WINCHESTER Prison staff should be promptly told when an inmate returns from hospital, a report has said.

Alun King, 45, of Aspen Place, New Milton, died on March 22 2022, after taking an overdose of a prescribed antidepressant.

A recent report from the Prisons and Probation Ombudsman found that more could have been done to ensure he had the correct prescription after he returned from hospital.

The report was published following the conclusion of an inquest at Winchester Coroners' Court on May 7. A narrative conclusion was given: “Alun died as a result of natural causes, though his ability to manage his respiratory challenges and his other co-morbidities was compromised by prescribed medication treatment that was potentially administered outside of the optimal prescribed times and a polymorphy review was due.”

The report, written by Adrian Usher, said that Mr King was prescribed the antidepressant to be taken twice a day under supervision. It said: “It is unclear how he managed to take an excessive amount. It is possible he was not swallowing his medication and saving it for later use, though there was no intelligence to suggest he was doing so.

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“Mr King was taken to hospital on March 20 when he became unwell. When he returned in the early hours of March 21 after discharging himself, no one told healthcare staff. This was a missed opportunity for healthcare staff to monitor Mr King and check for signs of clinical deterioration.”

The report's findings said it was unclear how Mr King was able to take an excessive amount of the drug as he was not allowed to administer it himself and collected it twice daily. There was also no evidence to suggest that he had intentionally overdosed on his medication.

The report added: “The clinical reviewer found that aspects of Mr King’s care were not equivalent to that which he could have expected to receive in the community. When Mr King returned from hospital on 21 March, no one told healthcare staff. The Head of Healthcare told us that they would have monitored Mr King had they known that he had arrived back at the prison.

“The Governor should ensure that healthcare staff are told promptly when a prisoner returns from hospital, regardless of the time of day or night.”

Mr King was the 15th prisoner to die at Winchester since March 2019. Of the previous deaths, ten were from natural causes and four were self-inflicted. 

The report concluded: “There are no similarities between the findings from our investigation into Mr King’s death and our findings from the previous investigations.”