Coroner calls for stronger safety regime after Pentonville Covid death
Rebuke over Pentonville Covid death after inquest
Friday, 13th August 2021 — By Helen Chapman
A coroner has called for more stringent measures to keep prisoners safe after an inmate in Pentonville died from Covid-19 during a virus outbreak.
An inquest into the death of Khairul Rahman, 45, heard concerns about how often he was monitored at the jail in Caledonian Road before his death in hospital in January.
Coroner Richard Brittain has now written to healthcare providers used by the prison detailing his concerns.
“There does not seem to be a robust system in place in the prison healthcare setting for contemporaneous or accurate retrospective documentation of the timing of clinical interactions,” he said.
“I remain concerned that the lack of accurate documentation means that a subsequent review of the appropriateness of clinical care, in particular, response times is hampered.”
Mr Rahman died on January 22 at University College Hospital from Covid-19 after treatment following an outbreak in the prison.
He had been placed as at “moderate risk” of falling seriously ill to the coronavirus back in May 2020 due to an asthma diagnosis.
He became unwell on January 4 this year but had not reported this to staff, who became aware of his illness three days later.
During the inquest, the coroner heard evidence that observations were planned to take place once a day. It was also heard the prison uses a scoring system suggesting observations should be taken every 4-6 hours for patients with symptoms such as Mr Rahman displayed.
However, no further treatment or care was provided to the prisoner until January 8 at 1pm when emergency services were called due to a deterioration in his condition.
He was transferred to intensive care at the hospital in Euston but he later died.
Mr Brittain’s report said that when asked about the disparity between once a day and every 4-6 hours observations, a medical director had said: “I think the honest answer is that at the time, we were struggling across all prisons to be able to monitor people on a regular basis, ie, specifically between 4-6 hours but we were relying on the prisoners working with us to self- report any changes in their symptoms.
“I can’t explain why we didn’t do a further observation before that point actually.”
The coroner has put the head of healthcare at the prison and the regional medical lead at the Practice Plus Group, an independent provider of NHS services working at the prison, on notice that future deaths could happen unless “action is taken”. He did not recommend what that action should be.
The report added: “Whilst recognising that the prison environment differs from a hospital setting, I remain concerned that the care provided was not as guided by the scoring system and that no alternative system appears to be in place that can be used effectively in the prison healthcare setting.”
The Tribune revealed earlier this year that emergency measures over staffing had been taken at the prison after 70 employees were off either sick with the virus or forced to self-isolate.
At that time, around 50 inmates were said to have tested positive.
Strict measures are now in place meaning a majority of the roughly 1,000 inmates are confined to their cells for up to 23 hours a day with rehabilitation and educational workshops suspended and visitations restricted to exceptional cases on compassionate grounds.
Staff have to wear surgical masks and sanitation stations are spread out around the prison.
A Prison Service spokeswoman said at that time: “Carefully implemented measures in our prisons – including shielding the vulnerable, rolling out mass testing and introducing safe regimes – have undoubtedly prevented many deaths and limited transmission.”
