\u2018Prevention of future deaths\u2019 report\u2019 (PFD)<\/a>, published on 13 April 2026, Jenny Goldring, coroner for inner south London, stated that Mark Robert Smith, aged 47 years, died at HMP Thameside, Greenwich, in January 2019.<\/p>\nAlthough his cause of death was cardiac arrest as a result of an epileptic seizure, the coroner also noted that, while not a direct cause of Smith\u2019s death, a \u201csignificant contributing factor\u201d was \u201ctoxicity related to pregabalin and sodium valproate level in someone with epilepsy together with a decline in physical and mental\u00a0wellbeing\u201d.<\/p>\n
The coroner wrote that before Smith\u2019s arrival at HMP Thameside on 8 January 2019, he had a documented history of asthma, epilepsy and depression. In addition, Smith was already prescribed pregabalin, dosulepin and sodium valproate, the coroner said.<\/p>\n
\u201cAll medication was maintained by the prison GP as before, with the exception of co-dydramol, which was replaced by an\u00a0as-and-when required dose of diazepam, and a change of route for pregabalin\u00a0administration from tablet to liquid, on a dose of 50mg per day for the first 7 days of\u00a0prison admission, increasing to 100mg per day thereafter,\u201d the coroner said.<\/p>\n
\u201cThere was a conflict between the pregabalin prescription shown on Systm 1 prison\u00a0medical records (3,100mls across 29 days), and the 50mg per dose recorded on the administration records. There was a failure to correct the prescription on Systm 1\u00a0despite it appearing a minimum of 6 occasions.\u201d<\/p>\n
She also said that on 17 January 2019, Smith was taken to Queen Elizabeth Hospital, Woolwich, after the prison GP observed \u201chigh temperature, tachycardia, sweating and generally delirious\u00a0presentation\u201d.<\/p>\n
\u201cHis medication upon arrival was kept to the same plan as prison,\u00a0including the increase in pregabalin dose to 100mg,\u201d the coroner said, adding that, while at the hospital, Smith was administered 2.5ml of liquid pregabalin twice per day\u201d.<\/p>\n
On 23 January 2019, a member of prison healthcare staff raised concerns about Smith\u2019s condition and requested a multidisciplinary team (MDT) meeting with Queen Elizabeth Hospital ahead of Smith\u2019s discharge back to prison, which did not take place, the coroner said. Smith was then discharged back to HMP Thameside on 28 January 2019.<\/p>\n
The coroner said that Smith was readmitted to hospital on 30 January 2019, after being observed to be having seizures on and off for three to four hours.<\/p>\n
\u201cDuring this admission at Queen Elizabeth Hospital, Mark was administered 2.5ml of liquid pregabalin twice daily,\u201d the coroner wrote.<\/p>\n
She added that Smith was discharged from Queen Elizabeth Hospital back to HMP Thameside on 4 February 2019, although staff were \u201cnot adequately prepared for Mark\u2019s return due to insufficient briefing and a declined MDT meeting\u201d.<\/p>\n
Following his return to prison, Smith\u2019s condition deteriorated rapidly, and he was kept on 15\u2011minute observations, the coroner highlighted.<\/p>\n
The coroner noted numerous checks were either missed or falsely recorded. She also said that there was \u201can inadequate handover\u201d between day and night healthcare staff.<\/p>\n
Smith was pronounced dead at 00:38 on 6 February 2019, after staff were unable to revive him. The coroner said that the defibrillator retrieved from the prison management office did not have batteries or pads.<\/p>\n
\u201cThe nature and extent of medical care and clinical observation by prison healthcare staff between 5 and 6 February [2019] possibly made a material contribution to Mark\u2019s death,\u201d the coroner wrote.<\/p>\n
The coroner said: \u201cThe inadequacy of handover and basic observation, and failings in sufficient record-keeping by the prison healthcare staff during the evening of 5 February [2019] after 20:30\u00a0meant that signs and symptoms of an epileptic seizure were not observed and, therefore,\u00a0an opportunity to perform life-saving measures in either administering medication to stop the seizure and\/or, ultimately, timely CPR, was missed.<\/p>\n
\u201cMark was administered doses of liquid pregabalin of more than 2.5 mL by healthcare staff while at HMP Thameside, and this probably made a material contribution to Mark\u2019s\u00a0death.\u201d<\/p>\n
\u201cOn the balance of probability, this is the most likely cause of the levels of pregabalin seen in the toxicology postmortem results,\u201d she added.<\/p>\n
Under her concerns, the coroner wrote: \u201cThe wrong dose of medication could be prescribed and\/or administered with life\u00a0threatening consequences.\u201d<\/p>\n
She noted that she had although she had seen \u201cevidence of significant\u00a0improvements in the healthcare provision at HMP Thameside since 2019 \u2026 as recently as 2024 to 2025 HMIP [HM Inspectorate of Prisons] and IMB [independent monitoring board] reports noted \u2018significant risks with management of medicines\u2019 and \u2018prescribing errors\u2019.\u00a0<\/p>\n
\u201cWhilst recent internal audits in 2025 show significant improvements, medication incidents (datix) are recorded in late 2025, and the principal pharmacist notes a very busy site with multiple prescriptions screened daily,\u201d the coroner added.<\/p>\n
The coroner also wrote: \u201cFurther, during the inquest it proved difficult to establish how Systm 1 (the\u00a0medical note system) operated and whether there were risks inherent in the\u00a0system itself. For example, it was suggested the system would convert mg into\u00a0ml or pre-populate entries such as 100 ml, in contradiction to the subsequent\u00a0PFD evidence provided.\u201d<\/p>\n
The coroner\u2019s report was sent to prison healthcare supplier Practice Plus, the chief executive of\u00a0Lewisham and Greenwich NHS Trust, the director at HMP Thameside and director general\/chief executive of HM Prison and Probation Service, all of whom have until 3 June 2026 to respond.<\/p>\n
In a statement to The Pharmaceutical Journal, a spokesperson for Practice Plus said: \u201cWe took over healthcare at HMP Thameside in 2023 and have ensured that any learnings arising from Mr Smith\u2019s tragic death have been addressed.<\/p>\n
\u201cAcross all of our prison healthcare services, we have layers of checks and safeguards in place to ensure safe and accurate prescribing of the medicines on our formulary, including on site where prescriptions are checked by a clinical pharmacist and a registered pharmacy technician. We very rarely prescribe liquid dosages of any drug, and pregabalin \u2014 which has since become a controlled drug \u2014 is only ever given in tablet form.\u201d<\/p>\n","protected":false},"excerpt":{"rendered":"A coroner has raised concerns over the potential for prescribing errors at a London prison after a prisoner…\n","protected":false},"author":2,"featured_media":391503,"comment_status":"","ping_status":"","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[7],"tags":[111,139,69,147],"class_list":{"0":"post-391502","1":"post","2":"type-post","3":"status-publish","4":"format-standard","5":"has-post-thumbnail","7":"category-science","8":"tag-new-zealand","9":"tag-newzealand","10":"tag-nz","11":"tag-science"},"_links":{"self":[{"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/posts\/391502","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/comments?post=391502"}],"version-history":[{"count":0,"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/posts\/391502\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/media\/391503"}],"wp:attachment":[{"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/media?parent=391502"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/categories?post=391502"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/tags?post=391502"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}