Prisoner Ombudsman publishes report into a Death in Custody

Published on July 20 2022

The Prisoner Ombudsman for Northern Ireland, Dr Lesley Carroll, has today published the findings of an investigation into the death of an individual in custody at Magilligan Prison.

Mr Samuel Pinkerton was 62 years old when he died on 23 August 2019 at Causeway Hospital following his transfer from Magilligan Prison on 22 August 2019. His primary cause of death is listed as Sepsis. An inquest is pending.

Mr Pinkerton was well known by Health Trust staff at Magilligan Prison and prior to his admission to hospital he had received regular medical treatment from nursing staff in relation to a number of chronic and complex health conditions.

Staff attending to him overnight on the 21 August 2019 treated him for a high temperature and recommended a hospital transfer. While Mr Pinkerton was initially resistant to the move, in the morning he agreed to be taken to hospital, and was escorted to hospital in prison transport rather than an ambulance.

Mr Pinkerton suffered a cardiac arrest while in hospital on 22 August 2019 and was taken to theatre. Following a further cardiac arrest in recovery, Mr Pinkerton died in the early hours of 23 August 2019.

As part of the Prisoner Ombudsman's Investigation, an independent clinical review was carried out by Senior NHS nurse specialist Kate Varley*.

The Prisoner Ombudsman invites independent clinical review of healthcare provision for those in custody to consider the standard of care provided. In Mr Pinkerton's case, there were particular challenges as he often imposed restrictions on his own care, for example, not attending appointments.

Ms Varley found that staff worked very hard to engage Mr Pinkerton in his primary healthcare and the team went above and beyond, recalling him for appointments more than the required two times.

Having reviewed the management of Mr Pinkerton's numerous long-term conditions, Ms Varley made two recommendations for improvement to care provision, one in relation to long term management of chronic conditions and the other in relation to the implementation of the Sepsis risk stratification tool. The implementation of these recommendations will contribute to effective handover of care to secondary services, in line with applicable NICE guidance. How information is shared between care givers in the custody setting and between custody and community remains an ongoing concern for the Prisoner Ombudsman who welcomed and endorsed both recommendations from the Clinical Reviewer and welcomed actions by the Trust in implementing these recommendations prior to publication of the report.

Commenting on the report Dr Carroll said:

"Both Prison Service and Trust staff did all they could to care for Mr Pinkerton. I have recommended changes to deliver assurance regarding standards of care, including monitoring and documenting that care. In many deaths in custody I am concerned about how information is shared between services. My recommendations in this case should ensure a standardised approach at the handover of care to secondary care services. In Mr Pinkerton's case, sepsis was a concern. The standardised care I recommend will include use of the risk stratification tool to identify sepsis.

It is of note that both Prison Service and Trust staff knew Mr Pinkerton well and they were aware of what he could cope with and what he found difficult. I have no doubt that they made the right decision to transfer Mr Pinkerton to hospital by Prison Service vehicle as he most likely would have refused to travel by ambulance. Nevertheless, the use of a Prison Service vehicle deviates from expected process and ran the risk of Mr Pinkerton having no access to emergency lifesaving equipment or paramedic support should he have arrested. Ambulance transport is the safest and best way to transport vulnerable people to hospital and an ambulance should have been called."

Commenting on the role of all those involved in the investigation Dr Carroll said:

"I am grateful to the Prison Service, the Trust and Kate Varley RGN for their contributions to this investigation. Others have helped in the information gathering process and I also extend my gratitude to them.

My report is written primarily with Mr Pinkerton's family in mind. I offer my sincere condolences to Mr Pinkerton's family on their sad loss and hope this report provides information that will be helpful to them. Following the death of a loved one in custody families are concerned to have as much information as possible about what happened and also be assured that any learning will be gathered and applied for the benefit of others in custody. While implementing my recommendations would not have changed the outcome for Mr Pinkerton, learning from his death should contribute to ensuring that individuals in custody with long-term health conditions benefit from regular, structured healthcare reviews that are properly documented and can inform handover to other care providers. I also hope that learning from Mr Pinkerton's death gives confidence to others who have a loved one in custody."

*Kate Varley is NHS Senior Head of Patient Safety and National Patient Safety Lead