New inmate was not warned about mixing drugs - coroner

Concerns have been raised about healthcare at a prison where a female inmate died a week after arriving.

Fallon Adams, 37, died on 9 February 2023 after taking a mix of prescribed and illicit drugs with sedative effects, a coroner said, and she had not been warned of the dangers of mixing drugs.

In 2024, the Care Quality Commission (CQC) found the healthcare team at HMP Peterborough were in breach of national guidance regarding checks for detoxing prisoners.

Northamptonshire Healthcare NHS Foundation Trust (NHFT), which runs healthcare at the prison, said it was committed to improvement.

Adams, from Ipswich in Suffolk, had been prescribed a series of medications that had sedative effects and which were enhanced by a non-prescribed drug she took.

Her family raised concerns that she was only showing "mild withdrawal during her time in custody" and that she was prescribed withdrawal medication despite national guidance recommending that it should only be prescribed where there is no alternative, their legal representative said.

She had not been warned by medical staff of the risks associated with taking other drugs, specifically over sedation and death, warned the Cambridgeshire coroner Simon Milburn in a prevention of future deaths report.

"It was accepted by the prison GP that Fallon could simply have been under close clinical observation as an alternative to chlordiazepoxide," the family's legal team added.

They also raised concerns that no welfare checks were done when she failed to pick up her medication the night before she died.

In 2024, the Care Quality Commission (CQC) found the services run by Northamptonshire Healthcare NHS Foundation Trust (NHFT) were in breach of national guidance in terms of checks for prisoners detoxing from drugs and alcohol.

The CQC reported that it did not have a good system for checking when patients missed their medication.

Legal representative for the family, Megan Phillips of Bhatt Murphy Solicitors, said that having never been in prison before - or prescribed withdrawal medication - Adams "wholly relied on the support and observation of prison and healthcare staff to inform her of the risks and monitor her adequately".

The family believed there were "inadequate observations" due to insufficient training of prison staff.

"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," Phillips added.

An inquest jury also highlighted a failure to conduct adequate welfare checks and observations which "allowed for missed opportunities to intervene".

However, this did not cause or reasonably contribute to Adams' death, the jury concluded in November 2025.

A spokesperson for Northamptonshire Healthcare NHS Foundation Trust (NHFT) said it was "committed to learning from all incidents" to improve practices and procedures.

An HMP Peterborough spokesperson said it had " implemented all learnings" following the inquest.

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