© Tom Blewitt & Zack Griffiths – HMP Prisons Justice Group
An independent investigation by the Prisons and Probation Ombudsman has concluded that serious failures in night-time welfare checks contributed to the death of a 33-year-old prisoner at HMP Birmingham.
Christopher Randall died in the early hours of 11 January 2025 from mixed drug intoxication, including the use of a synthetic cannabinoid, while undergoing detoxification in custody. He had been remanded to prison just five days earlier.
Mr Randall arrived at HMP Birmingham on 6 January 2025 following charges of theft and assault. Court documentation included a suicide and self-harm warning, noting extensive self-harm scarring and an attempted hanging two days prior to his arrest. During a welfare interview on arrival, Mr Randall denied suicidal thoughts, and prison staff decided that formal suicide and self-harm monitoring was not required.
A healthcare screening identified a complex mental health history, including anxiety, depression, PTSD, bipolar disorder and borderline personality disorder. Mr Randall also disclosed active withdrawal from alcohol and drugs. Toxicology testing on arrival was positive for cocaine, benzodiazepines, opiates and cannabinoids. He was allocated to the prison’s substance misuse service and placed on the Integrated Drug Treatment Strategy (IDTS) wing to begin detoxification, receiving methadone for opiate withdrawal and diazepam for alcohol withdrawal.
Under IDTS arrangements, prisoners should receive regular daytime clinical observations and nightly welfare checks during their first five days. While daytime checks were documented as completed and raised no immediate concerns, the Ombudsman’s investigation found that night checks were not carried out properly for three consecutive nights.
Nursing records repeatedly noted that Mr Randall could not be seen in his cell because a towel was draped over the end of his bed. On each occasion, the nurse recorded that he “may be asleep” and that the cell was not disturbed due to the time. CCTV evidence showed that despite notes stating that officers had been informed, no such conversations took place and no further action was taken. Required procedures for confirming breathing or signs of life were not followed.
In the early hours of 11 January, Mr Randall’s cellmate discovered that he was cold and not breathing and raised the alarm. Prison officers and healthcare staff attempted resuscitation, including CPR and defibrillation. Paramedics arrived within minutes, but Mr Randall was pronounced dead at 3.06am.
A post-mortem examination concluded that the cause of death was mixed drug intoxication involving a synthetic cannabinoid (MDMB-4en-PINACA), methadone, diazepam and cocaine. While methadone and diazepam were present at therapeutic levels, the pathologist noted that combining central nervous system depressants with stimulants carries unpredictable and potentially fatal risks. Evidence of thick mucus in Mr Randall’s airway suggested he had been deeply unconscious for some time before death.
The Ombudsman’s clinical reviewer determined that Mr Randall’s healthcare was not equivalent to the standard he could have expected in the community. The report concluded that had night checks been carried out correctly, staff may have identified that he was unconscious and intervened earlier.
The investigation also found that Mr Randall missed four doses of his prescribed diazepam after being transferred to the IDTS wing, as he was unaware of where to collect his medication. This lapse was not identified until he raised it himself, highlighting weaknesses in medication monitoring during detoxification.
While the prison was found to have a comprehensive strategy to reduce the supply and demand of illicit drugs, the report noted a rise in drug use at HMP Birmingham in January 2025, including two drug-related deaths within days of each other.
Following Mr Randall’s death, prison staff provided support to his family, fellow prisoners and staff members. An inquest held in December 2025 concluded that his death was drug related.
Although remedial action has since been taken by healthcare management, including enhanced auditing of night checks, the Ombudsman stressed that failures in basic observations represented a serious breach of duty of care.
Publishing the report, Ombudsman Adrian Usher said the findings underline the importance of focused, evidence-based and viable recommendations to prevent future deaths in custody.
HMP Prisons Justice Group 