Sheriff finds death of chronically ill prisoner at HMP Addiewell could have been avoided

John Smith died as a result of heart and lung disease on 20 April 2019 in his cell in HMP Addiewell. It was known to the prison service that he suffered from a number of conditions including severe chronic obstructive pulmonary disease and he had returned to the prison from hospital the day before his death.

The inquiry was conducted by Sheriff Douglas Keir under the Fatal Accidents and Sudden Deaths etc (Scotland) Act 2016 in Edinburgh Sheriff Court.

No hourly observations

The deceased was imprisoned in HMP Addiewell after being convicted of historic lewd, indecent, and libidinous practices and behaviour in January 2019. Prior to trial he had been diagnosed as having severe chronic obstructive pulmonary disease, a low BMI, prostate cancer, and hyperinflated lungs consistent with COPD. It was prognosed by the examining doctor that his chances of surviving the next 4 years were approximately 18%.

It was noted by the sheriff that Sodexo, the operator of HMP Addiewell under contract to the Scottish Ministers, implemented its own policies in relation to the operation of the prison. On admission to prison in March 2019 it was recorded in the prison’s records 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 16 April 2019, the deceased was transferred to St John’s Hospital, Livingston, after he displayed increasing breathlessness. He was found to be frail with features of advanced COPD, hyper-inflated chest, and bronchospasm, but discharged back to Addiewell on 19 April after his condition became stable with a number of prescribed medicines.

On his return to prison, the deceased was placed in a single occupancy cell in the prison’s Selkirk Unit. Following his removal from 30-minute observations at his own request, it was determined that he would be visually observed via the hatch on his cell door on an hourly basis. However, no such observations were conducted during the course of the night on which he died.

The cause of death was identified as bronchopneumonia, COPD, and ischaemic heart disease. It was submitted for the Crown that there was a lack of effective recording of the instruction of the deputy charge nurse to maintain hourly visual observations, and that this constituted a defect in the system which contributed to Mr Smith’s death.

Breakdown in communications

In his determination, Sheriff Keir began by noting: “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.”

On whether there were any precautions that could have resulted in Mr Smith’s death being avoided, he said: “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.”

Addressing whether observation by non-medically trained personnel would have identified any problems, the sheriff said: “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 continued: “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.”

Turning to the issue of defects in the prison’s system of working, Sheriff Keir said: “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.”

However, he added: “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.”

For these reasons, the sheriff concluded that, while Mr Smith’s death could have been avoided, there were no recommendations that fell to be made in light. The new SOP was found to have addressed the concerns raised concerning the system in place at the time of Mr Smith’s death.