Coroner Makes Damming Ruling Following The Death Of 74-Year-Old Retired Firefighter Whilst In The Custody Of HMP Hull

Ian Sprakes, Assistant Coroner for Hull and the East Riding has concluded that prison officers as well as healthcare staff made a number of failings in relation to the care and treatment of Mr Alpha Kalay whilst in custody at HMP Hull.

The Coroner made the following conclusion: “Mr Alpha Kalay, whilst an inmate at HMP Hull, tested positive for COVID-19 on the 8th of January 2021. Mr Kalay’s COVID-19 positive test was not received until the 12th of January 2021 when it was then recorded in his NOMIS records.

On the 11th of January 2021, Mr Kalay presented as unwell and was seen by a member of the mental health nursing team. A referral was made for a review by the medical healthcare team, due in part to Mr Kalay’s presentation and the fact that it was not possible to obtain oxygen saturation level readings from the oximeter, and temperature measurements were not obtained due to the unavailability of a thermometer.

This referral was not actioned by the medical healthcare team, and this failure represented a missed opportunity for a further required medical assessment of Mr Kalay’s condition. When Mr Kalay’s positive COVID-19 test was received on the 12th of January 2021, there was a failure to update and establish a care plan for his further management.

Healthcare involvement to assess Mr Kalay should have taken place on the 12th and 13th of January 2021. This did not occur and represented a significant missed opportunity to have assessed Mr Kalay’s medical condition. On the 13th of January 2021 there was a failure to inform and involve healthcare when it was considered that Mr Kalay was engaging in a ‘dirty protest’.

This represented a further missed opportunity for Mr Kalay’s medical condition to have been assessed. When, on the 14th of January 2021, at around 10 am Mr Kalay was transferred to the segregation unit there were further missed opportunities to have undertaken a full healthcare assessment of Mr Kalay which was indicated not only in relation to his positive COVID-19 test for which a specific medical assessment had not at that point been undertaken, and the fact that he was being transferred to the segregation unit which in itself mandated a full and detailed healthcare screening.

Concerns were raised at around 17:00 hours by a nursing associate in relation to Mr Kalay’s condition prompting a senior nurse review, resulting in Mr Kalay being transferred to the wellbeing unit. Further senior nursing assessment was undertaken, with very significant concerns due to what appeared to be a significant deterioration in Mr Kalay’s condition. This resulted in Mr Kalay being transferred on an urgent basis by ambulance to the Hull Royal Infirmary. On admission to hospital he was diagnosed with type 1 respiratory failure due to COVID-19 pneumonia. He had stage 3 acute kidney injury. Despite all supportive measures and medical interventions, Mr Kalay did not respond positively and sadly died on the 19th of January 2021.

Background

Alpha Kalay entered prison for the first time in his life in, August 2019, following an altercation with a teenager in his garden.

He was in his 70s and had served his country in the Royal Navy for nine years before a long career as a firefighter, during which time he had received a good conduct medal.

When entering prison, Mr Kalay suffered from spinal nerve damage and as a result had only 20% mobility in his legs so used walking sticks and a wheelchair for longer distances. Due to his spinal damage, he suffered from incontinence, an issue that was well documented in his medical records. Mr Kalay also had a number of other underlying health conditions which made him clinically vulnerable to the Covid-19 virus.

In prison, Mr Kalay was assigned a wing buddy to assist him with daily tasks and prison healthcare staff also visited him three times a week to help with his personal care and hygiene.

Towards the end of December 2020, Mr Kalay’s wing buddy tested positive for Covid-19. Mr Kalay was placed in isolation on 28 December and on 31 December all care and support he was receiving abruptly stopped with no alternative care plan put in place.

On New Year’s Day 2021 Mr Kalay was tested for Covid-19 and his results were negative, but his isolation period remained in force.

Ten days later a prison officer recorded that Mr Kalay’s cell was in an unacceptable state with food and debris on the floor. He also had dirty bedding and clothes. The officer viewed this as a behavioural issue rather than signs of illness.

On 11 January, a prison officer was concerned about how Mr Kalay was presenting and asked for a nurse to see him. The nurse recorded that Mr Kalay had told him he was struggling to breathe, was lacking energy and had a splitting headache. The nurse did not have a thermometer available and so failed to take Mr Kalay’s temperature, a basic clinical observation to take, particularly in the midst of the covid-19 pandemic. The nurse was also unable to obtain a blood oxygen reading which is known to be an indication that a patient has low oxygen levels.

Despite the nurse being unable to complete an assessment of Mr Kalay’s vital signs, he informed the prison officer that in his view, Mr Kalay did not have Covid-19. The nurse booked a follow up appointment for Mr Kalay to be seen by healthcare but this was never actioned by the healthcare team. The nurse also failed to provide a verbal handover of Mr Kalay’s condition as was practice.

A day later, staff noted in Mr Kalay’s prison and healthcare records that he had in fact tested positive for Covid-19, on 8 January, following another programme of mass testing on his prison wing. During this period he frequently asked for a shower but was told this was not permitted as he had tested positive for Covid-19.

Even though it had been confirmed that Mr Kalay had contracted Covid-19, he was not seen by healthcare staff on 12 January and no care plan was initiated following the test result.

Despite Mr Kalay’s pre-existing medical conditions, his age and his ethnicity, all of which put him at an increased risk of covid-19, he was not assessed by the prison healthcare team as clinically vulnerable or given any advice about shielding.

On the evening of 13 January, a prison officer reported faeces smeared around Mr Kalay’s cell. The officer did not take into consideration Mr Kalay’s medical condition and previous care arrangements. Instead they incorrectly treated the discovery as a ‘dirty protest’.

