The risk matrix

The researchers focus on the concept of the risk matrix which represents the collision of a number of related and unrelated and more or less predictable forces that converge in any individual case to lead to an unexpected death where substance use plays a part.

While the substance and its toxicity clearly are important, this is not the only factor at work and an adequate explanation requires attention to a number of interacting forces summarised below.

Risky substances

In addition to Spice, the researchers highlight the additional risks from people in prison using a combination of different substances, both illicit and prescribed.

Individual risk factors

We know that the increasing age of people in drug treatment is often cited as a contributory factor to the unrelenting rise in the number of drug-related deaths in the community over the last decade. The mean age of people who died from drug-related causes in prison was 39 years. Overall, 88% of people who died in prison from “non-natural” deaths over the 2015-2020 period had a recorded history of substance use, 57% were recorded as having mental ill health and 26% as having an underlying physical condition. The research provides details of the different mental health conditions of this cohort as well as their main offence – 65% of this group were in prison for violent offences.

Risky behaviours

The qualitative data analysis revealed examples where substances were being used in a ‘risky’ manner. In some cases, unknown substances were mixed with other prescribed medication or other illicit substances. In others, substances were stockpiled, and large amounts were taken all at once. For example, one man had a high level of prescribed medication in his system along with NPS. Although he had been prescribed both oxycodone and pregabalin, there was suspicion that he had obtained additional supplies of oxycodone within the prison and stockpiled it.

There were also instances where makeshift pipes and inhalers were constructed to consume substances and enhance their effects which increased harm. 

The drugs market in prison also generated risks and increased harm to individuals. In 29% cases, people had been involved in some way in the drugs supply in prison. There were a few deaths where substances had been concealed in the individual’s body and had burst.

Risky circumstances

The qualitative analysis revealed some of the ways in which the immediate situation increased the risk of death. PPO reports raised issues around the operational response to overdose events, including: delays between a medical emergency code being received and an ambulance being called, defibrillators not working or available or resuscitation not being started promptly.

Many of the deaths occurred during the night and only discovered when the cell was unlocked in the morning. At times, there was a lack of monitoring and people were left for many hours before staff went back to check on them.

Risky environments

The researchers also highlight the fact that prisons are typically risky environments and that these risks have been exacerbated by staff turnover, loss of experienced staff, lack of purposeful activity, poor standards of health care and lack of specific resources such as drug treatment, testing staff and sniffer dogs. They note that into this risk environment came an influx of new substances, initially undetectable and underestimated.

Conclusion

This is a detailed and informative study, showing the value of PPO reports (all published) as a source of valuable information for anyone wanting to tackle the scourge of preventable deaths in prison.

Thanks to Andy Aitchison for kind permission to use the header image in this post. You can see Andy’s work here