Inquest: neglect may have led to prisoner’s death

Kingston Prison

Kingston Prison

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A PRISONER died due to natural causes, contributed by neglect, a jury inquest concluded.

Anthony Nolan, 49, was found dead in his cell at Kingston prison, Portsmouth, on December 22, 2009.

The day before, Mr Nolan told prison officers he was suffering from chest and arm pains and wanted a member of the healthcare team to visit him in his cell.

He went down to see a nurse himself and was seen by Sarah Taylor, who said he would need an assessment including checks on his blood pressure and temperature, and an ECG.

But as a clinic was being held, and staff felt Mr Nolan did not need urgent attention, he was told to return later.

When he did, he was abusive to both nurse Taylor and nurse Kay Steele, and wasn’t seen due to the staff’s zero-tolerance policy.

Mr Nolan also contacted his solicitor, who faxed over a note asking for a medical examination to be carried out. However, Mr Nolan was not taken to hospital, and wasn’t visited by medical staff in his cell.

Instead staff felt his symptoms did not require any assessment until December 22.

On that morning a prisoner officer opened Mr Nolan’s cell, where he appeared to be watching television.

Another prisoner raised the alarm when he realised Mr Nolan was not moving.

A pathologist concluded Mr Nolan died of heart disease.

Coroner David Horsley advised the jury on what points it should agree on, to reach a verdict of death due to natural causes, contributed by neglect.

He said: ‘You must find that probably, Anthony Nolan was someone who could not provide care for himself, in his case incarceration.

‘So there was a gross failure to procure or provide medicine, and that failure has led to, or contributed to his death.

‘Probably would mean more likely than not.’

The 12-strong jury deliberated for almost two hours, before returning its verdict.

Mr Horsley is now considering writing to the Ministry of Justice, to ensure prison officers check on prisoners when they open the cells.

The coroner is waiting for more information, before he decides if he will send the suggestion.

Solicitor Jessica Simor, representing Mr Nolan’s family, said she is putting forward four recommendations to the coroner.

These are looking at the recruitment of medical staff, their training, having a prison-wide policy on zero-tolerance endorsed by the NHS and that information is gathered quickly after a prisoner’s death.

Judy Hillier, director of nursing and quality for Solent NHS Trust, said that since Mr Nolan’s death, it has striven to ensure staff continue to develop their skills and competencies in line with good practice and guidance.

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