Prescribing of painkillers such as tramadol should be overhauled in Northern Ireland’s prisons, a medical expert said.
A prisoner who had taken significant quantities of the commonly abused tablets during the lunchtime lock-up at Maghaberry died from a heart attack and drug poisoning, a review by Prisoner Ombudsman Tom McGonigle found.
In some prisons tramadol is not prescribed. A leading doctor in Northern Ireland has previously said it should be upgraded to a class A drug and pathologist Professor Jack Crane has also expressed concerns.
Dr Rob Hall, who reviewed the case for the ombudsman, noted there were some prisons, such as HMP Parc in Wales, where tramadol and pregabalin were not prescribed.
The ombudsman’s report said: “In relation to prescribing of tramadol, pregabalin and mirtazapine – all of which are known to be abused in prisons – Dr Hall said this review should be the trigger to overhaul prescribing in Northern Ireland prisons.
“He acknowledged that it will not be easy but advised there is sufficient evidence that alternatives to pregabalin, tramadol and mirtazapine can be safely used.”
Dr Hall, a retired GP from Suffolk, said the prisoner’s non-attendance at a neurologist following an earlier collapse had not been followed up. There were also missed opportunities to be seen by a doctor after he complained of chest pains.
The inmate, known as Mr I, collapsed in his prison cell and was taken to an outside hospital but never regained consciousness. His life support machine was turned off two days later. The post-mortem examination reported his death was due to a heart attack and tramadol toxicity.
The ombudsman said he had a long-standing history of abusing prescribed medication and illicit drugs.
His eligibility to hold his own medication was not reviewed when it should have been, which led to him being allowed to retain his medicines for four weeks before his death.
Mr I had previously complained of chest pains and had collapsed in the past.
However, the causes of his chest pains and collapses were not diagnosed even after hospitalisation and ECG tests.
Dr Hall said aspects of Mr I’s care were better in prison than they would have been in the community – he was seen regularly by a psychiatrist and his mental healthcare was regularly reviewed.
While in the Care & Supervision Unit (CSU), he had daily access to a nurse, was seen frequently by a GP and nursing records were detailed and of high quality.
The ombudsman said: “Dr Hall’s fundamental conclusion was that Mr I’s death was not foreseeable. However, it may have been preventable had the causes of his chest pains and collapses been diagnosed.”
He also said some aspects of the resuscitation attempt were well-managed. Others could be improved, in particular the maintenance of emergency equipment, although this would not have affected the outcome for Mr I.
The report made 11 recommendations for improvement, all of which have been accepted.