responded.
14. The investigator obtained copies of relevant extracts from Mr Tarrant’s prison and
medical records.
15. NHS England commissioned an independent clinical reviewer to review Mr Tarrant’s
clinical care at the prison.
16. We suspended our investigation in November 2023, pending the outcome of a
police investigation into the actions of some staff. We resumed it in July 2024, when
Kent Police told us that they had concluded their investigation and no criminal
charges would be brought.
17. The investigator and clinical reviewer interviewed eight members of staff in October
2024, accompanied for some interviews by another PPO investigator.
18. We informed HM Coroner for Mid-Kent and Medway of the investigation. The
Coroner gave us the results of the post-mortem examination. We have sent the
Coroner a copy of this report.
19. The Ombudsman’s office contacted Mr Tarrant’s cousin to explain the investigation
and to ask if the family had any matters they wanted us to consider. Mr Tarrant’s
cousin wanted to know what information about Mr Tarrant was available to staff
when he arrived at Elmley, the searching procedures, and details of the restraint,
including whether staff were trained to deal with the restraint of prisoners with
mental health issues or Acute Behavioural Disturbance (ABD), and what action had
been taken against the officers shown to have used excessive force and
inappropriate behaviour and language. We have addressed these issues in this
report and the annexed clinical review.
20. We shared our initial report with HMPPS and the prison’s healthcare provider,
Oxleas NHS Foundation Trust. They pointed out one factual inaccuracy, which has
been amended in this report.
21. We sent a copy of our report to Mr Tarrant’s family via their legal representative.
They identified no factual inaccuracies.
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Background Information
HMP Elmley
22. HMP Elmley, located on the Isle of Sheppey, holds men who are remanded and
sentenced in six houseblocks with a mixture of single and double cells. Oxleas NHS
Foundation Trust provides healthcare services.
HM Inspectorate of Prisons
23. The most recent inspection of HMP Elmley was in March 2022. Inspectors reported
that staff and prisoner relationships were better than in comparable prisons.
However, use of force had gone up significantly and leaders had not done enough
to understand the reasons for this rise. Inspectors were concerned that a much
larger number of use of force incidents than they usually saw were routinely being
classed as “miscellaneous” rather than being put in a more suitable category.
24. Although the security team had introduced weekly tasking meetings, inspectors
noted weaknesses in assessment of and action on intelligence reports. Staff
redeployment meant that 60% of intelligence reports about prisoners holding
unauthorised items, such as drugs or mobile phones, were not acted on with a cell
search. However, the strategic approach to drug supply reduction had greatly
improved, with new body scanning equipment and detection dogs proving effective.
Inspectors noted that there had been 57 suspicion-based drug tests in the previous
six months with a positive rate of 60%, indicating good intelligence on substance
misuse.
25. Inspectors noted that the safer custody team was well resourced and had recently
introduced some good initiatives and safeguards to identify and support prisoners at
risk. Inspectors found that against a background of significant workforce challenges,
mental health services had responded positively to prisoners in need of urgent
support.
26. Inspectors returned to Elmley in February 2023, to undertake an Independent
Review of Progress. They identified that Elmley still had substantial staff shortages.
However, they noted that the use of body-worn cameras during use of force
incidents was far greater than at other prisons and they described this as excellent.
Managers were now routinely using footage to improve de-escalation and highlight
good practice.
27. In relation to security issues, including the supply of drugs, inspectors found that
while subsequent actions from the weekly security meetings were often successful
in addressing issues, such as contraband being thrown into the prison for collection,
there was no coordinated strategy to maintain these successes in the long term.
Inspectors noted an increase of around 20% in the number of information reports
that were actioned than at the time of the previous inspection and they were
impressed that around 50% of searches resulted in a find.
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Independent Monitoring Board
28. 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 published annual report, for the year to 31 October 2022, the
IMB reported that weekly use of force scrutiny ensured that restraint was used
appropriately and safely. They found that use of body worn cameras was more
effective, evidencing the need for force and creating confidence in the system.
Previous deaths at HMP Elmley
29. Mr Tarrant was the eighteenth prisoner to die at Elmley since November 2020.
Twelve of these deaths were due to natural causes, three were self-inflicted and two
were drug related. In November 2021, another black prisoner died following
restraint by staff. Up to the end of December 2024, four prisoners have died at
Elmley since Mr Tarrant’s death. Two of those deaths were self-inflicted and two
were from natural causes.
