Peter Campbell
11 Mar 2026 · Coroner Mary Hassell · Inner North London
The coroner's concerns
1. drugs entering prison
“In the narrative conclusion, the jury recorded a failure to prevent drugs from entering the prison.”
2. failure to review medical records
“She did not read any part of his medical records before she saw him, and she did not know whether she was meant so to do. She was.”
3. insufficient patient interaction
“She spoke to him through the hatch in the cell door, with his cellmate present.”
4. lack of drug use discussion
“She did not have any meaningful discussion with him about his drug use, either the use that led to his collapse on 18 September 2024 or his use generally.”
5. inadequate harm minimisation advice
“She gave him various pieces of harm minimisation guidance in keeping with her training, including the advice to avoid using drugs whilst alone.”
6. lack of training compliance
“She did not know whether her interaction with Mr [name redacted] was in accordance with her training. I was told that it was not. She had not received further training or changed her practice since his death.”