What happened
Josh Tarrant, 34, was remanded in custody on 31 October 2023 and taken to HMP Elmley on the Isle of Sheppey that evening, having smuggled cocaine into the prison. At about 10.30pm the officer supervising his houseblock found him calm and lucid.
An hour later his demeanour changed completely. He asked for help, said he was hearing voices, and repeated “help me, help me, help me”. He knocked a television to the floor and ran out. Officers restrained him on the floor using Control and Restraint techniques, and he showed unusual strength.
The night nurse attended after a delay because she had no key to the locked gates, made little assessment, and did not declare a medical emergency. The move to healthcare took about half an hour, under restraint. He was pronounced dead at 2.13am.
The outcome
An inquest jury concluded on 11 December 2025 that he died as a result of cocaine toxicity following a lengthy and challenging restraint. He was experiencing an acute behavioural disturbance that healthcare staff did not recognise. The failure to call an ambulance by 23:29 was probably a significant contributing factor, and neglect contributed to his death.
The medical cause was cocaine intoxication, with cardiac hypertrophy and exertion during restraint. Three Prevention of Future Deaths reports followed on 9 February 2026. No prosecution is recorded in the sources held.
What went wrong
Between 11.30pm and midnight he showed what the coroner called the classic signs of acute behavioural disturbance. Expert evidence was that a trained person would have concluded this within minutes, and that treatment before 1am would probably have saved him.
Neither prison staff nor healthcare staff had any training in it. Prison Service Order 1600 (2005) required incidents of this kind to be treated as a medical emergency, not a control and restraint incident. The policy existed. The night shift did not have it.
What it teaches
Agitation after cocaine is a medical emergency, not non-compliance. A man who says he is hearing voices and asks for help three times is describing a body in trouble.
Three things decided this case: the length of the restraint, the failure to recognise the disturbance, and the delay in the ambulance call. Each was a chance to change the outcome, missed by a different part of the system.
A policy that never reaches a night shift is not a policy. What reaches it is what has been trained and drilled.
Questions for the room
- Which of the signs he showed between 11.30pm and midnight would you have logged?
- You are the senior officer on site. The nurse calls it a psychotic episode. What do you say next?
- A nurse cannot get through a locked gate to reach a man in a medical emergency. Whose job is that, and when was it last tested?
Evidence and limits
Confidence: confirmed. Two Prevention of Future Deaths reports were read in full, and BBC reporting from the inquest is consistent with them. A third report is referred to in the record but is not in the pack, so the full set of concerns is not represented here.
The inquest concluded on 11 December 2025 and the reports followed on 9 February 2026, so the case may be cited outward with that stated. BBC reporting of 20 November 2025 describes six officers and a longer walk than the coroner records; this page follows the coroner. No member of staff is named.
Our restraint reduction training covers reducing how often restraint is used, and the monitoring that has to go with it when it is.
Sources
- Courts and Tribunals Judiciary, Prevention of Future Deaths report, ref 2026-0076, 9 February 2026 · https://www.judiciary.uk/prevention-of-future-death-reports/josh-tarrant-2-prevention-of-future-deaths-report/
- Courts and Tribunals Judiciary, Prevention of Future Deaths report, ref 2026-0077, 9 February 2026 · https://www.judiciary.uk/prevention-of-future-death-reports/josh-tarrant-3-prevention-of-future-deaths-report/
- BBC News, 20 November 2025 · https://www.bbc.com/news/articles/cj979px8leno
Reviewed 20 October 2026.