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Fallon Adams

29 Dec 2025 · Coroner Simon Milburn · Cambridgeshire and Peterborough
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The coroner's concerns

  1. 1. over sedation and death from combined sedative medications

    “Whilst an inmate at HMP Peterborough [the deceased] ADAMS was prescribed methadone (for opiate withdrawal) and chlordiazepoxide (for alcohol withdrawal). She also took non-prescribed [REDACTED] apparently obtained from an illicit source within the prison. All of these medications have a sedative effect which in combination have the potential to cause over sedation and death.”

  2. 2. lack of specific warning about over sedation risks

    “I also heard evidence in relation to Regulation 28 issues. Whilst it is clear that a number of relevant changes were being made it was not clear that a specific warning in relation to the risks of over sedation was being implemented.”

Responses

2025-0647-Response-from-Northamptonshire-Healthcare-Foundation-Trust.pdf ↗

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

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Fallon Adams · Recurance