A city coroner has raised concerns with HMP Peterborough following the death of a woman at the city jail.

Fallon Adams died at the prison aged 37 in February 2023.

In a report to prevent future deaths, Simon Milburn, Area Coroner for Cambridgeshire and Peterborough, said Fallon came to her death by intoxication of mixed drugs – both prescribed and not prescribed.

The coroner said that the mixture of the drugs would have had a ‘sedative effect’ on Ms Adams – and at ‘no stage was Ms Adams given a specific warning or advice stating that taking additional non-prescribed medication could result in over sedation and death.”

The report said: “Failure to conduct adequate welfare checks and observations allowed for missed opportunities to intervene. Evidence of this was staff admitting to not being able to confirm respiratory movement observations, observations of movement and general observations of inmate.

"Unsatisfactory training was also highlighted in the evidence however this did not cause or minimally contribute to Fallon's death.”

Now Mr Milburn has set out a number of recommendations in a bid to prevent similar deaths happening in the future.

The report said that on February 9 2023, the alarm was raised by Ms Adam’s cell mate at about 7am.

Ms Adams had arrived at the prison eight days prior to her death. Her cell mate said Ms Adams was ‘heavily medicated’ describing her as being ‘off her face most of the time.’

Megan Phillips at Bhatt Murphy Solicitors, who represented Ms Adam’s family at the inquest said Ms Adams ‘wholly relied on the support and observation of prison and healthcare staff to inform her of the risks and monitor her adequately.’

She said: “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.”

An HMP Peterborough spokesperson said: “Our thoughts continue to be with Ms. Adams’ family and friends. A full Coroner’s Inquest has been held which examined all relevant matters and we have implemented all learnings, as well as building on the progress already made.”

A spokesperson for Northamptonshire Healthcare NHS Foundation Trust (NHFT) said: “We wish to convey our sympathies to the family and friends of Ms Adams for their loss. We are committed to learning from all incidents to ensure our practices and procedures are improved, and we will be preparing a formal response to the coroner to address the concerns raised in this report.”

The report to prevent future deaths is available to read at https://www.judiciary.uk/wp-content/uploads/2026/01/Fallon-Adams-Prevention-of-Future-Deaths-Report-2025-0647_Published.pdf