A prisoner died alone in his cell after packages of cocaine smuggled inside his body burst open and poisoned him.
Dean Robinson secreted four bags of the Class A drug in his rectum after being recalled to prison and sent to HMP Liverpool.
The 35-year-old had previously been jailed after scaling the roof of the Blarney Stone pub in the city centre in June 2016.
Mr Robinson was in handcuffs as he was being arrested when he escaped officers' grasp and fled onto Renshaw Street.
The Anfield man, also previously of Litherland, clambered onto the top of the popular Irish pub in a 90-minute stand-off.
During the incident, which caused Renshaw Street to be sealed off and traffic including buses on the busy route into the city centre to be closed, Mr Robinson hurled slates tiles onto the street below where crowds had gathered to watch.
In April 2017, he was jailed for 21 months for affray and possession of an offensive weapon, namely a rock found in a sock when he stopped by police at Rizzo’s off-licence in Mount Pleasant.
He stated he had the rock as he was sleeping rough and carried it for protection.
Mr Robinson was released from jail on licence at the halfway stage, but in the early hours of April 30, 2018, officers were called to the communal area of flats on Crosby Road South in Seaforth after locals reported suspicious behaviour.
Earlier this week, Liverpool Coroner's Court heard how the 35-year-old smelt heavily of cannabis and was searched, which revealed nothing.
Mr Robinson admitted he was wanted on warrant, which was confirmed by a check on the police national computer, and he was returned to jail.
The following day, May 1, the heroin addict was sent back to HMP Liverpool in Walton, and went through prison reception and healthcare screening when he was given methadone.
But 70 minutes after that process, Mr Robinson was discovered unresponsive in a single cell of the jail, prompting a "code blue" alarm.
CPR was started before he was taken to Aintree Hospital, where two bags of drugs were found concealed in his rectum.
Resuscitation continued but was unsuccessful and Mr Robinson was pronounced dead at 9.40pm on the same day.
A post mortem examination revealed two further bags of cocaine.
One bag remained intact, but the other had burst.
On Tuesday, Mr Robinson's cause of death was recorded as hypoxic-ischaemic brain injury, cardiac arrest and cocaine toxicity.
A conclusion of drug related death was given.
The government's Prison and Probation Ombudsman launched an investigation and criticised the Liverpool jail for some failings.
Sue McAllister said in her report: "I find that Mr Robinson’s clinical and substance misuse care fell below the standard he could have expected to receive in the community, although I am satisfied that this did not contribute to his death.
"I am also concerned that despite a comprehensive substance misuse strategy, Mr Robinson was able to traffic drugs into the prison.
"The prison will need to reassess their approach in line with the Prison Service’s recently published Prison Drugs Strategy."
A Prisons Service spokesperson said: "Our condolences remain with the family of Mr Robinson.
"Significant improvements have been made at the prison since his death including extra training for officers on how to deal with medical emergencies and measures to ensure detoxing prisoners are monitored overnight."
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In November 2018, a substance misuse service (SMS) pathway was launched to better care for prisoners with substance dependencies.
The prison’s drug strategy was updated in April 2019 in line with new national guidance
Six cells have been fitted on the induction wing with stabilisation doors.
This allows healthcare staff to observe detoxing prisoners overnight without unlocking their cells.
HMP Liverpool also introduced a body scanner to enable them to identify items being brought into the prison.
