On 27 November 2025, a jury in the Peterborough Coroner’s Court returned a conclusion that Fallon Adams, 37, died of mixed drug toxicity due to the combined effects of prescribed and non-prescribed medication. The jury found that a number of serious non-causative failings at HMP Peterborough were relevant to the circumstances of her death, including that a “failure to conduct adequate welfare checks and observations allowed for missed opportunities to intervene”.
The jury commented on serious issues in relation to the welfare checks and clinical observations, and in relation to the training of staff.
On 31 December 2025, HM Area Coroner Simon Milburn made a Preventing Future Deaths report raising the following matters for concern: “The evidence seemed to show 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. … Whilst it is clear that a number of relevant changes were being made it was not clear that a specific warning in relation to the risks of over sedation was being implemented.”
Megan Phillips at Bhatt Murphy Solicitors 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. 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.”
See press release here.
Read the Record of Inquest here and the Report to Prevent Future Deaths here.
Fallon’s family is represented by INQUEST Lawyers Group members Megan Phillips, Erica San and Alina Riedmueller of Bhatt Murphy Solicitors and Tayyiba Bajwa of Doughty Street Chambers. The family are supported by INQUEST Senior Caseworker Selen Cavcav.
