57-year-old William Clark – locked up in 2006 for armed robbery – died of ‘multidrug toxicity’
The death of a prisoner found with seven medications in his system which he should not have had raises fresh “concerns” about the trade in prescription drugs at a prison, a prisons watchdog has said.
William Clark, 57, was found unresponsive and died of multidrug toxicity on December 27 2024 at HMP Wormwood Scrubs, West London.
He had multiple controlled drugs and high-level medications in his system and there was also “a significant and unacceptable delay” in signalling there was an emergency and starting efforts to help Clark when he was found unresponsive, a report into his death has found.
He was found with seven medications in his system that had not been prescribed to him and three that were.
Prisons and Probation Ombudsman (PPO) Adrian Usher said: “It is impossible to determine how Mr Clark obtained the drugs which were not prescribed to him.
“However, the trading and diversion of medication at Wormwood Scrubs is not sufficiently managed or monitored.
“We have previously raised concerns that the head of drug strategy is not sufficiently supported to effectively tackle drug use and we remain concerned that this is the case.”
Clark was sentenced in 2006 to imprisonment for public protection (IPP) for armed robbery with a tariff to spend a minimum time in prison of five years and 18 days.
In the report, Mr Usher said: “This investigation found that there are no policies in place at Wormwood Scrubs to support those with an IPP sentence.
“I am concerned that the prison is failing to reflect HMPPS’s (HM Prisons and Probation Service) directions on the IPP sentence and the work that should be done to support these prisoners.
“Mr Clark could also have been better supported with a dedicated key worker. There was also a significant and unacceptable delay in radioing an emergency code and starting CPR when staff found Mr Clark unresponsive.”
Clark was released on licence in September 2017 and recalled in March 2018 following a further arrest for burglary.
In September 2018, he was sentenced to two years and six months imprisonment and released in May 2021.
In February 2022, was taken to Wormwood Scrubs accused of murdering his partner – the murder charge was later dropped.
Clark was unresponsive when an officer unlocked his cell on December 27 2024 so he could get his medication. She contacted other officers about what was happening.
The report states: “There was a delay of four minutes before staff radioed an emergency code when they found Mr Clark unresponsive and a further almost two minutes before they started CPR.
The clinical reviewer found that the healthcare Clark received was “mainly equivalent” to that which would have been provided in the community.
But they “shared our concerns about the management of medication queues”.
Among the seven different medications in Clark’s system that were not prescribed to him were two controlled substances – methadone and gabapentin – that are strictly regulated in prison, which inmates are never given to take away.
They must take them in front of healthcare staff who check the medication has been swallowed.
The ombudsman’s recommendations include a fresh look at the handling of IPP prisoners so they are “a priority cohort for key working with a consistent, dedicated key worker with whom they can build a meaningful relationship”.
The governor also needs to ensure there is “a robust quality assurance process” including staff knowing that immediately calling the correct medical response code, entering the cell at the earliest possible opportunity, and beginning CPR without delay are part of their responsibilities in a medical emergency.
In August an inquest jury, sitting at West London Coroners’ Court, found Clark’s death was drug related, the report states.
It adds: “The jury recognised failures with Mr Clark’s location at Wormwood Scrubs as an IPP prisoner, the failure to adequately oversee medication queues, under reporting of those suspected of being under the influence, and a delay in calling a code blue by staff who discovered Mr Clark.
“However, they concluded that none of these failures more than minimally, trivially, or negligibly contributed to Mr Clark’s death.”
Clark tested positive for cocaine and benzodiazepines in June 2022. The following month, he told staff he used non-prescribed medication and drugs. Staff referred him to the drug and alcohol service but he later declined to work with them.
Between April 2022 and February 2023, staff intelligence reports suggested Clark might be involved in supplying drugs in the prison.
It was said Clark had received payments from family members of other prisoners and one them told the prison he was supplying drugs on the wing.
Wing managers were told to monitor prisoner relationships.
The report states that by March 2024, staff suspected Clark to be under the influence of unknown substances three times, potentially involved in drug supplying within the prison and receiving medication from another inmate.
A month later, he tested “positive for benzodiazepines and cannabinoids and healthcare staff did not inform prison staff of the result”, the report states.
Staff opened a package of suicide and self-harm support measures for him in June when he spoke of taking his own life but closed it the next day.
Between June and December, a time when he took part in sessions with substance use services, he was “a polite prisoner who followed the regime, collected his medication, attended weekly bible studies, and caused no issues”.
In late June Clark heard he would not get parole.
Wormwood Scrubs and its NHS provider have accepted all the PPO’s recommendations.
A Prison Service spokesman said: “We have accepted the ombudsman’s recommendations and taken action at Wormwood Scrubs to strengthen oversight of medication, tackle drug misuse and improve support for IPP prisoners.”
Healthcare staff have been instructed not to dispense medication until an officer is present to supervise and to stop if they leave.
Compliance is monitored and risk assessments systems of the work have been revised.
The London Prison Group has appointed a regional drug and alcohol lead to provide strategic oversight of illicit substance management and give six-week updates to the Prison Group director.
IPP prisoners at Wormwood Scrubs are also prioritised for consistent key-working sessions.
A twice-yearly staff awareness campaign has been launched covering key response such as entering cells at the earliest opportunity and starting CPR without delay.
Stay informed about the latest West London news. Sign up for our MyWestLondon newsletter HERE to receive daily updates and more.
