R (Davies) v Birmingham Deputy Coroner
| Jurisdiction | England & Wales |
| Judge | Lord Justice Brooke,Lord Justice Longmore,Sir Martin Nourse |
| Judgment Date | 27 February 2004 |
| Neutral Citation | [2004] EWCA Civ 207,[2003] EWCA Civ 1739 |
| Docket Number | Case No: C3/2003/0993 |
| Court | Court of Appeal (Civil Division) |
| Date | 27 February 2004 |
[2003] EWCA Civ 1739
Lord Justice Brooke
(Vice-President of the Court of Appeal, Civil Division)
Lord Justice Longmore and
Sir Martin Nourse
Case No: C3/2003/0993
IN THE SUPREME COURT OF JUDICATURE
COURT OF APPEAL (CIVIL DIVISION)
ON APPEAL FROM THE ADMINISTRATIVE COUR
Moses J
Nicholas Blake QC & Paula Sparks (instructed by Jonas Roy Bloom) for the Appellant
Richard M Barraclough QC (instructed by Solicitor, Birmingham City Council) for the Respondent
Hearing date : 4 th November 2003
Approved Judgment
This is an appeal by the claimant, who is the mother of Darren Davies, against an order of Moses J on 11 th February 2003 whereby he dismissed her application for judicial review of a coroner's inquisition held into the death of her son in HMP Prison, Winson Green, Birmingham on 5 th March 200After a five-day inquest, the coroner's jury returned a verdict of accidental death on 1 st February 2002. The cause of death was recorded as cardiac arrest due to metabolic imbalance due to repeated vomiting.
On 1 st March 2001 the claimant's son Darren, who was then 23, was admitted to Winson Green prison. He was seen on his admission by Dr Rahman at about 7pm, who noted in a health screen record that he had taken heroin the day before. At the inquest his mother confirmed that this was correct. He was complaining on admission of aches and pains. Dr Rahman prescribed detoxification drug treatment, to be taken over a period of four days.
On the following day, 2 nd March, Darren attended at 8 am at the treatment hatch on his wing (C Wing) for his second dose, but the card which recorded the treatment prescribed to him had been placed in the tray designated for A Wing. For this reason the drug could not be prescribed, and he did not ask for the dose again after his card had been sent to C wing. Although there was a sick parade on C Wing between 9.30 and 11.30 am that morning he did not attend it. The evidence showed that he was being seen for categorisation that morning, and that he had also had visits from the prison chaplain and a drugs nurse, which might be the reason why he did not attend.
At about lunch-time that day he was moved to B wing. That wing held its sick parade on a different day. Although there was a nurse at the treatment hatch on B Wing on the way to the dining hall, he did not ever ask for a further detoxification treatment dose. While he was in B wing, he rarely left his cell. He shared it with Mr Collins, who gave evidence at the inquest.
Darren's sister told the inquest that she had rung the prison on the Friday to ask whether her brother had the medication he was to receive. The nurse who answered her telephone call told her that she was not in any position to check whether he had received his dose or not. She added that 80% of prisoners were on a detoxification programme, and the staff could not check on every one.
Mr Collins described to the inquest how Darren's symptoms worsened. He could not take water, and when he tried to do so, he was sick straight away and suffered from pain. On the Friday night Mr Davies rang the buzzer, and Mr Collins thought that a prison officer gave him paracetamol. He seemed to be in a lot of pain. Mr Collins described how Darren called for help on the Saturday evening by pressing the buzzer in the cell once or twice (he could not remember which). When the buzzer was rung at 9.15 pm that evening, a prison officer advised Darren to see a nurse the following day. Mr Collins added that this officer told Darren "you got on your boat, you ride it", meaning that it was his own fault for having taken drugs.
Mr Collins said that on the following day, Sunday 4 th March, Darren felt worse. He did not get out of his bed, or out of his cell for exercise. He complained of a bad chest. He could not move his fingers, which were clamped up. Dr Ralli, a prison officer from another prison who furnished an independent report, told the inquest that by now Darren was very unwell with vomiting and diarrhoea, and with no food or fluid intake, and that his internal metabolic and electrolyte systems were becoming abnormal. Mr Collins would clean up the cell when Darren dirtied it, so that it did not smell and they would not get into trouble for dirtying the cell. As a result the prison staff were not aware of the diarrhoea and vomiting.
