Jury finds serious failings contributed to death of prisoner

The jury at the inquest into the death of Christopher Tyler at HMP Thameside in October 2016 found that Mr Tyler died of a heart condition, contributed to by serious failings of Oxleas NHS Foundation Trust.

The inquest was held at Southwark Coroner’s Court from 3rd to 13th July 2018.

Christopher Tyler entered HMP Thameside on 14th October 2016. He fell ill shortly thereafter, but despite his vital signs being outside of the normal range and an ECG being conducted which showed abnormal findings, he was not transferred to hospital.

The GP who reviewed Mr Tyler at HMP Thameside incorrectly attributed his symptoms to drug withdrawal and subsequently to a chest infection. Expert witness Dr Marcus Bicknell described the GP’s failings as serious.

On 31st October Mr Tyler became acutely unwell. His cell mate attempted to call for help using the cell bell, but the call was not answered for around 30 minutes.

Mr Tyler was seen by prison healthcare staff who gave him oxygen as his saturation levels were very low, but he was then left alone in his cell. Prison and healthcare staff admitted in evidence that he should not have been left unattended when he was so unwell, and that an emergency code should have been called at that stage, which would have resulted in an ambulance coming to the scene.

Mr Tyler’s cell mate then used the cell bell to call again for help as Mr Tyler’s condition deteriorated and an ambulance was called. While Mr Tyler was being taken down to meet the paramedics, he stopped receiving oxygen when the oxygen tank used by prison healthcare staff became empty.

Mr Tyler died shortly after as a result of infective endocarditis, a rare condition where the valves of the heart become infected.

On Friday 13th July 2018, the jury came back with critical findings of the prison healthcare services, provided by Oxleas NHS Foundation Trust. The jury concluded that Mr Tyler suffered from a heart condition, symptoms of which he made clear to the medical and prison staff consisting of chest pain and breathlessness. The heart condition, if not treated, develops rapidly and the symptoms he presented with were similar to non-urgent illnesses such as chest infections. However, the jury found that Mr Tyler died in part because of the “serious failures in medical care at HMP Thameside”. The jury found that:

• the clinical assessments of Mr Tyler in the lead up to his death were inadequate given his symptoms and varying vital signs, which delayed a referral to hospital
• there was a lack of awareness that his symptoms were no longer linked to his drug withdrawal treatment
• there was a serious failure to give significance to Mr Tyler’s symptoms and consider alternative diagnoses
• there was a failure to ensure Mr Tyler was seen by a GP and referred to hospital

The jury concluded that the above failings prevented a possible diagnosis of endocarditis and ultimately contributed to Mr Tyler’s death.

Mr Tyler was represented by Claire Brigham of Hodge Jones and Allen and Richard Reynolds of Garden Court Chambers. Ms Brigham said that the failure to refer Mr Tyler to hospital at an earlier stage when he was clearly unwell was unacceptable.

“Mr Tyler was a vulnerable man who tried to convey to prison medical staff that he was very ill. Prisoners are entitled to receive the same standard of care as people in the community, but on this occasion assumptions were made about his symptoms without a proper history being taken or his vital signs being scrutinised. This led to substandard medical care.”

During the inquest, the coroner raised concerns about the delay of the prison officer first on the scene in calling a Code Blue, which generates the request for an ambulance.

Lisa Gananca, Mr Tyler’s sister, described Mr Tyler as a happy, family man and said “we had a very close relationship. The prison and the healthcare team failed my brother, they failed to take care of him and failed in their duties to look after him properly. The conclusion we have is positive and I want to thank the jury for that. Nothing will be able to bring my brother back but we now have clearer answers as to what happened”.

The family were assisted by the charity INQUEST.