AN Islander took a “fatal” amount of prescription medication despite a clinical nurse warning that he should not be given addictive drugs after his release from prison, an inquest has heard.
Islander Michael Connor was found lying dead at his flat in St Brelade by his mother Carolyn Connor on 20 February 2025.
Ms Connor said her son had been in and out of prison for minor offences and felt that the judicial system “let him down over” prior to his death at the age of 33.
At Morier House yesterday, acting coroner Deputy Viscount Matthew Berry resumed an inquest into Mr Connor’s death.
A post-mortem examination conducted by Dr Niki Stefanos, a consultant cellular pathologist at Jersey Hospital, was read into the record as part of the proceedings.
Giving evidence, she said that Mr Connor was found to have taken a dosage of alprazolam – also known as Xanax – in the “fatal range” prior to his being found unresponsive.
Dr Stefanos reported that the 120mg of alprazolam found in his system was significantly higher than the prescribed dosage of 6mg.
It was further heard that Mr Connor had also taken two other prescribed drugs – anti-anxiety medicine pregabalin and the opioid dihydrocodeine – alongside alprazolam.
The doctor said that three drugs had a “cumulative effect”, ultimately leading to his death by cardiorespiratory depression.
In a statement, his mother said that her son had struggled with socialising throughout his school years, before turning to alcohol and drugs in his adolescence.
She told the hearing that Mr Connor, who was in and out of prison for minor criminal offences, was “let down” by the Island’s judicial system “over many years”.
“He was clearly displaying behaviour and traits of autism and ADHD, [which] I mentioned many times to multiple professionals over the years,” she said.
However, Ms Connor said that concerns about her son’s neurodivergence “kept getting dismissed” by both probation and prison workers.
She added that her son came out of prison “a completely different person” after serving a four-month sentence at HMP La Moye from August to December 2024.
Faith Murray, a clinical nurse specialist for the Criminal Justice Pathway, told the inquest that she reviewed Mr Connor’s mental health on several occasions during his spell in custody.
She confirmed that he had undergone detoxification from the dihydrocodeine, benzodiazepines and alcohol as part of a “standard” procedure when somebody comes into prison.
It was heard that, during a handover on 3 December, Ms Murray had notified the prison healthcare team that Mr Connor should avoid being prescribed “any addictive medications” following his release from custody.
However, the inquest was told that he was later prescribed both dihydrocodeine and alprazolam by his GP on the day of his release.
Mr Berry told the hearing: “As we’ve heard from Faith Murray, Michael was detoxed from benzodiazepines, and opiates, and alcohol whilst in prison.
“He goes from prison to his GP surgery and then is immediately prescribed pregabalin, opiates and benzodiazepines, with 28 days’ supply of each.”
Dr Rizwan Anwer, who worked in Jersey as a staff grade psychiatrist between February 2024 and February 2025, assessed Mr Connor’s mental health on multiple occasions in the year leading up to his death.
He was asked by the acting corner whether he was “aware” that Mr Connor had been prescribed addictive medication during a consultation in January 2025.
“I cannot recall,” Dr Anwer said, “but as far as I am aware, I was not aware of the dihydrocodeine and alprazolam.”
He noted that the system in Jersey means that it requires the patient to “self-report” their prescriptions, even in a potentially psychotic state of mind.
Andy Weir, managing director for the Health Department, told the inquest that the Hospital is moving towards a single patient record, which will make it “much easier” to coordinate patient information.
He said that he “didn’t know” why information about Mr Connor not being prescribed addictive medication was not passed on to either his GP or psychiatrist.
“We couldn’t work it out,” Mr Weir reflected. “We couldn’t work out why someone hadn’t uploaded the information to the system.”
Mr Berry put to Mr Weir that it could have been because of an “operator error”, or a “technical error of some variety”.
The mental health chief responded: “So the thing that we’ve done now…is we’ve reviewed the discharge process from prison, twice since that time.
“You have now got a form, [and] you have to record on the form and pass on the information so that they can actually see that it has been done.”
The inquest continues.
