|
|
 |
| |
Woman prisoner found dead in her cell ‘was failed by staff’
Jail ignored warning signs before inmate died after taking heroin substitute
SYSTEMIC failure at Holloway women’s prison led to the death of an inmate, an inquest has heard.
Lyndsey Wright died in her cell on March 8, 2005, after being given a fatal dose of the heroin substitute methadone by prison staff.
City coroner Dr Paul Matthews told the inquest this week that poor training in a new electronic medical records system and the recent closure of special detox units had contributed to her death.
He said there had been “a substantial failure in the level of care which could be reasonably expected”.
On the morning of March 8, reception staff noticed Ms Wright “increasing drowsiness and disorientation”.
She had signed in the wrong place when given a release form for her methadone dose.
Ms Wright was taken to the detox unit but rather than being seen by a doctor she was taken back to her cell.
Stumbling and slurring her speech, she locked herself in her bathroom, where she was later found dead.
Dr Matthews said: “The cause of death was respiratory depression, caused by methadone toxicity.”
The coroner said reception staff had failed to communicate with each other and had not inputted Ms Wright’s medical history showing she was a “naive heroin user” into the prison’s computer system.
Staff failed to make basic nursing observations at the detox unit and warning signs of intoxication were not acted upon, the coroner found.
Dr Matthews said there were multiple indications that should have given rise to concern, including stumbling, slurred speech, inability to remain awake, signs of disorientation such as locking herself in the bathroom, her inability to use the prison phone and signing in the wrong place for her methadone dose.
“The level of observation and monitoring by the detox medical staff fell below that which could be reasonably expected and represents a comprehensive failure to provide basic level of care as her condition deteriorated, or acted on the numerous warning signs about her state of mind.”
They had been closed following a drop in prisoner numbers.
Sian Griffiths, casework service manager for the pressure group Inquest, said: “This is a damning indictment of Holloway Prison’s failure to protect the life of a vulnerable woman.
“Evidence at the inquest exposed how Lyndsey’s death could have been prevented had the prison’s healthcare provided her with basic medical care.”
A spokeswoman for the Ministry of Justice said: “Every death in custody is a tragedy, and our sympathies are with Lyndsey’s family.
“All deaths in prison affect families, staff
and other prisoners deeply.” |
 |
|
| |
| |
| |
| |
| |
|
|
|
