Inquest into the death of Tariq Dalton

Angelina Nicolaou, instructed by Duncan Lewis Solicitors represented the family of Tariq Dalton at the inquest at Surrey Coroner’s Court between 15 March – 15 April 2021. The inquest involved 8 interested persons.

Tariq Dalton died of a perforated ulcer whilst remanded at HMP Highdown. The jury were permitted to return a narrative conclusion which set out a number of failures and missed opportunities which contributed to his death

The jury’s narrative conclusion stated that Tariq attended a pain clinic and was assessed by the GP. He was prescribed Meloxicam pain relief without a co- prescription of a PPI, alongside other medications. The GP was unaware of two previous occurrences of vomiting blood (haematemesis) which were recorded on Tariq’s community GP records. However these records were not obtained. The jury noted that every prescribing clinician agreed that they wouldn’t have prescribed Meloxicam with a known history of haematemesis.


The jury found that Tariq was at a high risk of gastrointestinal irritation despite being assessed as moderate risk. They found that the continued prescription of Meloxicam throughout his time at HMP Highdown made a material contribution to his death.


The jury also referred to Tariq raising concerns about his health with staff which were recorded in his record, and noted that despite a number of requests for him to be seen by a GP, he was not assessed. The jury found that the failures to assess him in person by a GP were missed opportunities which made a material contribution to Tariq’s death.

The jury were also permitted to record ‘possible‘ contributions to Tariq’s death, and noted that the failure to prescribe a PPI to reduce the GI irritation caused by Meloxicam was a possible contributor, as well as ineffective communications between members of staff responsible for Tariq’s care. It was also recorded that Tariq’s behaviours and apparent mental health issues may have affected the care he received, and this may have contributed to his death.

INQUEST press release

File on Four –  A death sentence? The inmates dying after poor healthcare in prison

INQUEST: Deaths of racialised people in prison 2015 – 2022: Challenging racism and discrimination (featuring Tariq’s case)

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