R (Davies) v Birmingham Deputy Coroner

Tuesday, 11 February 2003

This is a tragic case. On 5 March 2001 Darren Davies died whilst in custody at HM Prison Winston Green. He was only 23. He died from the effects of dehydration following, but not necessarily caused by, symptoms of withdrawal from heroin. After an inquest held over a period of five days the jury returned a verdict of accidental death on 1 February 2002.

The claimant is the deceased's mother. She contends that the coroner failed properly to direct the jury as to the meaning of neglect, failed to permit evidence from an independent expert, Dr Ralli, relating to his views as to the quality of care afforded the prisoner, and failed adequately to leave to the jury the issue as to whether the system for his care on and after admission was defective.

The Facts

There appears to have been unanimity amongst the doctors as to the cause of death. Dr Tapp said that it was due to dehydration consistent with someone suffering from significant diarrhoea and vomiting. The cause might never be ascertained. It was unlikely to be drug withdrawal. He suffered from the symptoms of acute enteritis. Dr Ralli commented that the cramps which the deceased suffered from in his upper limbs, and particularly in his hands, were unusual. Dr Khan described the symptoms as being most unusual, particularly those of very severe dehydration. Dr Acland concurred in the unusual nature of the cause of death and took the view that he had died from the complications of dehydration.

The deceased was seen on his admission to the prison on 1 March 2001 by a Dr Rahman at about 7pm. Notes were made in a health screen record that, as his mother confirmed, he had taken heroin the day before. The deceased was complaining of aches and pains. He was prescribed, by Dr Rahman, detoxification drug treatment, to be taken over a period of four days. The next day, Friday 2 March 2001, the deceased attended for his second dose, but his card recording the treatment prescribed to him had been placed in the tray designated for a wing different from that on which he had been placed. Accordingly, the drug could not be prescribed and he did not attend again once the card had been sent to the correct wing, which was C wing. By mid-morning the deceased had been placed on a different wing, B wing. That wing held a sick parade on a different day, so he never received a further detoxification treatment dose. Whilst in B wing, he rarely left his cell. He shared that cell with a fellow inmate, who gave evidence, Mr Collins.

The deceased's sister gave evidence. She had rung the prison to ask whether he had the medication he was to receive. She was told by the nurse who answered the telephone call that she was not in any position to check whether he had received that dose or not.

His fellow inmate, Mr Collins, described his worsening symptoms. He could not take water. When he did try to do so he was sick straight away and he was suffering from pain. I have been furnished with all the transcripts of all the evidence as well as the summing-up. Mr Collins' evidence described the deceased calling for assistance by pressing the buzzer in the cell on Saturday evening. He could not remember whether it was twice or once on that Saturday night. The buzzer was rung at 9.15 on the Saturday evening. The deceased was advised by a prison officer to see a nurse the next day and, apparently, according to the fellow inmate Mr Collins, the prison officer who visited that evening said "you got on your boat, you ride it", meaning that it was his own fault for having taken drugs earlier.

On the next day, Sunday 4 March 2001, Mr Collins said that the deceased was worse. He did not get out of bed. He did not get out of the cell for exercise. He complained of a bad chest. His fingers were clamped up. He could not move them. He was worse on Sunday evening. He was still vomiting, was too weak to go to the lavatory and had spasms in his elbows and fingers. The buzzer was pressed. A prison officer called and he was advised to take paracetamol. The nurse, who also attended, advised the inmate to make sure that the deceased went for treatment on the Monday morning. The nurse who attended was a Nurse Spencer, who, I was told, was not a general nurse but had particular skills in the mental health field. She manipulated the deceased's joints. On returning to the health centre, she checked his record. She discovered that the health centre was full.

The next morning, the morning he died, the buzzer was pressed at 6.15. The deceased had fallen off the bed. He was lifted onto the bed by two prison officers and Nurse Spencer. The nurse told him that a doctor would see him. According to Mr Collins, he told the nurse that the deceased had been sick. In cross-examination he said he had cleaned up the vomit. Prison Officer Biddle gave evidence, saying he had visited the cell both on the night before, the Sunday, and the Monday morning. The night before, the deceased wrists were in an unnatural position and rigid, although on the Monday morning they were more flexible. The deceased was told he was going to be referred to a doctor that Monday morning.

Less than an hour later, at 7.10 in the morning, the cell buzzer was pressed again. By that time the deceased was unconscious. He was not breathing. Steps were taken to try to revive him. An ambulance was called, but, despite the attempts of a paramedic to resuscitate the deceased, he died.

Prison Officer Fitzgerald gave evidence, recalling two calls on Sunday night. The deceased was advised to see the doctor on the first occasion. One and a half hours later the deceased was still in pain. The nurse was called. His arms were hurting and Prison Officer Fitzgerald remembers the cell mate, Mr Collins, saying that the deceased had been sick. The deceased's arms were in a cramped position. On the Monday he had fallen on the floor and Prison Officer Fitzgerald described him being lifted onto a bed. She ascribed the symptoms to drugs.

Nurse Spencer gave important evidence describing attending on Sunday night, manipulating the deceased, giving him paracetamol and advising him to attend the health care centre the next day. She had seen those withdrawing from drugs suffering from spasms on previous occasions. The following morning she saw no evidence of dehydration. His lips were not sticking together. She did not find the symptoms particularly unusual. She did not think it odd that the deceased had failed to follow up the prescription he had been given for the detoxification programme. When she saw him on the Monday morning he was stretched out, but his hands were more supple. He was coherent in talking, and complaining of suffering from discomfort in the joints. She saw no evidence of diarrhoea or vomiting and smelt none of the effects of those symptoms. She ascribed the symptoms to drug withdrawal. She said she had no concern, other than wishing him to see a doctor that morning. If she had thought that it was necessary to call out a doctor, she could have done so easily. She attributed all the deceased's symptoms to withdrawal.

Dr Ralli was a prison doctor at another prison who furnished an independent report. During the course of that report, he made comments on clinical issues:

"(1) After Mr Davies reception assessment a treatment plan was established, the onus was placed on him to seek his treatments and further help if required.

"(2) No one checked to see why he did not attend for treatment or to attend reporting sick or to collect his meals.

"(3) Practices are in place for those considered to be at risk if they don't receive their treatment (diabetics, those on heart medicines) to be followed up; but this doesn't seem to extend to drug users. Given all the recognised risks amongst drug users on coming into prison especially from self-harm, this needs to be reviewed.

"(4) Follow up and taking the treatment prescribed may have prevented his deterioration.

"(5) Mr Davies presentation on the Sunday night was unusual the nurse did not elicit all the information about the vomiting, diarrhoea and no food or fluid intake nor that he had not taken any of his prescribed medicine.

"(6) She should have discussed the case with the duty doctor.

"(7) She should have been able to move him to an area for closer health care supervision. HMP Birmingham does not have such a resource, as the inpatients are not monitored by health care staff through the night.

"(8) Mr Davies collapse in the early hours is also very unusual again there should have been discussion with the duty doctor and arrangements for closer monitoring."

The last three points were excluded, by the coroner's ruling, from the jury, but it is to be noted that the fifth point, relating to the unusual nature of the presentation and the fact that the nurse did not elicit all the information, was before the jury. Further, in giving evidence, Nurse Spencer commented that, if there was a history of vomiting profusely, you would want to examine this person, perhaps...