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Key Events
30. On 28 October 2023, Mr Josh Tarrant was arrested for robbery, actual bodily harm
and criminal damage. Mr Tarrant had wounds to his hands for which he initially
refused treatment. He also refused to provide specimens to the police so that they
could establish if he was under the influence of drugs or alcohol. After being
charged with the offences, Mr Tarrant agreed to attend hospital where his hands
were bandaged and he was prescribed a course of antibiotics. While in police
custody he was searched and the police found no secreted items. The police told us
that they did not have the facility to perform body scans.
31. Mr Tarrant remained in police custody until he attended court on 31 October, where
he was remanded in prison and sent to HMP Elmley. His Person Escort Record
(PER – a document that accompanies prisoners between police custody, court and
prison that sets out the risks they pose) showed that Mr Tarrant was at risk of
suicide or self-harm (although his last self-harm incident was in 2022), had a history
of paranoia, anxiety and depression, and that he was known to community mental
health services.
32. CCTV footage from the van that took Mr Tarrant from the court to the prison showed
him putting his hands down the back of his trousers and, at one time, squatting
down while his hands were behind him. Police suspect that he might have been
retrieving secreted drugs. (This footage was not viewed until after Mr Tarrant’s
death.)
33. Mr Tarrant arrived at Elmley at approximately 6.20pm. He was strip searched and
went through a body scanner in line with standard reception procedures. No illicit
items were found and staff assessed that the scan images were clear. (The
investigator and the clinical reviewer viewed the body scan images and could see
no obvious signs of any illicit items secreted in his body.)
34. A nurse carried out Mr Tarrant’s reception health screening at around 6.40pm. She
noted that he had been in prison before, but not since 2014. Mr Tarrant told her that
he had a community mental health worker. Mr Tarrant said that he used cannabis
and alcohol but no other drugs. He declined a referral to substance misuse
services. She referred Mr Tarrant to the prison’s mental health team and to the GP.
She said that she was aware of his risk of suicide or self-harm but had no
immediate concerns about him as he engaged well and seemed calm. She said that
she received a telephone call from the police custody nurse to let her know that Mr
Tarrant had a hospital appointment the next morning in relation to the wounds to his
hands.
35. At around 7.00pm, Mr Tarrant saw a GP. Mr Tarrant said that he committed the
offences during a mental health breakdown, and he told the GP that he had been in
a secure mental health hospital three months previously due to psychosis. The GP
prescribed antibiotics for the wounds to Mr Tarrant’s hands which appeared to be
infected, as well as antipsychotic medication and a sedative. He referred Mr Tarrant
for a review with the psychiatrist. He told the investigator that he had no concerns
about Mr Tarrant’s presentation or concerns that he was under the influence of any
illicit substance.
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36. After being placed in a cell on the first night centre, Mr Tarrant made several phone
calls to family members and a friend between approximately 7.50pm and 8.15pm.
The investigator listened to the calls. During the calls Mr Tarrant was coherent and
engaged well, although he expressed concerns about the lack of support for his
mental health and how he would cope in prison until his next court appearance in a
month’s time. He also complained about the pain in his hands. He said he could not
remember what he had done to end up in prison but said he had suffered a mental
health breakdown. Those he spoke to were supportive and appeared to have a
calming influence on him, saying that he should keep in touch and they would visit.
37. At around 10.50pm, Mr Tarrant made a call to his mother, where he sounded
drowsy and breathless, potentially under the influence of something. He told her
that he was hearing voices and was planning to kill himself. Mr Tarrant’s mother
called the prison at around 11.00pm to express concerns about her son.
38. The custodial manager (CM) in charge of the prison that night received the
message that Mr Tarrant was threatening to self-harm and at 11.25pm, went to his
cell with four other officers to check on his wellbeing. When she arrived, Mr Tarrant
was facing the window with his back to the door. She said at interview that she tried
to speak to him through the door, but he did not respond. She said she was unable
to see clearly through the observation hatch and was worried that he might have
tied a ligature. She therefore opened the door and the five members of staff went
into the cell, activating their body worn video cameras (BWVCs).
