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An NHS trust has announced it will reinforce awareness of medicines management policies around out-of-hours medicines access, in response to the death of a prisoner.
George Haldenby, who was serving a sentence at HMP The Verne in Dorset, died in Dorset County Hospital on 29 January 2022 following a collapse. His causes of death were identified as congestive cardiac failure, and hypertensive and ischaemic heart disease.
In a ‘Prevention of future deaths’ (PFD) report published in May 2026, coroner Rachael Griffin expressed concerns about “lack of process in place in prisons without 24-hour healthcare provision to ensure hospital prescribed medication is available when prescribed out of working hours, especially over weekends and bank holiday periods”.
Griffin said that Haldenby was not prescribed his furosemide medication by the prison healthcare service between 10 and 26 January 2022.
On 21 January 2022 — a Friday — Haldenby was taken to hospital with deteriorating heart failure, after having seen the prison GP. While in hospital, his furosemide prescription was raised from 20mg a day to 80mg a day.
The new prescription was issued after the hospital pharmacy had closed for the day and the prescription was taken back to the prison, the coroner noted.
On weekends, the prison healthcare team comprised two nursing staff and two support workers. The report said the prescription was not filled until 26 January 2022.
Griffin also noted that furosemide was not held by the prison pharmacy as a critical medicine.
While HMP The Verne now has a duty doctor who can process out-of-hours prescriptions, the coroner noted that there is a “lack of local policy or process to ensure the prison and healthcare staff have an understanding of how to deal with the situation should a FP10 be issued outside of hours when a prescribing health professional is not available in the prison to ensure a prisoner receives necessary medications without delay”.
Responding to the coroner’s concerns, Oxleas NHS Foundation Trust — which provides healthcare for prisons, including HMP The Verne — said that while a formal process had been in place since September 2024 across the south-west region through the implementation of the south west ‘Out-of-Hours Standard Operating Procedure’ (SOP), it would recirculate the SOP and associated guidance to all healthcare teams.
It also confirmed that ongoing training sessions will continue to reinforce staff understanding and compliance and said its ‘Medicines Management SOP Log’ would be redistributed to all heads of healthcare to improve visibility of current medicines-related procedures.
The response also noted that the existing SOP had not been requested or submitted during the coroner’s investigation.
For any future death in custody investigations where medicines management issues are identified, it said it would ensure regional pharmacists or head of medicines management were consulted to ensure all relevant documentation is submitted.
In its own response to the coroner, HM Prison and Probation Service said further collaborative work was being undertaken between prison and healthcare managers to “establish a clear and robust local process incorporating defined escalation routes, roles and accountability measures”.
“This will ensure that staff have the necessary clarity and confidence to respond appropriately when out-of-hours medication issues arise, supporting timely access to essential treatment and continuity of care.”
In a response to the PFD report, NHS England said that the national health and justice service specification details the core service delivery and standards that must be followed, and noted that “delivery against this specification is usually managed locally under contract management”.
“Of note, the healthcare provider has changed at HMP The Verne since George’s death.”
NHS England added that all national health and justice service specifications are currently under review, with the review expected to be completed by autumn 2026.
