A coroner has warned that future deaths could occur in custody unless action is taken, following an inquest into the death of Fallon Adams of Ipswich at HMP Peterborough, where a jury identified numerous serious failings in welfare checks, clinical observations and staff training.
On 31 December 2025, HM Area Coroner for Cambridgeshire and Peterborough, Simon Milburn, issued a Preventing Future Deaths report after concluding that Ms Adams, aged 37, died from intoxication by mixed drugs while on remand.
He said his investigation revealed matters giving rise to concern and stated: “In my opinion there is a risk that future deaths could occur unless action is taken.”
The report followed a four-day inquest held at Cambridgeshire and Peterborough Coroner’s Court between 24 and 27 November 2025.
On 27 November, a jury returned a conclusion that Ms Adams died of “mixed drug toxicity due to the combined effects of prescribed and non-prescribed medication”.
While the jury found that the failings identified were non-causative, it concluded that they were relevant to the circumstances of her death. Among its findings, the jury stated that a “failure to conduct adequate welfare checks and observations allowed for missed opportunities to intervene”.
Ms Adams died in the early hours of 9 February 2023, just six days after arriving at HMP Peterborough on remand. It was her first time in prison.
In his Preventing Future Deaths report, the coroner highlighted concerns about the combined sedative effect of the medication Ms Adams was prescribed and the lack of warnings given to her about the risks.
He said the evidence showed that “at no stage was Ms Adams given a specific warning or advice stating that taking additional non-prescribed medication/diazepam could result in over sedation and death”.
He added that while changes were being made following the inquest, “it was not clear that a specific warning in relation to the risks of over sedation was being implemented”.
Ms Adams arrived at HMP Peterborough on 2 February 2023, when she undertook a drug test and disclosed previous drug and alcohol misuse to healthcare staff.
She was prescribed a detoxification regime including methadone for opiate withdrawal and chlordiazepoxide for alcohol withdrawal.
This was the first time she had ever been prescribed these medications.
The decision to prescribe this regime was taken remotely by a GP who did not personally assess Ms Adams.
Concerns were raised during the inquest by her family regarding the decision to prescribe chlordiazepoxide, given that national guidance clearly recommends it should only be prescribed where there is no alternative.
It was accepted by the prison GP that Ms Adams “could simply have been under close clinical observation as an alternative to chlordiazepoxide”.
Although Ms Adams was placed on close clinical observations during the medication regime, no concerns were raised by staff.
The GP later acknowledged that pulse pressure readings taken on 6 and 8 February 2023 “could not have been a correct reading”, describing them as “nearly impossible” and stating that they should have been repeated.
Despite this, the nurse who undertook one of those observations considered the readings “normal” and did not raise any concerns.
The inquest heard that national guidance recognises the risk of over-sedation associated with the combined use of methadone and chlordiazepoxide. However, this risk was not recognised in any local prison or prison healthcare policies, and healthcare staff were not aware of it.
There was also no evidence to indicate that Ms Adams was warned about the “high risk of oversedation” associated with her medication regime, a risk which the coroner said would likely be increased if additional illicit medication was taken.
At some point prior to her death, Ms Adams took diazepam which had not been prescribed to her. The precise timing remains unclear.
The circumstances surrounding how she obtained the drug are unknown, although it was reported by other prisoners after her death that the diazepam “may have been given to her by another prisoner”.
On the afternoon of 8 February 2023, the day before her death, Ms Adams’ cellmate told a prison officer that she had fallen and was overmedicated. The officer spoke to Ms Adams for just 44 seconds while she was sitting on the floor, before deciding that there was no need to inform healthcare staff.
Later that evening, Ms Adams did not attend to collect her evening medication. No concerns were raised by healthcare staff, and no attempts were made to find out why she had not attended.
During the night, four separate checks were carried out by prison officers and healthcare staff. The records of those checks stated that Ms Adams was breathing and moving. However, the pathologist told the inquest that Ms Adams was “likely already deceased at the time of those checks”.
The assistant director of healthcare at HMP Peterborough accepted that the clinical checks were “inadequate”, a failing that was accepted by the court.
Ms Adams’ cell was unlocked by a prison officer in the early hours of 9 February 2023. Shortly afterwards, her cellmate alerted staff that Ms Adams was unresponsive. A Code Blue was called and CPR was commenced, but Ms Adams was pronounced dead at the scene.
The coroner concluded that Ms Adams died sometime between 6.33pm on 8 February and 7am on 9 February 2023.
She was found on the top bunk of cell 8 on wing B1 of HMP Peterborough.
The coroner’s report recorded evidence from Ms Adams’ cellmate, who described her as being heavily medicated in the days before her death and said she was “being off her face most of the time”.
On the evening before her death, the cellmate said Ms Adams fell from the top bunk and hit her head. She said she put Ms Adams back to bed, checked her for injuries and last spoke to her at around 7.30pm. Ms Adams was heard snoring until around 8pm.
A visual check was carried out by staff at 5.59am, with the officer recording that he could see Ms Adams moving. At around 6.25am, the cellmate attempted to wake her and found her cold to the touch, describing lifting her leg as “a dead weight” before raising the alarm.
Following the conclusion of the inquest, Megan Phillips of Bhatt Murphy Solicitors, representing Ms Adams’ family, said: “Fallon Adams was in the prison estate for less than a week, she had never been to prison before, she had never taken any of the medication prescribed to her prior and she wholly relied on the support and observation of prison and healthcare staff to inform her of the risks and monitor her adequately.”
She added: “Several preventative and risk reducing measures were available to the staff at HMP Peterborough, yet their training was insufficient and resulted in inadequate observations.
“Mixed drug overdoses remain a prevalent issue in the prison estate and without robust prison policy and responsible care, cases like Fallon’s will continue.”
Ms Adams’ family is represented by solicitors from Bhatt Murphy Solicitors and counsel from Doughty Street Chambers and is supported by the charity INQUEST.
Other interested persons in the inquest included Northamptonshire Healthcare NHS Foundation Trust, who oversee health care at the prison.
A spokesperson for the trust said: “We are committed to learning from all incidents to ensure our practices and procedures are improved, and we will be preparing a formal response to the coroner to address the concerns raised in this report.”
T
