Inmate 'accidentally' died after smoking morphine patch
The accidental death of a prisoner who smoked a morphine patch in his cell could have been prevented, an inquest has found.
Timothy Shaw, from Basildon, was found collapsed in his cell at HMP Chelmsford on 28 February 2017, and died two days later at Broomfield Hospital.
A post-mortem examination found he died of a brain injury caused by drug toxicity.
The Ministry of Justice (MoJ) said the safety of prisoners was a priority.
Chelmsford Coroners Court heard Mr Shaw was a drug user serving a six-year sentence for robbery.
A jury at the inquest unanimously found the 34-year-old's death was accidental, but agreed that, with better communication and more resources, Mr Shaw's welfare could have been better managed and that could have prevented his death.
Action plans will be submitted to the prison service to advise on preventing similar deaths.
In a statement, Mr Shaw's family said they had hoped the prison would be "an opportunity" to help him overcome his problems, and said they were concerned at the lack of response from prison and healthcare staff to stem "a significant problem with substance misuse".
Andrew Neilson, from the Howard League for Penal Reform, said Mr Shaw's death was "one of a number" at HMP Chelmsford in recent years, and was "part of an overall picture" that showed the "pretty dire state" of the prison system.
He said it was "particularly concerning" Mr Shaw's request to be monitored for self-harming was not carried out.
"This seems to add to a picture that we can see in reports into Chelmsford prison of a jail which has a lot of problems around overcrowding, around violence, [and] around drugs," he said.
"Perhaps in some cases staff are very stretched and are unable to respond to situations like this one, where perhaps different procedures should have been followed."
An MoJ spokesperson said: "This is a tragic case and our deepest sympathies are with Timothy Shaw's family and friends.
"The safety and welfare of people in our custody is our priority and we are addressing all the recommendations made by the ombudsman in this case.
"These include developing a health care action plan alongside the NHS, and significant improvements in communication with the prison's drug providers."