Prisoner died after 'systematic failures' at Leyland's Garth Prison - nurse is suspended after investigation

A nurse has been suspended after a prisoner died at Garth Prison, near Leyland.
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After a lengthy investigation, last week it was revealed that the Nursing and Midwifery Council (NMC) has decided that Julie Warmington’s fitness to practice is impaired, and ruled that she can’t work for six months.

It follows the death of an inmate from a perforated stomach ulcer, who the NMC stated had been “subjected to systemic failings by the prison health service”.

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They said that Mrs Warmington’s failings were “only a part of the much wider picture.”

HMP Garth near LeylandHMP Garth near Leyland
HMP Garth near Leyland

What has happened?

The charges arose while Mrs Warmington was employed as a Band 5 Nurse by the prison.

On March 31, 2016, Patient A was transferred to Garth Prison from HMP Durham. A medical review upon his arrival found no physical health conditions.

Garth Prison Ulnes WaltonGarth Prison Ulnes Walton
Garth Prison Ulnes Walton

Patient A made his first complaint to the health care team on May 18, 2016, where he complained of having sharp abdominal pains and headaches on opening his bowels.

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Between then and November 2016, he made ongoing complaints of abdominal pain, rectal bleeding and vomiting.

On several occasions, requests for next-day GP appointments failed to occur and a referred to a colorectal specialist at hospital was cancelled by the hospital and then further dates declined by the prison.

By November 2016, the prisoner was complaining of persistent vomitting.

On December 7, 2016, tests confirmed that Patient A had a stomach ulcer caused by H pylori bacteria and was started on medication.

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By December 29, 2016, Patient A was still experiencing vomiting, and said that his health problems were causing him to contemplate self-harm or suicide.

An urgent apppointment for the GP clinic was cancelled and rebooked to a regular GP clinic for January 6, 2017. This was also subsequently cancelled by the hospital.

On January 5, Patient A complained of pain in his side which was so bad he couldn’t get out of bed.

Mrs Warmington told a prison officer that Patient A’s complaint did not warrant an immediate GP review nor a visit to healthcare, and declared him fit for work.

Code Blue emergency

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On January 10, 2017, Patient A told an officer that he was in a lot of pain. The officer continued his duties but within 15 minutes returned as other prisoners were banging on their cell doors reporting that Patient A was dying.

The officer observed Patient A bent over and complaining of pain and called a code blue emergency – which immediately alerts healthcare staff and the control room to call an ambulance.

When Mrs Warmington arrived, Patient A was on all fours and swore at her she asked him to sit up. She exited from the cell and said that she would not treat him while he was being aggressive.

Prisoners continued to express concern about Patient A and within an hour were refusing to attend work until Patient A was seen.

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An officer spoke to Mrs Warmington on the phone and it was said that she refused to see Patient A because of his earlier behaviour.

Patient A was unable to walk at this point, so the officer and several prisoners carried him up two flights of stairs in a wheelchair before the officer wheeled him into the GP.

The GP diagnosed psychogenic hyperventilation and prescribed antacid. Patient A never collected this.


The next day – January 11, 2017, Patient A was found collapsed and unresponsive on his cell floor. Officers were unable to find a pulse and so started CPR and called a Code Blue emergency.

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Mrs Warmington said she heard a call for assistance but did not realise it was a code blue. She failed to take an emergency bag with her, and instead it was taken by a healthcare assistant.

The CPR was not successful and the prisoner was declared dead at 9.57am.

The post-mortem concluded the cause of death was peritonitis caused by a perforated duodenal ulcer.


Mrs Warmington made full admissions to the following charges:

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- On November 10 2016, she did not tell Patient A to come back if his symptoms worsened, did not develop a care plan for Patient A and did not arrange a GP appointment.

- On November 24, 2016 she did not see Patient A in person and did not escalate his case to a GP.

- On January 5, 2017, did not carry out any observations on Patient A or arrange for another nurse to see him and did not escalate the case to a GP.

- On January 11, 2017, she failed to take the emergency bag.

Charges that were proved against her were:

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The on January 10, 2017, she did not ensure that observations were carried out, did not arrange for Patient A to be seen by a GP and refused to attend Patient A’s cell later in the day.

The panel found that Mrs Warmington’s conduct was a contribution to the loss of a chance of survival.

After the death

Mrs Warmington left the prison healthcare almost immediately after the death of Patient A and had been practising in a primary care setting without any

restrictions on your practice since then, without any concerns raised. The panel also heard many positive testimonials from colleagues.


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The panel was of the view that Mrs Warmington’s acftions “did fall seriously short of the conduct and standards expected of a nurse and amounted to misconduct.”

On handing out a six month suspension, a report states: “The panel considered that this order is necessary to mark the importance of maintaining public confidence in the profession, and to send to the public and the profession a clear message about the standard of behaviour required of a registered nurse.”

The Ministry of Justice has not responded to questions from the Post on the issue.

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