A coroner has raised concerns about prisoners’ out-of-hours access to medicines following the death of an inmate at HMP the Verne.
In a prevention of future deaths report published on August 14, senior coroner for Dorset Rachael Clare Griffin highlighted the absence of a process to “ensure hospital-prescribed medication is available when prescribed out of working hours”, as well as a lack of “regular refresher first aid and CPR training” for prison staff.
The report follows an inquest into the death of HMP the Verne inmate George Haldenby, who died of congestive cardiac failure and hypertensive and ischaemic heart disease on January 29, 2022.
It said Haldenby had a history of heart disease and later developed severe heart failure following an “incident of self-harm in March 2020”, and was prescribed “various medications to manage his heart disease”.
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It added that between January 10 and January 26, 2022, he “was not prescribed his furosemide medication by the prison healthcare”.
On January 21, after visiting the prison GP with “deteriorating heart failure”, Haldenby was taken to Dorset County Hospital, where his furosemide dosage was “increased from 20mg a day to 80mg a day”.
According to the report, the increased dosage was prescribed after 6pm, by which time the hospital pharmacy was closed for the weekend, and the prescription could not be dispensed.
The prison GP did not work on weekends so the prescription from the hospital “was not actioned until the next GP review” on January 26.
The first 80mg dose of furosemide was not taken by Haldenby until January 27, the report added.
Staff “believed he was faking”
Griffin said that on the morning of January 29, Haldenby was moved by several officers to the care and separation unit (CSU) to be showered and assessed after defecating in his cell the previous evening.
She noted that Haldenby “struggled to move to the CSU” and “collapsed” shortly after arrival.
She added that the healthcare staff who visually assed Haldenby “believed he was faking the collapse”, and instructed officers to sit him up before leaving the room.
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The officers grew concerned and placed Haldenby in the recovery position, and “could not feel a pulse” nor feel him breathing.
They called the healthcare staff again, who made an emergency call and initiated CPR, but Haldenby died later that day in hospital.
Griffin cited evidence from the Home Office-registered forensic pathologist, the doctor who issued Haldenby’s prescription in hospital and a consultant cardiologist, all of whom agreed that a “lack of medication played a part” in Haldenby’s death.
Coroner’s concerns
In her report, the coroner emphasised that “without all staff being suitably and regularly trained in signs of collapse and administering CPR, there could be a delay in delivering effective CPR” to prisoners.
Griffin also highlighted that where a prisoner is issued an FP10 prescription following hospital treatment, it “cannot be processed at the prison in the absence of a doctor or prescribing nurse”.
If a hospital pharmacy is shut, “there will be a delay in prisoners receiving necessary and lifesaving medication over a weekend or bank holiday period until staff are in the prison who can action the prescription”, she said.
Griffin acknowledged that HMP the Verne now has a duty doctor who “can be called upon out of hours to progress such prescriptions” - but stressed that there was still a “lack of local policy and process” regarding out-of-hours FP10s and the steps staff should take to “ensure a prisoner receives necessary medications without delay”.
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She also noted that while the prison keeps certain critical medications locked away on site, furosemide, which was “critical in Haldenby’s care”, was not one of them.
The coroner concluded that without renewed training and robust processes regarding out-of-hours prisoner prescriptions, there remains “a significant risk of future deaths”.
The report was sent to Haldenby’s family, Practice Plus Group, Dorset County Hospital, NHS England, the prison and probation ombudsman, the governor of HMP Guys Marsh and the governor of HMP Portland.