Darren was worse on Sunday evening. He was still vomiting and was now too weak to go to the lavatory. He had spasms in his elbows and fingers. When the buzzer was pressed at about 8 pm, a prison officer called and advised him to see a doctor in the morning. At 9.20 pm a night agency nurse called Nurse Spencer attended. She advised Mr Collins to make sure that Darren went for treatment on the Monday morning. Nurse Spencer was not a general nurse: she had particular skills in the mental health field. Darren complained to her of stiffness in his arm joints, and she noted that his hands were in a strange position. She manipulated his joints and gave him two paracetamol tablets. She did not take a history from him. As she was leaving the cell, Mr Collins told her that Darren had been feeling poorly. When she returned to the prison's health centre, she checked his record. She also ascertained that the health centre was full.
On the Monday morning, 5 th March, the buzzer was pressed at 6.15 am. Darren had fallen off his bed. Two prison officers and Nurse Spencer lifted him back onto it. Nurse Spencer told him that a doctor would see him. Mr Collins told the inquest that Darren had been sick, and that he had cleaned up the vomit. Prison Officer Biddle for his part told the inquest that he had visited the cell on both the Sunday night and on the Monday morning. On the Sunday night Darren's wrists were rigid and in an unnatural position. On the Monday morning they were more flexible. Darren was told he was going to be referred to a doctor that morning.
At 7.10 am, less than an hour later, the cell buzzer was pressed again. By this time Darren was unconscious and not breathing. Steps were then taken to try to revive him. An ambulance was called, but he died despite the attempts of a paramedic to resuscitate him.
Prison Officer Fitzgerald told the inquest that she recalled two calls on the Sunday night. On the first occasion she advised Darren to see the doctor in the morning. One and a half hours later he was still in pain, so that the nurse was called. His arms were hurting and in a cramped position, and Prison Officer Fitzgerald remembers Mr Collins saying that Darren had been sick. On the Monday he had fallen on the floor, and Prison Officer Fitzgerald described how he was lifted onto a bed. She ascribed his symptoms to drugs.
Nurse Spencer told the inquest how she had attended on Sunday night, when she manipulated Darren, gave him paracetamol, and advised him to attend the health care centre the next day. This was not the first time she had seen spasms being suffered by someone withdrawing from drugs. The following morning she saw no evidence of dehydration. Darren's lips were not sticking together, and she did not find his symptoms particularly unusual. Nor did she think it odd that he 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 complained of discomfort in his joints. His blood pressure and his pulse were normal. She saw no evidence of diarrhoea or vomiting, and she smelt none of the effects of those symptoms. She ascribed his symptoms to drug withdrawal. She said she had no concerns, other than that she wanted 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.
Four doctors expressed their opinions as to the cause of Darren's death. Dr Tapp, a pathologist instructed by Darren's family, said in a written report that he died of dehydration, consistent with someone suffering from significant diarrhoea and vomiting. The cause might never be ascertained, but it was unlikely to be drug withdrawal. He suffered from the symptoms of acute enteritis. Dr Ralli for his part said that the cramps from which Darren suffered in his upper limbs, and particularly in his hands, were unusual. Dr Khan, who was an expert on the effects of opiate withdrawal, described Darren's symptoms as being most unusual, particularly those of very severe dehydration. Dr Acland, the Home Office pathologist, concurred in the unusual nature of the cause of death. He took the view that Darren had died from the complications of dehydration.
In his written report Dr Ralli made the following comments on clinical issues:
(1) After Darren's reception assessment at which a treatment plan was established, the onus was placed on him to seek his treatments and to seek further help if required.
(2) Nobody checked to see why he did not attend for treatment, or attend reporting sick, or collect his meals.
(3) Practices are in place for those considered to be at risk (diabetics and those on heart medicines) if they do not receive their treatment to be followed up; but these practices do not seem to extend to drug users. Given all the recognised risks (especially from self-harm) amongst drug users on coming into prison, this matter needs to be reviewed.
(4) If his case had been followed up, and if he had taken the treatment prescribed for him, this may have prevented his deterioration.
(5) Darren's presentation on the Sunday night was unusual. The nurse did not elicit all the available information about the vomiting and diarrhoea, or about the...
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