A coroner has told the Ministry of Justice and a prison governor to take urgent steps to prevent future deaths in jail after an inmate took his own life.

An inquest last month ruled that Ian Miller committed suicide in his cell at Usk Prison after being given the “devastating news” that he could not live at home with his children after his release.

It was revealed that he had several drugs in his system at the time of his death, which he hadn’t been prescribed.

And Gwent Senior Coroner Caroline Saunders has now issued a Prevention of Future Deaths report calling for stricter control over the management of medication in the jail.

The jury inquest heard that Mr Miller was due for release on October 27, 2019, but was told at a probationary meeting that he would not be able to live at the family home or with his father-in-law.

He could not have unsupervised contact with his children, and might be homeless, he was warned.

In her report, Ms Saunders said: “Key persons present at the meeting did not have a prior relationship with Ian and did not know how devastating this news would be to him, and he was not placed under closer supervision.

“On 21st September 2019, Ian Miller took his own life by suicide. Despite efforts by prison staff and the emergency services, Ian could not be revived, and he died in the prison at 4.55pm.”

The cause of death given at the inquest was due blood loss from a cut wrist.

But Ms Saunders added in her report sent last week: “During the course of the inquest, evidence revealed matters giving rise to concern.

“In my opinion there is a risk that future deaths will occur unless action is taken.”

She has told the prison authorities the management of medication prescribed to prisoners should be improved, after the toxicologist determined there were a number of drugs in Mr Miller’s blood and urine that he had not been prescribed.

“The court was informed that all prisoners at HMP Usk are required to be capable of managing their own medication. The medications are not kept in a locked facility.

“The evidence provided clearly indicated that prisoners were trading prescribed medication which had become a form of currency within the prison.

“Ian’s former cellmate indicated this practice was rife and indeed Ian bought medication from other prisoners.

“Evidence was heard from the governor/head of safety at HMP Usk who informed the court that he was not aware of this practice, and it appears this was also not known by the prison officers.

“The court was informed that there is a system of randomised checks in place within the prison to attempt to determine whether prisoners are appropriately managing their medication, however prisoners have clearly found ways around this.

“Whilst the ingestion of unprescribed medication did not contribute to Ian’s death, this practice, if left unchecked, clearly puts the lives of other prisoners at risk in the future.”

She urged: “In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action.”

Ms Saunders also called on prison chiefs to confirm the steps they are taking to address the risks posed by prisoners at HMP Usk trading prescribed medication, and they have until March 2 to respond.

Their response “must contain details of action taken or proposed to be taken, setting out the timetable for action”.

Otherwise, they must explain why no action is necessary.