Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0097, written 4 Apr 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 4 Apr 2021 |
|---|---|
| Reference | 2021-0097 |
| Deceased | Imre Thomas |
| Coroner | Nicholas Rheinberg |
| Coroner area | Lancashire and Blackburn with Darwen |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Alcohol, drug and medication related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1. NHS England P.O.Box 16738, Redditch, B97 9PT
2. NHS England, North West Preston Business Centre, Watling Street Road,
Fulwood, Preston, Lancashire, PR2 8DY1
1
CORONER
I am Nicholas Leslie Rheinberg, assistant coroner for the coroner area of Lancashire
and Blackburn with Darwen
2
CORONER’S LEGAL POWERS
I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009
and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
3
INVESTIGATION and INQUEST
Following his death at HMP Garth on 12th September 2019 an investigation was
commenced in respect of Imre Paul Thomas born on 3rd October 1973. The investigation
concluded at the end of the inquest on 29th March 2021. The conclusion of the inquest
jury was that the deceased died by misadventure of asphyxia due to aspiration as a
result of tramadol and multiple drug toxicity.
4
CIRCUMSTANCES OF THE DEATH
Sometime prior to 2014 the deceased had fractured bones in his hand. At some point
the area had become infected and the deceased was suffering increased levels of pain.
In August 2017 the deceased attended a GP appointment at HMP Garth. Pain killing
medication in the form of dihydrocodeine was prescribed and an appointment with a
consultant orthopaedic surgeon was arranged for November of that year. The
appointment was cancelled. In between August 2017 and the deceased’s death in
September 2019 a total of nine orthopaedic appointments were cancelled, three by the
hospital, two by the deceased and four by the prison because the prison was unable to
arrange an escort. The deceased complained of increasing levels of pain which he
claimed was not met by the prescribed dihydrocodeine. The deceased took to acquiring
painkilling medication from other prisoners and his death on 12th September 2019 was
as a result of an overdose of tramadol and other prescription medication illicitly obtained.
HMP Garth and HMP Wymott stand adjacent to each other on a site in Leyland
Lancashire. Together they have a population of over two thousand prisoners. Each
week between them they send approximately 35 prisoners out for hospital appointments
thereby employing a minimum of seventy officers as escorts at a significant cost to the
NHS. As was seen in the present inquest, hospital visits are cancelled for a variety of
reasons including lack of officer escorts and hospital cancellations. Such cancellations
carry with them a risk of harm to prisoner patients and the cumulative effect of
cancellations could potentially give rise to serious untreated illness or death. There are
several clinic rooms at the healthcare departments of both prisons which could be used
for specialist clinics by visiting hospital consultants thereby avoiding cancellations to the
benefit of both prisoner patients and hospitals saved from cancelled or late
appointments together with cost savings in respect of prison officer escorts.
1
5
CORONER’S CONCERNS
During the course of the inquest the evidence revealed matters giving rise to concern. In
my opinion there is a risk that future deaths will occur unless action is taken. In the
circumstances it is my statutory duty to report to you.
The MATTERS OF CONCERN are as follows. –
Cancelled hospital appointments putting vulnerable prisoners at risk. As the
commissioning body you are asked to investigate the possibility of organising special
prison clinics for visiting hospital consultants.
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you have the
power to take such action.
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
namely by 1st June 2021. I, the coroner, may extend the period.
Your response must contain details of action taken or proposed to be taken, setting out
the timetable for action. Otherwise, you must explain why no action is proposed.
8
COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to the following Interested
Persons namely the family of the deceased and the Greater Manchester NHS Trust. I
have also sent it to the heads of Healthcare at HMP Garth and HMP Wymott who may
find it useful or of interest.
I am also under a duty to send the Chief Coroner a copy of your response.
The Chief Coroner may publish either or both in a complete or redacted or summary
form. He may send a copy of this report to any person who he believes may find it useful
or of interest. You may make representations to me, the coroner, at the time of your
response, about the release or the publication of your response by the Chief Coroner.
9
Dated 4th April 2021 SIGNED Nicholas Rheinberg
Assistant Coroner
2
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