Family And Lawyers Call For Lessons To Be Learned After Staff Didn’t Properly Check On Brother Who Died From A Haemorrhage

The family of a man who died after staff at a Kent prison didn’t have a plan in place to manage his health conditions, has welcomed a pledge by the Prison Service to take action.

John Henderson, died aged 54 in HMP Rochester. An inquest found that John, who suffered from epilepsy, causing seizures, and high blood pressure, had died from a sudden and fatal haemorrhage during the early hours of 27 May 2021.

Following John’s death, his sister, Janet Henderson, 49, instructed specialist public law and human rights lawyers at Irwin Mitchell to help establish answers regarding what happened to her brother.

The inquest hearing found serious issues in relation to the observation, treatment and management of John’s health. The inquest heard that John was moved to HMP Rochester after he was diagnosed with epilepsy in August 2020. On arrival, the healthcare team was made aware of his condition and high blood pressure. No action was taken following an abnormally low oxygen reading of 85% at a health screening in January 2021 and attempts by hospital neurologists to facilitate appointments for John were not acted upon.

On 26 May 2021, a member of staff who carried out checks at 8.45pm and 6am the next morning recorded that John appeared  to be sleeping. Another check followed at 8am but staff did not look into his cell, which they were required to do. The cell was unlocked at 9.15am, but it was 10.30am before John was found unresponsive in bed. John was pronounced dead at 10.52am and paramedics said he likely died six hours earlier.

The Prison and Probation Ombudsman launched an investigation which concluded John’s clinical care was “bordering on poor”. Staff hadn’t acted when his blood saturation was dangerously low; there was no long-term care plan for his epilepsy and hospital neurologist appointments were not facilitated.

Assistant coroner Ian Brownhill issued a Prevention of Future Deaths report asking the Prison Service and Oxleas NHS Foundation Trust, who provided healthcare services at HMP Rochester, to set out what steps it would take to reduce the risk of similar deaths in future.

The coroner’s report outlined concerns over information sharing procedures for prisoners with chronic conditions, including seizures, diabetes and cardiac issues. “There wasn’t “a clear process for prisoners to consent to disclosure of medical information to frontline officers so that they could be made aware that a particular prisoner may be prone to sudden or unexpected medical episodes.”

The coroner was concerned this lack of process meant that a prisoner could have “a sudden (but perhaps predictable) acute medical episode and front-line prison staff may not be made aware of what was causing the issue or how to respond.”

In a written response to the Prevention of Future Deaths Report, Oxleas NHS Foundation Trust confirmed it has worked with HM Prison and Probation Service to introduce a personal management plan to share information between healthcare staff and prison officers.

Healthcare staff will now identify prisoners with chronic conditions who need to be monitored during the induction process. An alert will be added to a prisoner’s record, providing guidance to prison staff about observations required and actions to take if a prisoner’s condition deteriorates.

In a written response to the Prevention of Future Deaths Report, HM Prison and Probation Service confirmed that in response to the Assistant Coroner’s concern that no one had checked on John’s welfare at the start of the day on 27 May 2021, the Governor of HMP Rochester has addressed this by requiring officers to carry out a morning welfare check each day. All prison officers must now ensure that prisoners respond to the prison officers during the morning welfare check.

Expert Opinion

“John’s loved ones continue to be devastated by his loss. Janet had grave concerns over John’s care while he was in custody and some of these were clearly shared by the coroner, given the contents of the Prevention of Future Deaths report.

“Nothing can bring John back, but we’re pleased the inquest fully investigated the circumstances leading up to his death. It’s some solace to the family that the lessons learned should help ensure that the issues seen in this case are not repeated in the future.” Kathryn Gooding

Speaking about her brother, Janet Henderson said: “John had his struggles but he was making efforts to turn his life around. I think the epilepsy and seizures had been a wake-up call and it’s devastating that he won’t now get the chance to make a fresh start.

“When we heard about John’s care in custody, we had real concerns. Prisons have a duty of care for those under their supervision and we were shocked to see the range of issues John faced. 

“It’s a relief to know these omissions didn’t lead to John’s death but they could so easily lead to someone else’s. It’s some comfort that lessons appear to have been learned and that the prison service now has a proper plan in place to monitor those with health conditions. If it saves the life of another person in custody, John’s death will not have been in vain.”

The inquest concluded that John died from natural causes as a result of ischaemic heart disease.

John’s family was represented by Kathryn Gooding and Oliver Carter of Irwin Mitchell, barrister Daniel Grütters of One Pump Court, and supported by INQUEST caseworker, Caroline Finney.