A PRISONER died from the “toxic” effects of prescription drugs including two which were obtained illicitly.

The details of Martin Brake’s death in Armley jail, where many Bradford prisoners are sent, were revealed in a fatal incident report from the Prisons & Probations Ombudsman.

He had been sentenced to 47 months in prison for burglary, fraud and theft and died at the age of 55 in March 2020.

Brake was on an incentivised substance-free living wing, where prisoners are given privileges in exchange for agreeing to stay drug-free.

The report says: “Mr Martin Brake died on 29 March 2020, from the combined toxic effects of prescription drugs at HMP Leeds.

“Most of the prescription drugs found in Mr Brake’s system had been prescribed to him.

“The clinical reviewer was concerned that despite the known risks of prescribing that combination of drugs to Mr Brake, no one ever carried out a medication review.

“Two of the prescription drugs found in Mr Brake’s system had not been prescribed to him so he must have obtained them illicitly.

“Although Mr Brake told a prison GP that he had been buying prescription drugs from other prisoners, the GP did not pass this information onto wing staff or the substance misuse team.”

Brake had chronic obstructive pulmonary disease and suffered from chest infections and complained of pain in his arm, back and leg.

He was prescribed a range of pain relief and in September and October 2019, told a GP he was buying pregabalin on the wing for pain in his arm and neck.

“The GP did not tell wing staff or the substance misuse team,” says the report.

“A post-mortem examination found that Mr Brake died from methadone, amitriptyline, mirtazapine, gabapentin, pregabalin and codeine toxicity. Pneumonia and ischaemic heart disease were listed as contributory factors.”

A clinical reviewer found Brake was prescribed as a high amount of central nervous depressants – methadone, codeine, amitriptyline and gabapentin – and noted codeine is not advocated as a long-term option in prison due to its “highly addictive and tradeable” nature.

She said it should be prescribed with caution alongside gabapentin due its depressive effects on the central nervous system.

The clinical reviewer was concerned that she could see no evidence of any medication reviews in Mr Brake’s medical records.

On the illicit drugs, the report says: “The apparent ready availability of prescription drugs to buy or trade is a concern and is something that discipline staff should have been made aware of.”

The clinical reviewer found the care Brake received for his substance misuse issues “was not equivalent to that which he could have expected to receive in the community”.