Winchester Prison inmate Alun King from New Milton was on “cocktail” of prescribed medications before death, inquest hears

A New Milton prison inmate died after having to take medication outside of his prescribed schedule, an inquest has found.

Delivering a narrative conclusion and “acknowledging the constraints on all prison systems”, jurors sitting at Winchester Coroners’ Court found Alun King (44), of Aspen Place, died of natural causes.

The inquest previously heard King was found collapsed and unresponsive on the floor of his cell at Winchester Prison at 11.33pm on 21st March 2022 – less than 30 minutes after a welfare check.

He died in the early hours of the next day, with a post-mortem later finding he had high levels of a prescription anti-depressant in his system.

Assistant coroner Sarah Whitby noted that two witnesses during the inquest described King as being on a “cocktail” of prescribed medications, including anti-depressants, when he arrived at the prison on 12th March 2022 awaiting trial for a “serious” criminal offence.

On his entry into prison, staff had assessed King as being at risk of self-harm and a risk to other inmates’ safety. King had been placed under Assessment, Care in Custody and Teamwork (ACCT) monitoring after self-harming shortly after arriving at Winchester Prison.

Following a four-day inquest, 11 jurors returned a narrative conclusion that King died as a result of “natural causes, although 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”.

Jurors had previously been told inmates at the prison would queue up to take their prescription medications under the supervision of an officer once per day. If they were suspected of “diverting” their medication, the officer had the authority to inspect their mouths.

Jurors also noted King was due for a review of his medication at the time of his death.

After hearing evidence from healthcare professionals and prison staff, jurors found King’s primary cause of death of respiratory depression was contributed to by central nervous system depression and a combined use of complex prescribed medications.

Jurors found these factors exacerbated King’s existing chronic lung disease, due to recurrent food aspiration, pneumonia and chronic obstructive pulmonary disorder (COPD).

The inquest previously heard King was admitted to hospital in Winchester on 20th March, two days before his death, suffering from respiratory issues.

The coroner said his speech appeared slurred and he was lethargic with low blood oxygen levels. She said King was admitted to hospital under the supervision of two prison guards, who reported that he seemed sleepy around 9pm on 20th March before later waking up and being “chatty”.

Against the advice of doctors, King later discharged himself from hospital – joking with staff that he was “immortal” – before he was returned to prison on 21st March.

Delivering their narrative conclusion, the jury foreman said: “The communication and management of Alun’s fluctuations in health in HMP Winchester, especially following his admission to Royal Hampshire County Hospital on 20th March and self-discharge on 21st March, 2022 appear to have been inconsistent.

“Acknowledging the constraints of all prison systems and the potential tension with medical healthcare needs, it is noted that prescribed medications were administered at standard times as opposed to potential prescribed times for the individual. A polypharmacy review by a relevant specialist was recommended for Alun but there is no evidence this was completed in full.”

Jurors also acknowledged that King arrived at prison on a “complex mix” of medications, and non-prescribed and illicit drugs. They also acknowledged there was no evidence of King planning to take his own life or that he was taking medications in excess of those prescribed by the prison doctor.

After thanking jurors for their work, the assistant coroner said the evidence heard in the inquest about the timing of medication delivery in the prison was part of a “broader point”.

She said: “I think the prison is very aware of the healthcare part of prison, and very aware of the problems of those coming in. Around 50% of them have issues like drug abuse. They’re very well aware of these problems.”