Prisoner treatment delay criticised
Delays to the emergency medical treatment of a murderer who died after collapsing in his prison cell in Northern Ireland have been criticised by the Prisoner Ombudsman.
Newly recruited officers at Maghaberry high-security jail left David Brown, 46, for five minutes while they contacted a nurse and did not immediately call an ambulance.
However, his death in December 2012 from a brain haemorrhage could not have been prevented, watchdog Tom McGonigle said.
He was serving a life sentence after battering a mother to death with a brick almost 20 years earlier.
The watchdog's report concluded: "When Mr Brown was discovered in an unresponsive state, slumped off the side of the toilet in his cell, the Northern Ireland Prison Service (NIPS) staff response was inadequate."
The alarm was not immediately raised, a nurse faced unnecessary hold-ups reaching the landing and there was a delay in requesting an ambulance. While the inexperienced officers were away, other inmates entered his cell - infringing the dying man's dignity, the review added.
Brown pleaded guilty to murdering Mrs St Clair-Gunn, who was 46 and from Sandy Row in south Belfast, in May 1994.
The mother of two girls suffered fatal head injuries after being attacked following a night out. Her partially clothed body was dumped in the Shankill Road area of west Belfast.
Brown had been in prison since his arrest shortly after the killing.
The Prison Service has undergone major changes involving a redundancy package for long-serving staff and recruitment of new warders.
The two officers had only been out of training for four weeks; while both said they had not been trained in how to deal with this type of incident, the Prison Service training department flatly contradicted this.
The Ombudsman review said: "There were a series of inactions that indicated failure to recognise the gravity of the situation."
:: Brown was left unattended for five minutes with his cell door open;
:: The alarm was not immediately raised, meaning medical support staff were delayed in reaching the cell. It was almost 20 minutes after his initial discovery before an ambulance was requested;
:: The nurse was not made aware that it was an emergency;
:: It took seven minutes before the senior officer was informed;
:: Other prisoners were not locked in, some briefly entered his cell.
Brown died in hospital on December 15. Tests revealed prescribed painkilling drugs in his system. No other common substances were detected, despite speculation about a white powdery substance found around his nose at the time of his death. It was not possible to establish what the substance was.
A neurologist said his haemorrhage was not survivable.
Brown had been complaining of headaches and was seen twice by healthcare staff. The independent consultant neurosurgeon enlisted by the Ombudsman did not criticise his medical management at the prison and did not feel an opportunity to achieve an earlier diagnosis existed, or that another outcome could have been achieved.
The report recommended NIPS should ensure that all new recruits are able to identify potential emergencies and act swiftly and appropriately upon them.
It said clear instructions should be produced to determine what actions are to be taken when a prisoner has been found unconscious.
The service was warned to ensure meaningful support was provided to staff following every death in custody.
There have been three deaths at Maghaberry since Brown died. One appears to have been self-inflicted and two appear to have involved natural causes.
Maghaberry established a Prisoner Support and Safety Team (PSST), comprising a governor and five members of staff, in 2011. They have several responsibilities including supporting vulnerable prisoners but Brown was not engaged with them.
Prison service director general Sue McAllister said a number of important issues were raised by the Ombudsman in relation to response and inactions by staff. Recommendations for improvement in each have been accepted and implemented by NIPS.
"We will also continue to work in collaboration with the South Eastern Health and Social Care Trust to improve standards of prisoner care."
Mrs McAllister added: "I would extend my deepest sympathy to the family in what have been very difficult circumstances."