39. The CM said that Mr Tarrant kept repeating the words “help me” and she tried to
explain to him that the staff were there to help him and to understand what he
needed. Mr Tarrant then moved his arm, knocking his television off the unit. When a
member of staff went to pick up the television, Mr Tarrant pushed past all the
members of staff and ran out onto the landing and, as staff tried to stop him, he
ended up on top of an officer, the only male member of staff. The CM described it
as a very challenging situation during the night state and she immediately radioed
for further assistance. While waiting for assistance, staff were able to get two sets of
handcuffs onto Mr Tarrant who was continuously shouting “let me out” and asking
for his mother.
40. An officer heard the CM’s radio call and immediately went to assist. The CM said
she had specifically called for the officer as she knew he was experienced in control
and restraint (the recognised techniques by which prison staff can apply force to
prisoners). The CM remained concerned for Mr Tarrant’s mental health and felt that
the best decision was to move him, under restraint, to the healthcare in-patient
department (IPD) for constant observation and assessment. The officer said that
when he arrived on the first night centre, the CM asked him to take control of the
situation, which he did. Staff began to move Mr Tarrant to the IPD, which should
have taken no more than five minutes.
41. During the move, Mr Tarrant refused to comply and kept dropping his body to the
floor. This resulted in a difficult and physically exhausting situation for staff and Mr
Tarrant. BWVC and CCTV footage shows that staff took several pauses and were
seen resorting to a range of carrying techniques, some of which were not approved
methods. After approximately ten minutes, a nurse attended to observe the restraint
and monitor Mr Tarrant. She said she was unable to do any physical monitoring due
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to the level of aggression displayed by Mr Tarrant, so she could only watch and
listen for his breathing.
42. While the majority of staff interacted with Mr Tarrant in a professional manner, trying
to reassure him, two members of staff were seen using unapproved methods to
move Mr Tarrant down the stairs and along the landings. One of these members of
staff also used unprofessional and abusive language towards Mr Tarrant. BWVC
footage identifies four incidents of concern towards Mr Tarrant during the restraint,
namely, a punch to his leg, an elbow strike to his upper back, two kicks to his lower
leg area, and a kick and stamp on his lower right leg while on the stairs. Fortunately,
none of these incidents resulted in injury to Mr Tarrant. The police investigation
concluded that there was insufficient evidence to charge the members of staff with
any offence.
43. Staff eventually located Mr Tarrant in a constant supervision cell on the IPD at
around 11.59pm, nearly 30 minutes after he ran out of his cell on the first night
centre. The cell on IPD allowed staff to have a visual sighting of Mr Tarrant at all
times through a Perspex screen with bars. Mr Tarrant immediately began damaging
the cell, breaking the Perspex screen and throwing the furniture around the room.
He made a ligature from the elastic of his boxer shorts and tied it to the bars of the
cell in an attempt to self-strangulate. Staff opened the door and cut the ligature and,
when closing the door again, Mr Tarrant’s finger became trapped in the door. Staff
immediately opened the door and he moved his hand. All those who witnessed this
said they were shocked that he did not seem to notice the pain from shutting his
finger in the heavy iron gate.
44. The CM said she was concerned that Mr Tarrant was at risk from the damage he
had made to the constant supervision cell, so she made the decision, in conjunction
with the Duty Governor (who she had telephoned at home), to move him to the cell
next door which did not have any bars or Perspex. At around 1.17am (now 1
November), staff again restrained Mr Tarrant and moved him to the neighbouring
cell. Mr Tarrant continued to resist but he was relocated and changed into special
clothing (which cannot easily be torn into strips to reduce his risk of ligature making)
by 1.25am. Staff removed Mr Tarrant’s handcuffs and left him lying face down on
the floor of the cell.
45. As staff left the cell, they noticed that Mr Tarrant did not move as they had expected
him to. They closed the door but did not immediately lock it. An officer said he
realised very quickly that something was wrong, and, within approximately 30
seconds, staff went back into the cell to check on Mr Tarrant. They found that he
was unresponsive and not breathing. The CM immediately radioed a code blue (an
emergency code which tells the control room that a prisoner is unresponsive or not
breathing and an ambulance is required immediately).
46. Staff immediately started CPR while waiting for paramedics to arrive. During this
time, a nurse inserted an airway and staff continued administering chest
compressions and oxygen. Paramedics arrived at around 1.44am and took over
CPR. A critical care nurse from the Ambulance Service removed the airway inserted
by the nurse, saying that it had been inserted incorrectly. Paramedics continued
with CPR but were unsuccessful. At 2.13am, they pronounced Mr Tarrant’s life
extinct.
