John Singleton

1. 1. failure to collect prescribed medication

   “During the inquest it came to light that [the deceased] was prescribed medications for depression and epilepsy whilst incarcerated. His compliance with medications was found to be sporadic and as a result he failed to collect a number of prescriptions to enable continuity of his medication. Some of the reasons around this were anxiety in attending to collect his medications and also periods of self-isolation. Whilst Healthcare at the prison were aware of some of the periods of non-compliance and in fact a”

2. 2. ineffective medication compliance monitoring system

   “The action taken by the prison after [the deceased]'s suicide was to put a cross check system in place by which pharmacy technicians cross reference the medication by way of a weekly stock check to identify the prisoners who have not collected medications or had the same dispensed, so that referrals can be made to the Healthcare team and or GP to task. Such a system is less than ideal as it is both resource heavy, carries real risks of not being accurate and in the Coroners view, for prisoners in possess”

3. 3. lack of automated medication compliance alerts

   “An automated flag alert via the system upon the failure to dispense or collect medication by a prisoner would be a far more efficient and effective way in which prisoners failing to comply with medications could be identified and actioned quickly and in which future deaths could be prevented”

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