Michael McDonagh was found unresponsive in his cell at HMP Forest Bank in February 2019
Staff at Forest Bank prison felt caring for prisoners on stretched resources was like working in a 'war zone', with mistakes 'not surprising,' an inquest has heard.
"To do one thing very well and in a way that's best practice means there is something you decide not to do," he added. He said he had first raised the concerns in October 2018 but the change did not happen until February 2019, as Mr McDonagh was 'anxious' about coming off the drug. The decision was eventually made in his absence on February 7 as he refused to meet with Dr Plunkett, the court heard.
"In retrospect I wish I had put him on an ACCT," he said, but added he believed he made the right choice with the information he had at the time.
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