Frank Bowmaker represented the family of Joe, whose inquest took place from 14 to 24 September 2026.

Joe was an inmate at HMP Brixton when he died on 2 February 2024. He had taken an overdose of his prescription medication. Joe had a diagnosis of emotionally unstable personality disorder and a history of mental ill-health, overdose and addiction.

The jury heard that, on 13 December 2023, a forensic psychiatrist allowed Joe to have a week’s worth of his medication in his cell (“in possession”). This was a potentially lethal amount in overdose. Four weeks later, the jury found that Joe asked to collect his medication daily instead (“not in possession”). Five days after that, he was identified as being at risk of suicide and/or self-harm and an ACCT was opened. In the final week of Joe’s life, his keyworker recorded him as saying that he was struggling with his addiction, had been beaten by prisoners due to debt and was self-isolating in his cell.

Despite these events, Joe continued to be allowed a week’s worth of his medication “in possession” in his cell until his death.

On the balance of probabilities, the jury found that:

• On 13 December 2023, insufficient consideration was given to Joe’s history of overdose, self-harm and substance misuse. The risk assessment was not wholly appropriate. If it had been, Joe’s death would have been prevented.
• Appropriate steps were not taken after Joe reported difficulty managing with his medication. If they had been, Joe’s medication would have been changed to “not in possession” and his death would have been prevented.
• The ACCT should have triggered a review of Joe’s medication before he died. The outcome of the review would have been that Joe’s medication was changed to “not in possession”. Had there been a review, Joe’s death would have been prevented.

Frank was instructed by Shakera Rahman at Duncan Lewis Solicitors.