Prisoner Ombudsman Publishes Report into the Death of a Prisoner

Mr I collapsed in his prison cell and was taken to outside hospital but never regained consciousness. His life support machine was turned off two days later. The post mortem examination reported his death was due to a heart attack and tramadol toxicity.

He had a longstanding history of abusing prescribed medication and illicit drugs, and it transpired that he had taken significant quantities of tablets during the lunchtime lockup on the day he died. His eligibility to hold his own medication “In-Possession” was not reviewed when it should have been, which led to him being allowed to retain his medicines for four weeks prior to his death.

Mr I had previously complained of chest pains and had collapsed in the past. However even after hospitalisation and ECG tests, the causes of his chest pains and collapses were never diagnosed.

The clinical reviewer, Dr Hall, identified aspects of Mr I’s care which were better in prison than they would have been in the community, such as the fact that he was seen regularly by a psychiatrist and his mental healthcare was regularly reviewed. While in the Care & Supervision Unit (CSU), he had daily access to a nurse, was seen frequently by a GP and the nursing records were detailed and of high quality.

Dr Hall’s fundamental conclusion was that Mr I’s death was not foreseeable. However it may have been preventable had the causes of his chest pains and collapses been diagnosed. He also said some aspects of the resuscitation attempt were well-managed. Others could be improved, in particular the maintenance of emergency equipment, though this would not have impacted on the outcome for Mr I.

This report makes 11 recommendations for improvement, all of which have been accepted. Most significant are that the SEHSCT needs to improve reviews of In-Possession medication and feedback from outside hospital appointments. The NIPS needs to notify prison Healthcare Departments about failed drug tests and evidence of prisoners trading medications.

Prisoner Ombudsman Tom McGonigle said “Mr I’s unfortunate demise highlights the risks for prisoners who abuse prescribed medications, and the risks are even greater when other ailments exist - in his case it was an undiagnosed heart condition. I extend my sympathy to Mr I’s family and hope others may learn from their sad loss.”

Media contact

McCann Public Relations, Telephone: 02890 666322
Maria McCann: 07802934246 or Natalie Mackin: 07974935855

Notes to editors

1. The Prisoner Ombudsman’s Terms of Reference require the Office to investigate all deaths in prison custody. For further information see Terms of Reference for Investigation of deaths in prison custody.

2. The Ombudsman aims to provide the facts of the case and publish all material that is necessary to serve the public interest. This is balanced against legal obligations in respect of data protection and privacy for everyone concerned, and their views are therefore taken into account when publication is being considered. Mr I’s family indicated they are content for the findings of this investigation to be published, but requested that he should not be publicly identified.


Posted on November 02 2016