HMP Forest Bank prisoner death result of medicine check failures

Michael McDonagh was found unresponsive in his cell in 2019

A prisoner died following the mismanagement of a methadone prescription, an inquest jury has concluded.

Michael McDonagh, 27, was found unresponsive in his cell at HMP Forest Bank in Salford in February 2019.

Bolton Coroner's Court heard he had been prescribed methadone after he self-medicated with opiates.

However, jurors concluded that he had not received adequate care after the prescription.

The panel found that the medical professionals responsible for the prescription had failed to carry out adequate enquiries into McDonagh's dependence on and tolerance to opiate medication before deciding to prescribe the drug.

They also concluded that prison health staff failed to monitor him in the days that followed in line with national health guidelines.

The court heard McDonagh should have been checked twice daily for five days for any side effects to the medication.

The jury found it was "probable" that the latter failing contributed to his death.

They also criticised the "serious failure of communication and task allocation between nursing staff" at the prison.

His post-mortem concluded that he died as a result of Bronchopneumonia, precipitated by acute central nervous system depression resulting from the combination of drugs in his system that included four prescription drugs, one of which was methadone.

Margaret Pomeroy (centre) said she will never forger her son's 'happiness and laughter'

His mother, Margaret Pomeroy, said: "HMP Forest Bank failed my son.

"I have been campaigning for over four years to get this inquest heard, to find out what happened to Mickey.

"It should never have come to this. Mickey was a prisoner, but he deserved to be treated with care and kindness, just like any other person. I cannot understand how a mistake like this was allowed to happen by the people that were supposed to be taking care of him."

She added: "The day that they handed him methadone they handed him a death sentence.

"This verdict will not bring Mickey back but I hope that lessons will be learned so that no one else has to die in this way."

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