An inquest has revealed failings in the emergency response at a north east prison where a Newcastle man died after a drug cocktail was found in his system.
Simon Boyle, of Cowgate, Newcastle, died on December 2, 2018 at HMP Holme House in Stockton, where he was serving a five-year sentence for possession of a firearm. An autopsy revealed that the 31-year-old had died from the effects of a combination of methadone, psychoactive substances (PS) and alprazolam (a powerful tranquiliser).
The Prisons and Probation Ombudsman conducted an independent investigation into Boyle’s death and a report, published in 2020, ‘identified shortcomings in emergency response‘ after he was found unconscious in his cell .
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At around 5:20 a.m. on December 2, an officer saw Boyle lying on the floor of his cell and was unable to get a response from him or his cellmate, who was his uncle. The officer phoned a manager for help and medical staff showed up and saw clear signs that Boyle had been dead for some time.
They provided medical support for Boyle’s uncle who was breathing but unresponsive and at 5:45 a.m. he was taken to hospital by ambulance. At 7:15 a.m. a second ambulance arrived and paramedics confirmed Boyle had died.
The Prisons and Probation Ombudsman’s report said Boyle’s substance abuse and mental health care “was equivalent to what he could have expected to receive in the community.” However, it highlighted a number of concerns about the emergency response on the day of his death.
He said an emergency code was not used to effectively communicate the nature of the emergency when Boyle was found unresponsive because the officer did not know if he was cleared to radio a ‘ emergency code blue ” during the night.
However, investigators said this did not affect the outcome of Boyle, who was dead when found.
The report also noted that health personnel did not bring the official emergency response bag with them when responding to the emergency call. He said that while it made no difference in Boyle’s case, “in other circumstances it could be the difference between life and death.”
Investigators also pointed out that control room staff failed to notify emergency services that two inmates required medical assistance in accordance with prison guidelines.
He said: “This would have allowed the ambulance service to make an informed decision on what resources they needed to deploy. As a result, paramedics caring for Boyle’s cellmate could not confirm Boyle’s death and a second ambulance had to be called to confirm his death.”
The prison has been advised to ensure that staff understand their responsibilities in the event of a medical emergency and to ensure that healthcare staff bring official emergency response equipment with them when responding in the event of an incident.
In its recommendations, the report states: “The Governor should ensure that all staff are informed and understand their responsibilities during medical emergencies, including using the appropriate medical emergency response code, by radio if possible. , to effectively communicate the nature of the emergency. .”
He continued: ‘The healthcare manager should ensure that healthcare personnel bring official emergency response equipment with them when responding to a medical emergency.’
The report also recommended that “the governor ensure that control room personnel tell the ambulance service how many people need medical assistance so that it can deploy its resources appropriately.”
Sue McAllister, CBPrisons and Probation Ombudsman, said in the report: “My investigation identified lapses in the emergency response when Boyle was found unresponsive. Although this did not affect Boyle’s outcome, these lapses could mean the difference between life and death in other medical emergencies.”
The report also recommended that the prison ensure that major drug problems at Holmes House are identified.
Ms McAllister added: “I fear Boyle was able to obtain illicit drugs at Holme House with apparent ease. The prison must continue its efforts to prevent the supply and demand of illicit substances.”
HMP Holme House said it accepted the recommendation made in the report and said the staff’s thoughts were with Boyle’s family.
He pointed out that a number of measures, including body scanners, search dogs and enhanced searches of staff and visitors, are used to detect illicit items.
A Prison Service spokesperson said: “Our thoughts are with Boyle’s family and friends. We welcome the report’s findings and have implemented all of the Ombudsman’s recommendations.
“Drug discoveries have halved at HMP Holme House over the past four years, where they have benefited from a £125m investment to boost prison security across the country.”