Care of inmate who collapsed and died criticised

An ombudsman has criticised the emergency care of a prisoner who collapsed and died after an ambulance was called off when healthcare staff mistakenly believed he had taken drugs.

Thomas Simmons, 45, was in his cell at HMP Humber on 19 April 2022 when he suffered a seizure, which arose from an old head injury following an assault before he was jailed. He died in hospital the next day.

A Prison and Probation Ombudsman report said it had "concerns about the way in which the emergency response was managed" after an ambulance was stood down as staff thought he was "under the influence of an illicit substance".

The prison's healthcare provider said it could not disclose details of Mr Simmons' care.

Mr Simmons, who had been in and out of prison, had a history of substance misuse and was being monitored for suicide and self-harm because of his mental health issues.

He was sentenced to 11 months in jail on 19 July 2021 for possession of a bladed article, three months after he was assaulted and suffered a major head injury.

A year later, staff found the prisoner collapsed on the floor of his cell at about 15:30 BST, prompting staff to call "a medical emergency code", the report said.

He was put into the recovery position and, within eight minutes, a nurse said the ambulance was no longer required.

He was later given medication to reverse the effects of opioids because staff suspected he had ingested "illicit drugs". But Mr Simmons' condition deteriorated and he began to have a seizure and started to vomit, the report said.

The nurse requested an ambulance again but left the cell as she felt unwell, leaving an unqualified staff member to "manage the emergency situation, with a suction machine that did not work".

It took about 15 minutes before another nurse arrived with a working suction machine and took charge of the situation.

Mr Simmons later suffered a cardiac arrest and the ambulance arrived shortly before 17:00, with paramedics resuscitating him. However, he died in hospital in the early hours of the morning.

An inquest on 19 November 2024 concluded he died from a brain injury caused by a seizure but the delay in administering medication during his seizure contributed to his death, the report said.

In his findings, Prisons and Probation Ombudsman Adrian Usher said: "The clinical reviewer concluded that Mr Simmons' mental health and substance misuse care was of a good standard and equivalent to that which he could have received in the community.

"However, the clinical reviewer considered that the level of care given during the emergency response was inadequate."

He also said there were "some failings in the ongoing family liaison from the prison" and recommended sufficient trained family liaison officers.

In a statement, City Health Care Partnership CIC, which was responsible for the healthcare, said: "We were deeply saddened to hear of the death of Mr Simmons and our thoughts are with his family and friends.

"City Health Care Partnership CIC cannot disclose any details about the care of individual patients as this would be a breach of confidentiality but if any serious incidents occur in our services we do thorough and detailed reviews of what has happened and put any recommended improvements in place."

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