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Contact with Mr Tarrant’s family
47. Mr Tarrant did not provide next of kin details when he arrived at the prison. After
making enquiries with the police and checking previous prison records, staff
eventually traced contact details for his grandmother. Due to uncertainty about Mr
Tarrant’s grandmother’s address, the prison’s appointed family liaison officer (FLO)
telephoned Mr Tarrant’s grandmother at around 9.30am on 1 November and told
her that her grandson had died. The Prison Service contributed to Mr Tarrant’s
funeral expenses in line with national instructions.
Support for prisoners and staff
48. A prison manager 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.
49. The prison posted notices informing other prisoners of Mr Tarrant’s death and
offered support. Staff reviewed all prisoners assessed as at risk of suicide or self-
harm in case they had been adversely affected by Mr Tarrant’s death.
Post-mortem report
50. The post-mortem report concluded that Mr Tarrant died from cocaine toxicity. It
listed cardiac hypertrophy (disease of the heart muscle that affects its ability to
pump blood around the body) and exertion during restraint as factors that
contributed but did not cause the death.
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Findings
Cause of death - cocaine
51. Mr Tarrant died from cocaine intoxication within eight hours of arriving at Elmley.
Staff who saw Mr Tarrant when he arrived on 31 October, including the doctor with
responsibility for substance misuse, were confident that he did not present as under
the influence of drugs. The investigator listened to phone calls made by Mr Tarrant
to his family that evening. During the earlier calls up to 8.15pm, he was coherent,
engaged well, and did not appear to be under the influence. However, by the time of
the call to his mother at 10.50pm, his voice was slurred and his tone had changed,
suggesting that he may have taken illicit drugs in the intervening two and a half
hours.
52. It appears likely that Mr Tarrant brought drugs into the prison, though there is a
possibility he obtained them in the first night centre. During the investigation, we
found evidence of 12 other incidents relating to cocaine within the prison in the days
leading up to Mr Tarrant’s death. None of these were linked to the first night centre.
The Acting Head of Security told us that it was a constant battle trying to disrupt the
organised criminal gangs and prevent drugs getting into the prison. He said that,
although not impossible, it was less likely for drugs to be present on the first night
centre due to its transient nature. This suggests that Mr Tarrant brought the drugs in
with him (which would account for his movements in the van on the way to Elmley)
and that the searching regime and body scan did not find them. We note that Mr
Tarrant had bandaged hands so there is a possibility that he concealed drugs under
the bandages.
53. In their last inspection of Elmley in February 2023 (which was an independent
review of progress), HMIP inspectors found that while targeted actions against
specific areas of concern, including the supply of drugs, were often successful, the
prison lacked a coordinated strategy to maintain these successes in the long term.
The Governor may wish to consider requesting drug diagnostic support from
HMPPS headquarters.
Use of Force
54. Force was used to move Mr Tarrant from the first night centre to the IPD after he
rushed out of his cell at around 11.25pm. Mr Tarrant resisted throughout which
meant this was a difficult and prolonged procedure, which clearly caused distress to
Mr Tarrant. While the use of force did not directly cause Mr Tarrant’s death, the
pathologist found that the exertion during the restraint was a contributory factor.
55. During the investigation, we considered why staff had moved Mr Tarrant rather than
placing him back in his cell on the first night centre. The CM, the officer in charge
that night, thought that Mr Tarrant was suffering a mental health breakdown, based
on the concerns that had been raised by his mother. She said she considered the
option of moving him to the segregation unit but thought that the IPD would provide
him with a more appropriate level of support where he could be constantly observed
by healthcare staff. Both the Governor and Deputy Governor said that they
supported the CM’s decision to move Mr Tarrant to the IPD. Both said they did not
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consider Mr Tarrant could be adequately and safely managed in a standard cell on
the first night centre.
56. We consider that, as far as was safe and practicable, staff attempted to de-escalate
the situation and informed Mr Tarrant of the reasons why they were moving him to
the IPD. We note the clinical reviewer’s comments that baseline observations
should have been carried out on Mr Tarrant during the restraint, but we accept that
staff had concerns about his level of aggression and the safety of healthcare staff.
