Prisoner’s death at HMP The Mount raises concerns over drug use
A report by the Prisons and Probation Ombudsman has highlighted critical failings surrounding the death of a prisoner in July 2022
An investigation into the circumstances surrounding the deaths a prisoner at HMP The Mount has raised serious concerns about the ongoing supply of synthetic drugs, including PS (synthetic cannabinoids), in the prison.
A report by the prisons and probations ombudsman into the death of Max Marchant, 27, in July 2022 criticises the prison's handling of drug supply and demand, as well as delays in the emergency response when Marchant was found unresponsive in his cell.
HMP The Mount, located in an open and accessible rural area near the M25, has long been struggling to control the entry of illegal substances, particularly PS.
Despite the prison’s lower security measures and its location at a key junction for County Lines drug routes, the authorities have taken steps to combat the flow of drugs. A recent report highlighted that, while some measures had been implemented successfully, such as intelligence analysis and legal mail checks, the threat from drugs continues to evolve, making it difficult to keep pace.
These concerns have been exacerbated by the prison’s chronic staffing shortages.
At one point, 40% of staff were unavailable for operational duties, with 50% of officers not available to perform their roles, leaving the facility 30 officers short of the required staffing level.
In light of these issues, the prison began an emergency regime in October, restructuring the workforce to provide more consistent operations, but this was seen as a short-term solution. A significant gap in the effectiveness of drug testing programs was also noted, as the prison only managed to complete 17 mandatory drug tests in one month, with a population of over 1,000 inmates. This led to a lack of intelligence on the scale of the drug problem.
Moreover, the impact of staffing shortages on drug supply reduction measures, such as cell searches and support for the regional dog team, further complicated efforts. Without these critical resources, the prison is unable to accurately assess the extent of the problem. Even though some new measures have been introduced, including counter-corruption training and the implementation of a protocol for inmates found under the influence of drugs, it is feared that unless more action is taken to address the staffing crisis, the flow of illicit substances into the facility will persist. The report recommended urgent action from the Director General of Prisons to address these shortages and improve the prison’s ability to deliver a more effective drug strategy.
The report also revealed that, before his death, Mr Marchant was known to have used PS, despite being supported by a well-being worker. Although he had been made aware of the risks of PS, he was moved to a wing that was known to have a large quantity of the drug. His transfer was deemed to have increased the likelihood of him using PS due to his autism and ADHD, which affected his impulse control. "The fact that he died less than 36 hours later is stark," the report noted, urging staff to consider a prisoner’s individual risks before moving them between wings.
Mr Marchant’s case also highlighted the issue of debt and hooch brewing. Throughout his six-year sentence, he was involved in the illegal prison economy, with debts contributing to his behaviour. The prison’s efforts to manage these debts were questioned, with little being done to break the cycle that led to Mr Marchant’s persistent involvement in hooch brewing. Although he had a care plan in place, there were no records of his reintegration plan after returning to a standard wing, and he was found brewing hooch shortly after. The review noted the prison was in the process of reviewing its debt strategy and suggested care plans should be created for known debtors to help address the root causes of such behaviour.
In addition to these concerns, the response to medical emergencies at the prison has come under scrutiny. The failure to call a code blue emergency when Mr Marchant was found unresponsive led to delays in seeking medical assistance, with staff failing to promptly request an ambulance. The report also highlighted the absence of clear guidance for staff on when resuscitation should not be attempted, especially when signs of death are evident. The staff’s confusion led to distressing and undignified actions, and the report reiterated the need for better training on when resuscitation is inappropriate.
Finally, the investigation found that the prison’s mental healthcare was inadequate. Mr Marchant’s autism and ADHD were not sufficiently considered in his treatment, which largely focused on disciplinary issues rather than addressing his mental health needs. The clinical review highlighted the lack of risk assessment and evidence-based care for mental health patients, with the prison failing to provide appropriate interventions. It was recommended that the prison ensure that mental health staff are trained to recognise neurodiversity and make the necessary adjustments to support prisoners with conditions like autism and ADHD.
In light of these findings, a number of recommendations were made to improve safety, health care, and drug strategies at HMP The Mount. These included better management of staffing issues, clearer protocols for medical emergencies, and improved mental health care for inmates, particularly those with neurodiverse conditions.
A ministry of Justice spokesperson said “Our thoughts remain with the family and friends of Max Marchant.
“We've since accepted all of the report’s recommendations, and significant improvements have been made. These include bolstering frontline staff and clamping down on drugs and debt.”