Prisoner arrived at Leyland jail without critical medication - and died two weeks later

The Prisons and Probation Ombudsman probed the death of 51-year-old John Creevy in January 2022, and found that the physical care he received was not always equivalent to that which he could have expected to receive in the community.

The background

In 2015, Mr Creevy was sentenced to seven years in prison for robbery and violence against a person. He had epilepsy and was sent to HMP Liverpool. On March 12, 2020, Mr Creevy was transferred to HMP Lowdham Grange near Nottingham, and between March 2020 and January 2022, he had 24 epileptic seizures. In October 2021 he was also diagnosed with cellulitis in his left leg and several serious illnesses relating to his heart and lungs.

Transfer to HMP Garth

On January 13, 2022, Mr Creevy was transferred from Lowdham Grange to HMP Garth. Lowdham Grange did not inform Garth about Mr Creevy’s epilepsy, important impending follow-up appointments nor his recent admission to hospital. Mr Creevy arrived at Garth without his critical prescribed medications and an initial health screen was not completed. The next day, Mr Creevy did not attend an epilepsy review at hospital as information about the appointment was not handed over to Garth.

Death

At around 8.30am on January 25, 2022, an officer found Mr Creevy unresponsive. The officer shouted for assistance from another officer and radioed a medical emergency code blue (used when a prisoner is unconscious or has breathing difficulties) and an ambulance was called straightaway. Healthcare staff found no signs of life and did not try to resuscitate Mr Creevy. At 9.11am, paramedics arrived and confirmed that Mr Creevy had died.

The inquest, held from June 20-23 2023, concluded that Mr Creevy’s death was due to natural causes.

Review

A report issued this week by the PPO states: “The clinical reviewer found that the physical care that Mr Creevy received was not always equivalent to that which he could have expected to receive in the community. She found that Lowdham Grange did not pass information to Garth about Mr Creevy’s epilepsy, his recent hospital admission and follow-up appointments. Mr Creevy arrived at Garth without critical medication, and he was not fully assessed on arrival.”

Recommendations

A series of recommendations have been made to The Head of Healthcare at HMP Lowdham Grange, which should ensure that prisoners with significant health needs are transferred in line with national instructions, including that:

• significant health information is shared with the receiving prison, including about significant diagnoses, recent emergency hospital admissions and hospital follow up appointments; and

• all critical prescribed medications are transferred with prisoners to enable continuity of care.

Additionally, the Head of Healthcare at HMP Garth has been told they should ensure that reception health screens are completed for all newly arrived prisoners, in line with NICE guidelines.

Both Trusts responsible for the two prisons have accepted the recommendations and have completed actions to improve policies and methods of working.