HMP Five Wells criticised over handcuffing 'comatose' prisoner who died of a brain haemorrhage
A 28-year-old prisoner who was dying of a brain haemorrhage was handcuffed while he was unconscious, a report into his death has revealed.
The first inmate to die at HMP Five Wells was restrained while unconscious and sedated, a new report has revealed.
Stefan Slack, 28, was the first prisoner to die at the Wellingborough prison after it opened in early 2022.
His death on November 20, 2022, has not been reported until now, and his name has never been made public. Since he died there have been a subsequent 14 deaths at the jail.
A Prisons and Probation Ombudsman report has now made recommendations to the G4S-run prison after they found that his restraint was ‘unacceptable’.
Mr Slack, from Harrogate, was imprisoned at York Crown Court for three-and-a-half years in June 2021 after being convicted of grooming a 15-year-old girl in an attempt to get her to meet him for sex.
He was initially taken to HMP Hull before he was transferred to Stafford, and then Five Wells in March 2022.
At 12.40am on November 19, 2022, Mr Slack rang his cell bell and told a prison officer that he had a headache. The officer was concerned he appeared confused and telephoned the healthcare centre.
Mr Slack told two nurses that he had stood up and briefly lost consciousness, and that he may have hit his head on a table when he collapsed.
While the nurses were examining him he became agitated, confused and lost consciousness.
Paramedics arrived sometime between 1.51am and 1.53am and entered the prison gate at 1.57am and found Mr Slack unresponsive but alive.
No security risk assessment was carried out because of the urgency with which Mr Slack needed to be taken to Northampton General Hospital. But escorts were briefed verbally.
The ambulance left the prison at 2.42am with the prisoner in handcuffs.
Once at the hospital, a CT scan revealed a bleed on his brain and Mr Slack was transferred, while sedated for surgery, to John Radcliffe Hospital. Handcuffs were removed in the ambulance on the way.
He had surgery and was in intensive care when he died, with his mum by his side, at 1.38pm on November 20.
A post-mortem report showed that Mr Slack had died of a spontaneous intracerebral haemorrhage – which is bleeding within the brain not been caused by injury or surgery.
The ombudsman, which reports on all deaths in custody settings, raised concern at delays after the ambulance arrived at Five Wells.
Prisons must ensure there are no unnecessary delays in escorting paramedics, but in this case, paramedics reported delays in entering and leaving the
prison while waiting for the gates to be opened, applying handcuffs and observing other security protocols.
The ombudsman said: “Staff were expecting the ambulance, so a wait of several minutes before getting through the main prison gate seems excessive, without good cause. It is essential that there are no avoidable delays in enabling paramedics to gain access to the prison.
They made a formal recommendation that the prison ‘should ensure that there are no delays in ambulances entering and leaving the prison; and that in a medical emergency, access from the prison gate to the wing is coordinated, to allow paramedics to reach an incident quickly’.
When considering restraining prisoners being taken to hospital, the High Court in 2007 said that staff need to distinguish between a prisoner’s risk of escape when fit and the prisoner’s risk when he has a serious medical condition.
The Ombudsman said: “Mr Slack was an enhanced prisoner on the prison’s incentives scheme. His case notes were positive, and he had no recent negative behaviour or disciplinary charges. The night duty security manager concluded that the risk of escape was ‘normal’ and recommended the use of handcuffs and an escort chain. The operational manager authorised this.
“The Head of Security told the investigator that many of the operational staff at Five Wells are new to the prison environment, but they have all received training in escort duties and the use of restraints."
The ombudsman said he was ‘content’ with the lack of a risk assessment when Mr Slack left the prison, but added: “It is unacceptable that Mr Slack was restrained while unconscious and sedated.”
He formally recommended all staff should undertake training on the legal use of restraints, and that restraints should not be used when a patient is unconscious or during serious or invasive treatment.
Prison key workers and family liaison officers were praised for providing an ‘exceptional standard of support.’
The ombudsman said: “Their advice, help and interactions were evidenced by detailed record keeping. We commend their professionalism, responsiveness and compassion.”
A jury inquest held between September 30 and October 7 found that Mr Slack died of natural causes.
The other prisoners to die at Five Wells since 2021 are Derrick Johnson, John Boswell, Brian Haines, Dean Newton, Nicholas Lowe, Tudor Owen, Jason McDonagh, Roger Lemon, Reece Pryce, Kevin Golby, Harold Day, Kenny Grubb, Keith Potts, and Anthony Foster.