Wormwood Scrubs prisoner died with 7 unprescribed drugs

A prisoner at HMP Wormwood Scrubs died from multidrug toxicity on December 27, 2024, with seven unprescribed medications and three prescribed ones in his system. William Clark, 57, was found unresponsive in his cell at the West London prison. An inquest jury later found his death to be drug-related.

Concerns over drug trading and delays

A report by the Prisons and Probation Ombudsman (PPO) raised concerns about the trade and diversion of medication at Wormwood Scrubs, stating it is not sufficiently managed or monitored. PPO Adrian Usher noted it was impossible to determine how Mr Clark obtained the unprescribed drugs. The report also highlighted a significant and unacceptable delay in staff initiating emergency procedures when Mr Clark was found unresponsive, including a four-minute delay before an emergency code was radioed and a further two minutes before CPR began.

Mr Clark had been serving an imprisonment for public protection (IPP) sentence, handed down in 2006 for armed robbery. The PPO report found no policies were in place at Wormwood Scrubs to support IPP prisoners and that the prison was failing to reflect HM Prison and Probation Service directions on supporting these inmates. Mr Clark could also have benefited from a dedicated key worker, the report stated.

Among the unprescribed medications found in Mr Clark's system were methadone and gabapentin, both strictly regulated controlled substances in prisons. Inmates are required to take such medication in front of healthcare staff to ensure it is swallowed. Intelligence reports between April 2022 and February 2023 suggested Mr Clark might have been involved in supplying drugs within the prison, with reports of him receiving payments from family members of other inmates.

Inquest findings and prison response

In August, an inquest jury at West London Coroners' Court found Mr Clark's death was drug-related. The jury acknowledged failures concerning his location at Wormwood Scrubs as an IPP prisoner, inadequate oversight of medication queues, under-reporting of those suspected of being under the influence, and the delay in calling a code blue. However, the jury concluded that none of these failures contributed more than minimally, trivially, or negligibly to Mr Clark's death.

Wormwood Scrubs and its NHS provider have accepted all the PPO's recommendations. A Prison Service spokesman stated that actions have been taken to strengthen medication oversight, tackle drug misuse, and improve support for IPP prisoners. Healthcare staff have been instructed not to dispense medication without an officer present, and risk assessment systems have been revised. A regional drug and alcohol lead has been appointed for strategic oversight, and IPP prisoners are now prioritised for consistent key-working sessions. A twice-yearly staff awareness campaign has been launched covering emergency response protocols.