The Public Law team acted for the family of James*, a 38-year-old man who died in February 2012 while serving a sentence of imprisonment at HMP Littlehey. James had type 1, insulin-dependent diabetes, and on 25 February 2012, during an outbreak of norovirus at the prison, he developed symptoms of sickness and diarrhoea.
James was confined to his cell as part of the outbreak control measures. Food and drink were brought to his cell and he was visited daily by healthcare staff who asked how he was, but didn’t assess his diabetes. They didn’t monitor his ketone levels or his blood sugar levels. James didn’t have any equipment to monitor his ketone levels.
On 29 February 2012 at 8.30am, a nurse visited James. She noticed that James was unwell and told him she would return later to check his blood sugar level. She didn’t do so. She attended a meeting and asked another nurse to check on James.
James was found collapsed in his cell at 10am on 29 February 2012 by a nurse and an officer at the prison. An ambulance was called and the nurse started CPR. A locum doctor was called to assist, who instructed that CPR should be halted and pronounced James dead shortly after 10:15am. Upon their arrival at 10:19am, the locum doctor informed paramedics that James ‘had passed’. However, one of the paramedics noted that James was warm to the touch and was concerned that no attempt at resuscitation was being made. The paramedic was unable to determine how much time had passed since CPR had been stopped.
‘99% of people treated in hospital for ketoacidosis recover’
Irwin Mitchell represented the family at the inquest into James’s death, which was held in January 2014. The clinical reviewer for the Prisons and Probation Ombudsman gave evidence at the inquest that by 27 February 2012, a competent nurse would have instigated a regime of active checking of blood sugar and ketone levels. The clinical reviewer considered that had James been properly monitored, by 28 February 2012 it was reasonable to assume that he would have been in hospital. He accepted that 99% of people treated in hospital for ketoacidosis recover.
A diabetes expert appointed by the Coroner stated that if ketone checks had been carried out on 27 February 2012, James would probably have been in hospital. If ketone checks had been carried out on 28 February he certainly would have been taken to hospital. The expert advised that he would have expected qualified nurses to be aware of the potential dangers of inter-current illness and diabetes.
‘An entirely preventable death’
After hearing evidence over a period of three days, the Coroner concluded that James “died an entirely preventable death as a consequence of an unacceptable failure to monitor and provide basic medical attention and also in circumstances where there was no system in place to ensure that such fundamental absence of attention could have been avoided.”
Following the inquest, the Public Law team secured compensation from the Ministry of Justice for the failures identified at the inquest which resulted in James’s tragic death.
*the name of the deceased has been changed to protect the confidentiality of him and his family.
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