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Sheriff Determines That The Death Of Prisoner At HMP Addiewell Could Have Been Avoided

Sheriff Keir found that the death of a man in HMP Addiewell, Scotland’s only privately run prison could have been avoided. It was determined that there were defects on the then current system of working within the prison. On the 20th of April 2019 John Smith died, in his cell, due to heart and lung disease. The prison service had been informed that Mr Smith suffered from severe chronic obstructive pulmonary disease and he had returned to the prison from hospital the day prior to his death. 

The deceased was imprisoned after being convicted of historic lewd, indecent, and libidinous practices and behaviour in January 2019. Prior to the trial Mr Smith had been diagnosed with having severe chronic obstructive pulmonary disease, a low BMI, prostate cancer, and hyperinflated lungs consistent with COPD. The physician examining him determined that there was approximately an 18% chance of him surviving the next 4 years. The prison had on record that the deceased suspected asthma, COPD, dependence on a wheelchair, low vision with cataracts, impaired hearing, prostate cancer, poor mobility, and frailty, and he was placed on the prison’s suicide prevention policy until 22 March 2019.

On the 16th of April 2019, the deceased began to display breathlessness. At this stage he was transferred to St John’s Hospital in Livingston. It was noted that he was frail and suffering from advanced COPD, hyper-inflated chest, and bronchospasm. However, on the 19th of April 2019 his condition became stable and he was transferred back to HMP Addiewell. He was placed in a single occupancy cell and requested that the 30-minute observations be stopped. Instead, he was observed every hour from a hatch on his cell door. It was noted that no observation took place on the night he deceased. 

It was determined that the cause of death was bronchopneumonia, COPD, and ischaemic heart disease. The crown submitted that there was ineffective recording of the instruction of the deputy charge nurse to maintain hourly visual observations. This was a considered a defect in the system and ultimately contributed to Mr Smith’s death.  

Sheriff Keir determined that: “There was no dispute that Mr Smith’s death arose as a result of natural causes. In the circumstances, Mr Smith’s death did not result from an accident, and it is therefore not necessary to make a formal finding under [section 26(2)(d)] of the 2016 Act.”

In relation to the measures taken to avoid the death he stated: “I am satisfied that there was a breakdown in communications between the healthcare staff and the prison staff and that this was exacerbated by the absence of written/recorded instructions specific to Mr Smith, the end result of which was that the intended overnight hourly observations were not carried out.”

He continued: “There was consistent evidence from witnesses that where someone was suffering from respiratory distress, there would be noticeable visual cues including rapidity of breathing, the person sitting up and leaning forward due to their inability to breath, and also that the person would be panicking as they struggled for breath.” 

He went on to say “Accordingly, I am satisfied that had there been effective communication between healthcare and prison staff, resulting in hourly visual observations being carried out, the signs of respiratory distress as Mr Smith’s condition deteriorated over a period of several hours would have been picked up during the course of those hourly observations.”

Addressing the issue of problems in the prison’s system, Sheriff Keir stated: “There was unchallenged evidence before this inquiry that instructions from healthcare staff to prison staff at HMP Addiewell for matters such as the overnight observation of prisoners were not routinely communicated/recorded in written form.”

He concluded that: “That said, it must be recognised that a new Standard Operating Procedure for the welfare of patients with deteriorating long-term conditions, illness or injury, such as Mr Smith, was implemented by Sodexo within HMP Addiewell with effect from 26 August 2020.”

The sheriff reasoned that Mr Smith’s death could have been avoided. However, there were no recommendations that were made as a result. It was considered that the new system addressed the issues which were identified at the time. 

 

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