A 34-year-old father of five suffered cardiac arrest and died in HMP Elmley on the Isle of Sheppey due to cocaine toxicity following a prolonged restraint incident. Healthcare staff overlooked clear indicators of a medical emergency, according to the inquest verdict.
Incident Timeline
Josh Tarrant faced charges of robbery, actual bodily harm, and criminal damage after crashing a Nissan Qashqai in Sittingbourne on October 28, 2023. Police held him in custody for three days before his court appearance, after which officials remanded him to HMP Elmley on October 31 evening.
Despite a search, Tarrant smuggled cocaine into the facility. He appeared calm initially but grew distressed during a call with his mother, mentioning voices and suicidal thoughts. She alerted prison authorities afterward.
Around 11:30 p.m., roughly an hour after likely ingesting the drug, staff checked his cell. Tarrant stood bare-chested, staring out the window, repeating “help me” incoherently. He knocked over a TV and attempted to exit, prompting physical restraint.
During the restraint, Tarrant exhibited extraordinary strength, lifting multiple officers. The on-duty nurse suspected a psychotic episode but conducted minimal assessment and avoided declaring a medical emergency, which would have prompted an ambulance call. Instead, staff transferred him to the healthcare wing—a journey that stretched from five to 30 minutes.
Inquest Conclusions
Assistant coroner Scott Matthewson, presiding at Oakwood House in Maidstone, determined that Tarrant displayed acute behavioral disturbance (ABD)—a condition marked by psychosis-like symptoms, repetitive outbursts, random violence, and pain insensitivity. Staff failed to recognize these “textbook” signs and delayed treatment.
In the new cell, Tarrant remained agitated, damaging fixtures with forceful blows from his limbs and head, seemingly unaware of injuries. Staff relocated him again, but he soon became unresponsive. An officer discovered no breathing or pulse, triggering a “Code Blue” and CPR attempts.
Healthcare providers committed errors during resuscitation, including incorrect equipment use and improper i-Gel insertion that obstructed his airway. Paramedics arrived at 1:44 a.m. but could not revive him; Tarrant was pronounced dead at 2:13 a.m. on November 1, 2023.
The coroner noted that ABD training was absent among staff. Prompt intervention before 1 a.m. likely would have saved his life. Matthewson issued a Prevention of Future Deaths report, warning that without ABD education for prison nurses, similar fatalities risk recurrence. The Prison Service must respond by April 6.
Official Response
A Prison Service spokesperson stated: “Healthcare in prisons is the responsibility of the NHS – but we will carefully consider the coroner’s findings and will respond to the report in due course.”
Oxleas NHS Foundation Trust, provider for HMP Elmley, has been contacted for comment.
