David Morgan: Dead prisoner shown 'shocking lack of concern' by jail staff

David Morgan was an inmate at Chelmsford Prison at the time of his death

A prisoner who died was shown a "shocking lack of compassion, empathy and concern" by nearly all staff involved in his care the day he fell ill at an Essex jail, a report found.

David Morgan, 35, died following a drug overdose at HMP Chelmsford in 2018.

The treatment of Morgan, thought by staff to be drunk, was "nothing short of inhumane", said a delayed report.

The Prisons and Probation Ombudsman said it was not the first death at the jail to cause them "real concern".

Morgan told prison staff at 09:45 BST on 22 August 2018 that he had taken an overdose of his prescription medication in response to news he was to be transferred to another jail, where he said he would not be safe.

This overdose was not investigated, according to the Ombudsman's report, which describes it as an "extremely disturbing case".

"Almost every member of staff involved in Mr Morgan's treatment on 22 August showed a shocking lack of compassion, empathy and concern for his well-being and decency," the report said.

When Morgan became unwell, "staff made the assumption" without any evidence that he had drunk "hooch" or illegally made alcohol.

A nurse, told of the alleged overdose, agreed he should be taken to a holding cell to "sober up".

"Instead of being properly assessed by clinical staff, he was left in a holding cell for some two-and-a-half hours, becoming increasingly distressed and unwell," the report said.

Mr Morgan repeatedly fell on to the floor and a metal bench, and "despite the presence of several staff and the almost constant presence of a nurse" he "sustained a broken nose, a broken eye socket and fractures to both his legs during these falls".

He was taken to hospital after becoming unconscious, but died eight days later.

'Disturbed by uncaring culture'

The nurse's actions "fell so far short of what was expected that the clinical reviewer has reported her to the Nursing and Midwifery Council", the report said.

A use of force on Morgan was "unjustified" and "restraints were inappropriately applied" when he was unconscious during his transfer to hospital.

Acting ombudsman Kimberley Bingham, who drafted the report, called on the prison governor to apologise personally to Morgan's next-of-kin, "for the failure of her staff to exercise their duty of care to him while he was in their custody".

"I am particularly disturbed by the uncaring and disrespectful culture that appeared to exist among both prison and healthcare staff," she said.

A Prison Service spokesperson said: "The events that led to David Morgan's death were unacceptable and HMP Chelmsford has implemented all of the Ombudsman's recommendations.

"We have invested £1.2m to improve safety and security at the prison, put staff through extra mental health training and provided extra leadership support to change staff attitudes and increase morale."

'Awful treatment'

The ombudsman report noted there had been several deaths at Chelmsford since Morgan's, in which concerns had been expressed about healthcare at the prison.

An ombudsman investigation into a death in April 2019 concluded the healthcare provided was "unacceptably poor" and there had been a catalogue of failings by both health and custodial staff.

"We found that the death, like Mr Morgan's, was preventable," the latest report said.

"The prison needs to demonstrate that it now has the strong leadership and positive partnerships needed to ensure that the awful treatment Mr Morgan received is never repeated," it added.

It also found Morgan should not have been allowed to keep in his cell the muscle relaxant Baclofen, which is "toxic in overdose and is not a suitable medication for prisoners to be allowed in possession".

In 2021, an urgent warning was issued by the prisons inspector about the jail's failings.

HM chief inspector of prisons, Charlie Taylor, said inmates there were not being kept safe in one of the UK's "most violent local prisons".

Update 20 September 2023: This article has been updated to specify that the report highlighted a lack of compassion amongst those caring for Morgan on the day of his overdose.