In these challenging circumstances, we do not consider that the decision to move
Mr Tarrant to the IPD, under restraint, was an unreasonable one. We consider it
would be fair to say that no one could have foreseen how challenging and
prolonged the restraint would be, nor envisaged the need for a further restraint after
Mr Tarrant was located in a constant supervision cell on the IPD.
57. However, it is concerning that two members of staff involved in the restraint used
unapproved methods and displayed unprofessional behaviour during the restraint.
This included striking Mr Tarrant on his leg and back as well as kicking and
stamping on his legs while he was on the stairs. We are aware that both members
of staff were investigated by the police and no charges were brought against them.
We are satisfied that the prison carried out a thorough investigation into the actions
of both members of staff and took disciplinary action against them. Both received
further training and one also received a written warning.
58. While the post-mortem report concluded that the prolonged restraint may have
affected Mr Tarrant’s unknown underlying heart condition, we do not know if the
level of cocaine in his body alone may have caused his death. We consider that, on
both occasions, the use of force was necessary in the circumstances and, while we
accept that two members of staff acted unprofessionally, we found no evidence that
their behaviour directly contributed to Mr Tarrant’s death. We make no
recommendations in relation to the use of force against Mr Tarrant.
Clinical care
59. The clinical reviewer found that the care Mr Tarrant received was not of the required
standard and not equivalent to that which he could have expected to receive in the
community.
Lack of recognition that Mr Tarrant was under the influence of drugs
60. The clinical reviewer found that healthcare staff wrongly presumed that Mr Tarrant’s
presentation was due to his mental health without assessing whether there might be
a physiological cause, such as drug intoxication. He noted that no baseline
observations, such as his heart rate and blood pressure, were taken at Mr Tarrant’s
reception health screen. Nor were observations taken during the restraint. Had they
been staff might have identified that something was physiologically wrong and drug
intoxication might have been considered. He recommended supplementary training
focusing on the recognition of clinical deterioration secondary to progression of
substance intoxication and its appropriate treatment. We recommend:
The Head of Healthcare should arrange supplementary training for healthcare
staff on the recognition of substance intoxication and its treatment.
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Emergency response
61. We found that prison and healthcare staff acted swiftly as soon as they became
aware that Mr Tarrant appeared unresponsive. They went back into the cell within
30 seconds and immediately began CPR.
62. The clinical reviewer concluded that the airway inserted by the nurse was, on the
balance of probabilities, incorrectly inserted. This meant that Mr Tarrant’s airway
was compromised for around 16 minutes. We cannot say what impact this had on
the resuscitation attempts and eventual outcome for him. The actions of the nurse
were investigated by the police and no charges were brought against her. Given
that there was no clear evidence that the airway was incorrectly inserted, we are
satisfied that Oxleas NHS Trust took appropriate action to carry out their own
investigation and provide the nurse with further training and guidance.
Governor to Note
63. Mr Tarrant’s family were informed of his death by telephone rather than in person.
The prison’s FLO said that Mr Tarrant did not provide details for his next of kin on
arrival, only his own address where he lived alone. The FLO said she made efforts
to try to find his next of kin, including liaising with the police, and she was eventually
able to trace his grandmother’s address from his last time in custody in 2014. Due
to the passage of time, she was not sure if Mr Tarrant’s grandmother still resided at
the address, which was quite some distance from Elmley. With the agreement of a
prison manager, she contacted Mr Tarrant’s grandmother on the telephone number
provided and informed her of her grandson’s death.
64. While we appreciate that there were some logistical reasons why staff at Elmley
were unable to attend the home of Mr Tarrant’s next of kin in a timely manner, we
consider that alternative arrangements, as outlined in PSI 64/2011, could have been
made to ensure that the family received the news in person. This may have
included liaising with a prison nearer to the home of the next of kin so that they
could attend the address on behalf of Elmley’s FLO or asking the police to attend
the address. We bring this to the Governor’s attention.
Inquest
65. At the inquest, held on 17 November 2025, the jury reached a narrative conclusion:
“Josh Yemi Tarrant died as a result of Cocaine toxicity following a lengthy and
challenging restraint. Josh was experiencing an acute behavioural disturbance
which was not recognised by Healthcare staff. Healthcare's failure to provide
sufficient medical treatment at the earliest appropriate opportunity by calling an
Ambulance by 23:49 was probably a significant contributing factor in Josh's death.
Josh's death was contributed to by neglect.”
12 Prisons and Probation Ombudsman
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