Contrary to national and local policy, the officer failed to engage Mr Kalay in conversation to ascertain why he had commenced what he assumed to be a ‘dirty protest’. He also failed to contact the prison healthcare team to assess Mr Kalay before concluding that his behaviour was a ‘dirty protest’ and initiating the disciplinary proceedings for this.

The next morning, prison staff moved Mr Kalay to the segregation unit as a consequence of what had been recorded as a ‘dirty protest’. Nurse A was asked to assess and sign off on Mr Kalay’s suitability for segregation from a healthcare perspective. Nurse B, an experienced nurse, had delegated this task to Nurse A, despite her only having just joined the prison and still completing initial training. Nurse A had not been trained in how to do this, so refused to sign-off on the move to segregation. Contrary to policy, without seeing Mr Kalay in person and without consulting his medical records, Nurse B assessed that Mr Kalay would be able to cope with segregation.

The Duty Governor on the day, Gary Sword, did not question the officer’s assertion that Mr Kalay was engaged in a ‘dirty protest’. He said that he relied on the opinion of an experienced officer despite the fact that that officer had never dealt with a ‘dirty protest’ before. The Duty Governor also failed to elicit any response from Mr Kalay himself. There is no record of anyone hearing Alpha speak after 11 January 2021.

By chance a Nursing Associate who had been involved in Mr Kalay’s care previously, learned that he had been taken to the segregation unit. She was surprised by this as it seemed totally out of character and went to check on Mr Kalay in segregation. She found him cold, dehydrated, confused, unable to communicate and wearing only a t-shirt covered in faeces. His breathing rate and heart rate were raised. His fingers were so cold she was unable to get a blood oxygen reading which she was concerned about as it is a known sign of a low oxygen rate. She wrapped Alpha in blankets and gave him two bottles of water which he drank very quickly. She was very concerned by his presentation and telephoned the healthcare reception and requested that Nurse B see him.

Nurse B carried out her own assessment of Mr Kalay and was also unable to obtain an oxygen saturation level. Rather than calling an ambulance however, she moved him to a wellbeing unit for observation.

The Nursing Associate was surprised to learn that Mr Kalay had not been taken directly to hospital. She was uneasy about this and asked another nurse to attend the wellbeing unit with her. When they arrived, prison officers were still insistent that Mr Kalay was on a ‘dirty protest’. The Nursing Associate repeatedly challenged this assertion and expressed her concerns that Mr Kalay was incontinent because he was seriously unwell.

Again, the Nursing Associate noticed there was no drinking water for Mr Kalay to access and he was again very thirsty. The nurse found he was very short of breath and shaking; confused and drowsy; not aware of his incontinence.

Mr Kalay was still naked from the waist down as he was not physically capable of retrieving a blanket that had been around him whilst sitting in his wheelchair that had fallen to the floor. The nurse recorded that both Mr Kalay’s breathing and heart rates were raised but she was similarly unable to obtain a blood oxygen reading. She gave him oxygen anyway given his shortness of breath and called an ambulance.

When the paramedics arrived, prison staff told them that Alpha was on a ‘dirty protest’. The paramedics were able to get an oxygen reading for Mr Kalay which fluctuated between 64% and 78%. Anything below 94% is considered a medical emergency.

Mr Kalay was admitted to Hull Royal Infirmary with covid-19 pneumonia and a grade 3 acute kidney injury. The kidney injury was determined at the inquest to be purely caused by extreme dehydration which experts opined would have commenced on or around 8 January 2021, six days before he entered hospital. He had to be sedated in order to facilitate urgent hospital treatment on 15 January. Sadly, Mr Kalay did not respond to treatment for covid-19 pneumonia.

Mr Kalay’s condition deteriorated rapidly on 18 January and he died at 3.37 p.m. on 19 January 2021.

A respiratory expert provided evidence to the inquest confirming that earlier hospital treatment would have significantly increased his probability of surviving. The expert also pointed to various failures in terms of Mr Kalay’s care whilst in HMP Hull including the fact that they failed to treat him as high risk in relation to the covid-19 virus and that there was no appropriate treatment regime within the prison with regards to Covid-19. He and other medical experts also opined that the so-called ‘dirty protest’ was in fact a symptom of Covid-19 which should have been picked up on.

Melanie Kalay, Mr Kalay’s daughter commented on the verdict: “Losing my dad in this way in the midst of the pandemic was an incredibly painful experience. My dad was clearly very ill and it has been difficult to understand how prison and medical staff at the prison could have treated him in any way than other than as a poorly elderly man. They deprived him of his dignity and failed to keep him safe and well. Whilst I welcome the Coroner’s conclusion regarding the failings of the prison and healthcare staff, it does not change what happened to my dad and the inhumane way in which he was treated. I hope that no other prisoner is ever left in such a degrading way again.”

Ruth Waters-Falk the family’s solicitor commented: “Mr Kalay was an elderly man who was deprived of the most basic care and humanity whilst in prison at HMP Hull. He was incredibly vulnerable to the Covid-19 virus and yet no form of care plan was ever put in place in relation to this and no form of treatment was ever administered once he tested positive for the virus. Mr Kalay was patently ill for a number of days and yet his symptoms were incongruously treated as a behavioural issue rather than the medical emergency which it so clearly was. The prison’s insistence that Mr Kalay was engaging in a ‘dirty protest’ is shocking and we hope that steps will be taken by the prison to ensure this doesn’t happen again. The long list of failings outlined by the Coroner reflects just how badly Mr Kalay was let down.”

Ruth Waters-Falk of Hodge Jones & Allen acted for Mr Kalay’s family. Barrister James Robottom of Matrix Chambers represented the family at the inquest.

Mr Kalay leaves two children. He was born in Sierra Leone.