New guidelines have already been introduced by police and the prison as a result of the death of remand prisoner, Michael Joseph Davidson.
Coroner of inquests John Needham made 15 recommendations which will be sent to the Health and Home Affairs ministers, chief constable, prison governor, Department of Health, the Drugs and Alcohol Team (DAT), the forensic medical examiner (FME) and general practitioners.
Among the recommendations is the need for more training, supervision and auditing regarding medical documentation completed and passed to the prison by police when transferring prisoners to Jurby.
Mr Needham also recommends: an investigation into whether urine testing for new prisoners should be carried out; the need for DAT records to be more easily available to the FME; the need for emergency radio alerts in the prison to be more specific; the Department of Health’s need to liaise with ambulance and accident and emergency staff regarding medical training for prison staff.
The coroner of inquests did, however, acknowledge that there have been improvements since Mr Davidson’s death, saying: ‘There is significant evidence of changes made already so as to improve matters.’
Mr Davidson, aged 26, died in his prison cell on March 13, 2012, with an inquest finding death was due to toxicity as a result of a combination of methadone, dihydrocodeine and diazepam.
The inquest also decided that the cause of death was the result of an accident but was contributed to by neglect on the part of the state.
Prescription drugs had been given to Mr Davidson while in police custody and also upon arrival at the prison.
On March 11, while in police custody, Mr Davidson was given 60mg of dihydrocodeine and 40mg of diazepam at 10.50am, then 60mg of dihydrodcodeine at 6pm, 60mg of dihydrocodeine and 20mg of diazepam at 9pm, and 60mg of dihydrocodeine and 40mg of diazepam at 8am the following morning on March 12.
He arrived at the prison that same day and was given 40mg of diazepam at approximately 2.40pm, and then 40mg of methadone at approximately 3.40pm, before being locked in his cell at 8.40pm. He was found dead by fellow prisoners the following morning.
The jury also decided that Mr Davidson had not been honest about medication with medical staff and that this was also a contributory factor in his death.
Police issued a statement after the inquest, saying: ‘We take our responsibility and duty of care to detainees seriously.
‘As the coroner has said in his findings, the process has improved and is different now, and we will follow his recommendation.’
The Department of Home Affairs also said in a statement: ‘A comprehensive review has already taken place since Mr Davidson’s death and measures have been introduced to improve procedures and communication between agencies.
‘Appropriate steps will now be taken to address the recommendations made by the coroner of inquests.’
The Department of Health said in a statement that they will ‘work to consider the recommendations fully and implement any necessary changes’.
They also said that there had been a comprehensive review since Mr Davidson’s death.