Coroner demands action on prison safety

In a significant development following a troubling inquest, a coroner has called for better guidance for prisons on managing illicitly brewed alcohol, or "hooch", as well as the handling of medications. This request arose after the death of 35-year-old Sheldon Jeans, who was discovered dead in his cell at HMP Guys Marsh on or about 13 November 2022. An inquest jury concluded that his death, classified as misadventure, was due to the consumption of hooch and four different medications that had not been prescribed to him.

In response to the findings, the coroner has issued a prevention of future deaths report, highlighting the absence of national policy relating specifically to hooch and medication management in prisons. The report has been disseminated to the Department of Health and Social Care, HM Prison and Probation Service, HMP Guys Marsh, and Oxleas NHS Foundation Trust with a deadline of 19 September 2025 for their response outlining necessary actions.

During the inquest, troubling evidence surfaced about the prevalence of hooch in prisons, which is illicitly brewed from substances available to inmates. Alarmingly, in September 2022, just prior to Sheldon’s death, more than 215 litres of hooch were confiscated at HMP Guys Marsh. The inquest revealed hooch's sedative properties, which can become dangerous when consumed alongside certain medications.

The coroner remarked that while existing policies address the use of illicit drugs, they fail to address the risks associated with alcohol. Additionally, concerns were raised about inmates having access to medications that have not been prescribed to them. In Sheldon’s case, he had ingested four types of medication that were unauthorized.

The jury determined that while the substances in isolation were not fatal, their combination led to respiratory depression. It was highlighted in the inquest that medications at HMP Guys Marsh can either be administered under supervision or given to inmates for personal management. However, the process for how Sheldon accessed his medications remains unclear, although it was noted that prisoners can visit each other's cells during times of unlock.

The coroner’s report also pointed to evidence illustrating the disordered environment some inmates inhabit, with medications found unsecured in cells. This raises substantial concerns about the lack of policies governing how medication is stored and the necessary steps to take when prescriptions are discontinued.

Sheldon’s family expressed their devastation over his loss and emphasised the need for reform within the prison system. "Prison is not just a place of accountability – it is also a place of rehabilitation," they stated. They hope that the coroner’s report serves as a catalyst for real change.

In support of the family, Leigh Day partner Benjamin Burrows commented on the report's significance. "The coroner has highlighted some key issues," he said, urging for proactive measures across prisons nationwide to prevent future tragedies similar to Sheldon’s death.