By Prisoner who fell to his death was protesting over his medication
A prisoner fell to his death after climbing over a railing in protest, claiming his prescribed medication had been stolen.
David Atkinson, 42, was on a methadone programme and was also prescribed anxiety and painkilling medication pregabalin.
In January 2018 he told staff the pregabalin had been stolen and he needed more but prison staff said a prison GP would have to carry out a review first.
Two days later he became agitated, climbing over the railings of the first floor in protest before falling.
Atkinson sustained life-threatening injuries and was taken to hospital but never recovered and died on January 16, 2018.
Prison ombudsman Elizabeth Moody carried out an investigation into Mr Atkinson’s death.
Mr Atkinson was convicted of assault and breaching a restraining order on 10 October 2017 and he was sentenced to 26 weeks in prison, with a conditional release date set for 8 January 2018.
While in prison, Mr Atkinson had tested positive for illicit drugs and there were concerns about his behaviour.
He was described as acting “aggressive frequently and had a poor attitude to staff”.
On January 3, 2018, he was given seven-days’ worth of pregabalin but later told staff the medication had been stolen.
When he was told he would have to wait to see a GP before any more medication could be given, Mr Atkinson acted “aggressively and unpredictably” before threatening suicide.
Mr Atkinson told staff he was suffering withdrawal symptoms and was in pain, going on to tell a fellow prisoner he was going to climb over the railings in protest.
CCTV footage shows Mr Atkinson climbing over the rail and placing his foot on a red alarm bell to steady himself.
The bell was unable to hold his weight and gave way, causing him to fall to the floor.
Ms Moody identified a number of concerns following her investigation and listed three specific findings.
In the report she said: “Staff did not start ACCT (suicide and self-harm procedures) monitoring despite Mr Atkinson harming himself and threatening to kill himself. This decision might have been understandable if effective alternative steps had been taken to understand and address his concerns. They were not.
“A GP should have reviewed Mr Atkinson’s medication when he told staff that it had been stolen. This did not happen.
“Humber has started work on reviewing its policy of allowing prisoners to keep tradable prescribed drugs in their cells and to administer them themselves, known as holding medication in-possession. We consider that this work should be prioritised.”
Ms Moody then went on to make a number of recommendations following Mr Atkinson’s death.
She said: “The Governor should ensure that staff start ACCT procedures whenever a prisoner has recently self-harmed, expressed suicidal intent or has other significant risk factors. When, exceptionally, they decide not to begin ACCT procedures for prisoners with significant risk factors, they should clearly record the reasons.
“The Head of Healthcare should ensure that all clinical staff refer prisoners to GPs when they report their medication missing so that decisions on re-prescribing medication are fully considered and promptly taken.
“The Governor and Head of Healthcare should ensure the ongoing work on the administration of pregabalin and other tradable medications is completed as a matter of urgency and that Humber’s medication in-possession policy is updated to reflect any changes made.”
HMP Humber bosses were also asked why there was no safety netting on the wing. They told the ombudsman the railings on the wing were of a sufficient height to prevent prisoners from accidently falling or being pushed over them.
