A Corby A man with serious mental health problems has died in prison aged 21 after taking spices, an investigation has found.
Thomas Hall did not receive the emergency care he would have received had he been treated in the community, according to a fatal incident report from the Prisons Ombudsman.
The report concluded her death at HMP Ranby was an accident, although ombudsman Sue McAllister said there was a delay between ‘code blue’ and the start of CPR it was ‘totally unacceptable’.
An agency nurse who treated Mr. Hall was referred to the Nursing and Midwifery Council and no longer works at the prison.
Hall, who lived at Corby’s Kingswood estate, was sentenced to two years in prison for robbery in October 2018 and was transferred to Ranby days later.
In late November, the report indicates that Mr. Hall damaged prison property and accessed the roof of the workshop before threatening to take a staff member hostage in an attempt to obtain a set of keys.
He was transferred to the segregation unit for 21 days of confinement in his cell, but said he would continue his bad behavior until he was transferred out of Ranby.
The segregation staff checked on him every hour and the nurses and the governor on duty saw him daily. On December 14, at 8:12 pm, staff saw Mr. Hall unconscious and blue around the mouth in his cell. Prison officers waited three minutes to enter the cell due to previous threats against them and the fact that they mistakenly thought that three staff members had to be present before they could enter.
Staff called a ‘code blue’ and a nurse arrived without a defibrillator. Officers who went looking for him found the medical room locked, so they had to go back for the key. This caused a seven minute delay and basic life support was not started until 20:19.
The defibrillator arrived a minute later, at 8:20 pm, but no shockable heart rhythm could be found. Although CPR was continued, paramedics who arrived 16 minutes later were unable to revive Mr. Hall and he was pronounced dead at 9:01 p.m.
The ombudsman’s report states: “The nurse is no longer employed as an agency nurse by the Healthcare Trust and has referred her conduct to the Nursing and Midwifery Council for investigation into her clinical practice.
“Examination of CCTV and body camera footage shows there was a seven minute delay from the time the code blue was called until CPR began. There was an additional one minute delay before a defibrillator arrived. and another two minutes. a minute late before the emergency medical care team arrived, which was totally unacceptable.
“It is impossible to know, if CPR had been started earlier, with the medical team available, if the outcome would have been different for Mr. Hall. It is imperative that all staff respond to medical emergencies as quickly as possible and that first aid is provided as soon as possible.”
Mr Hall’s death was the third drug-related death at HMP Ranby since 2015 and the ombudsman had previously raised emergency response concerns regarding a death in 2017.
Mr Hall had a ‘significant’ history of illicit drug use and had refused offers of help from the prison’s substance abuse team. He also told staff upon his arrival at HMP Ranby that he had schizophrenia and was self-medicating with cannabis rather than taking prescription medication. He had spent time as an inpatient in mental health wards after being sectioned and regularly heard voices telling him to “do bad things.”
He was awaiting an appointment with a psychiatrist at the time of his death.
A clinical reviewer found that Mr. Hall’s care had been equivalent to what he would have received in the community prior to his collapse, but the emergency response fell short.
The report stated: “As Mr. Hall was in the segregation unit because he had threatened staff, we are not saying that they should have entered the cell, but we are concerned that they believed they could not under any circumstances.
“The clinical reviewer found that the care provided to Mr. Hall during the emergency response was not equivalent to what he might have expected in the community. The nurse who responded to the medical emergency code did not have the proper medical equipment with her and there was a delay before CPR was started. We can’t say if this made a difference to the outcome for Mr. Hall.
“The autopsy found that Mr. Hall died as a result of the use of psychoactive substances. We are convinced that there is nothing to suggest that this was anything other than an accident.
“Ranby has comprehensive policies to address the supply of illicit drugs into the prison. However, we are concerned that despite this, Mr Hall was apparently able to access and use drugs in the segregation unit (where he was housed for the 15 days ). before his death).”
A post-mortem examination found that Mr. Hall’s cause of death was toxicity from synthetic cannabinoids. Toxicology results showed that he had taken Spice prior to his death.
The ombudsman made a number of recommendations to the prison, including;
– that the Governor ensure that the key drug problems in Ranby are identified and that the prison’s local drug strategy addresses these key problems.
– that the Governor ensure that staff fully understand the expectation that the preservation of life should take priority when considering entering a cell
– that the preservation of life should have priority when entering a cell
Prison inspectors, who visited Ranby just five months before Mr Hall’s death, had raised alarm about the prevalence and easy availability of illicit drugs, along with the associated problems of debt and violence. Incidents of psychoactive substance use were common. They were also concerned that the regimen in the segregation unit was lacking.
Psychoactive substances, which are also known as “legal highs” and have street names that include Spice and K2, are a serious problem throughout prisons because they are difficult to detect. They can increase heart rate, raise blood pressure, and reduce blood supply to the heart.
