Wigan jail criticised by watchdog for slow response as inmate died from cardiac arrest

Serial burglar Edmund Carley was an inmate of Hindley Prison in May 2018 when he complained that he had difficulty breathing.

The Prisons and Probation Ombudsman, Sue McAllister, has now finally published a report which says that there was too relaxed an approach to attending to the 39-year-old and a failure to comply fully with the procedures for handling medical emergencies.

She said this “led to an unacceptable delay in starting resuscitation, calling an ambulance and escorting the paramedics to Mr Carley’s cell.

"Staff must be reminded of their responsibilities and the need for urgency when dealing with potentially life-threatening incidents.”

The report’s publication had been delayed until the completion of a recent five-day inquest at Bolton Coroner’s Court which concluded Mr Carley died from natural causes to which combined methadone and the drug known as Spice were contributing factors.

Ms McAllister’s findings said that Mr Carley had first complained about breathlessness at 10.26pm on May 1 2018 but it was only after 10.49pm when he had collapsed and a member of staff was carrying out CPR that an ambulance was called.

Paramedics arrived but it was too late and Mr Carley was pronounced dead at 11.09pm.

The report said that first of all there was a five-minute delay before anyone responded to the inmate’s cell alarm, then a night officer telephoned the communications room and, when Mr Carley’s condition appeared to worsen, he radioed the night manager.

The communications room contacted a nurse and the night manager at 10.36pm. The nurse reviewed Mr Carley’s medical notes, collected equipment and went to meet the night manager.

It was only at 10.49pm, that the night manager, an officer and the nurse went into the cell and found the prisoner unresponsive and 999 was rung.

It emerged that the nurse had not been aware of the urgency of the situation and the night officer was unaware that in a life threatening emergency and subject to a personal risk assessment, staff were permitted to enter a cell at night with the emergency key.

During investigations a fellow inmate said that Mr Carley, who had taken drugs before, had been smoking the synthetic cannabis known as PS or Spice heavily and complained of chest pains but didn’t seek medical help.

Among Ms McAllister’s key recommendations were that the “Governor should identify and address the key weaknesses in reducing the supply of drugs at Hindley and revise the Supply Reduction and Substance Misuse Strategy in light of the findings.”

And “the Governor should ensure that all staff understand the importance of entering a cell without delay in an emergency in order to help preserve the life of a prisoner."

A Prison Service spokesperson said: “Our thoughts remain with Mr Carley’s family and friends.

“Since this incident, HMP YOI Hindley has rolled out additional training to staff and improved procedures to ensure paramedics can swiftly treat prisoners.

“To stop the scourge of drugs in our prisons and help keep prisoners safe we have also invested £100m into tough security measures across the entire estate – including an X-ray body scanner and enhanced gate security at HMP YOI Hindley.”

Hindley is a category C prison for adult men sentenced to less than four years imprisonment, and young adults aged 18 to 21 serving sentences between 12 months and four years. It can hold up to 664 men.