Hodge Jones & Allen

Prison and nursing staff receive damning verdict. Case referred to DPP.

 

6 May 2010

 

HM Coroner for Mid Kent & Medway announces his intention to refer the case to the Director of Public Prosecutions (DPP) after damning jury verdict condemns both the prison and nursing staff at HMP Elmley.

 

On 4 May 2010, the jury returned a critical verdict following the death of 23 year old William Duke at HMP Elmley on 9 November 2005.  He died of an asthma attack in a three man cell.  The jury found he died from natural causes contributed to by neglect.

 

The inquest opened on 6 April 2010 before HM Coroner for Mid Kent & Medway Roger Sykes at Sessions House, Maidstone, Kent.  Evidence was given that Mr Duke had suffered from chronic asthma from a young age. He was remanded into custody for breaching his bail conditions.   On 7 November 2005, he was transferred to HMP Elmley on the Isle of Sheppey.  He was placed in a three man cell with two other prisoners.

 

Mr Duke saw the prison doctor on 8 November 2005 and reported that his seretide inhaler had run out, which helped prevent the onset of an asthma attack.  A new seretide inhaler was ordered but, although healthcare staff knew that this inhaler should be dispensed to Mr Duke the same day, it was never given to Mr Duke before his death.

 

Mr Duke began to experience breathing difficulties during the evening of 8/9 November 2005.  The cell bell was pressed around 1am and prison officers attended.  Mr Duke reported that he was suffering from breathing difficulties and chest pain. He also told prison staff that his other inhaler, a salbutamol inhaler which helps to relieve asthma symptoms, was not working in the sense that it was not having any effect. The nurse in the healthcare block at the prison was contacted, but failed to attend. 

 

Mr Duke’s cell mates allege there was another cell bell between 1am and 5am; this was denied by prison staff. 

 

Around 5am, Mr Duke’s asthma became critical.  The cell bell was pressed and prison officers attended and contacted Senior Officer Robert Woolacott, who was in charge of the prison.  He was one of the few people with a complete set of keys enabling access between various parts of the prison at night including healthcare and the prison house blocks.  Mr Woolacott was alleged to have said that he rushes for no-one.  Mr Woolacott refused to answer any questions at the inquest as to his whereabouts between 10.10pm on 8 November 2005 and 5am on 9 November 2005 on the grounds that to do so might incriminate him.  By the time medical assistance reached Mr Duke in his cell at about 5.55am it was too late.  He had collapsed on the bed and had died.  Some of the jury’s key findings include: -

 

1. Mr Duke died between 5am & 5.30am on 9 November 2005;

 

2. The system in place at HMP Elmley to ensure that Mr Duke received his seretide inhaler on the same day as prescribed was seriously inadequate;

 

3. The nurse’s response to the 1am call was seriously inadequate;

 

4. There was a serious failure by prison staff to ensure that adequate checks were performed on Mr Duke between 1am & 5am;

 

5. Between 5am & Mr Duke’s death, when his condition was obviously acute, no emergency procedures were followed to provide urgent medical attention.  This was a serious failure on the part of prison officers;

 

6. The training of the nurse on prison policies and procedure was seriously inadequate;

 

7. The training of prison officers on emergency procedures was seriously inadequate. 

 

After the jury’s damning verdict, HM Coroner Roger Sykes stated that Mr Duke’s death was entirely preventable.  Prisoners should receive the same standard of care as in the community.  He announced his intention to refer this case to the Director of Public Prosecutions to decide whether the nurse should be prosecuted for gross negligence manslaughter. He will report the nurse to the Nursing and Midwifery Council. He also announced that he will be reporting Robert Woolacott to the Head of the Prison Service after he refused to answer questions on the grounds of self-incrimination.  He will be contacting the Governing Governor about training, supervision and support for the prison officer on the house block.

 

Lastly, HM Coroner will be writing to the Secretary of State for Justice and the Secretary of State for Health with numerous recommendations to prevent future fatalities at HMP Elmley and throughout the prison establishment.  The family hopes Mr Duke’s death will lead to essential reform and important lessons being learnt.   

 

After the verdict Mrs Duke, William Duke’s mother, released the following statement through her solicitors: -

 

"Mrs Duke would like to thank HM Coroner and the jury.  Mrs Duke had faith in HM Coroner all along.  Billy died an appalling death.  It is clear Billy should never have died, let alone that way.  It was a damning jury verdict.  Mrs Duke is delighted that individuals will be held to account and the case is being referred to the Director of Public Prosecutions (DPP) to consider a criminal prosecution of the nurse for gross negligence manslaughter."

 

Mrs Duke would also like to extend her thanks to the charity INQUEST, who support has and continues to be invaluable to her and other families, who have lost loved ones in state custody.

 

Anna Thwaites, her solicitor at Hodge Jones & Allen LLP, said: -

 

"There was a catalogue of serious failures at HMP Elmley that led to Billy’s tragic death.  This case raises serious concerns about the care Billy and others receive in prison. We await an urgent response from the relevant authorities on what action will be taken following concerns raised by both HM Coroner and the jury."

 

Mr Duke’s family is represented by INQUEST Lawyers Group member Anna Thwaites from Hodge Jones & Allen LLP and Counsel Nick Brown from Doughty Street Chambers.