Corby man Thomas Hall, 21, who had severe mental health issues, had taken spice before 'wholly unacceptable' delay in CPR

A Corby man with severe mental health issues died in prison aged just 21 after taking spice, an enquiry has found.

Thomas Hall did not receive the emergency care he would have done if he had been treated in the community, a fatal incident report by the Prison Ombudsman said.

The report concluded that his death in HMP Ranby was an accident, although ombudsman Sue McAllister said a delay between the ‘code blue’ and the beginning of CPR was ‘wholly unacceptable’.

An agency nurse who treated Mr Hall has been referred to the Nursing and Midwifery Council and no longer works at the prison.

Mr Hall, who lived on Corby’s Kingswood estate, was sentenced to two years in prison for burglary in October 2018 and was transferred to Ranby days later.

At the end of November, the report states Mr Hall damaged prison property and gained access to the roof in the workshop before threatening to take a member of staff hostage in an attempt to obtain a set of keys.

He was moved to the segregation unit for 21 days of confinement to his cell but said he would continue his poor behaviour until he was transferred out of Ranby.

He was checked hourly by segregation staff and seen daily by nurses and the duty governor. On 14 December, at 8.12pm, staff saw Mr Hall unconscious and blue around the mouth in his cell. Prison officers waited three minutes to enter the cell because of the previous threats against them and the fact they erroneously thought three members of staff needed to be present before they could go in.

Staff called a ‘code blue’ and a nurse arrived without a defibrillator. Officers who went to get it found the medical room locked so had to return to get the key. This caused a seven minute delay and basic life support was not started until 8.19pm.

The defibrillator arrived one minute later, at 8.20pm, but no shockable heart rhythm could be found. Although CPR was continued, paramedics who arrived 16 minutes later could not revive Mr Hall and he was declared dead at 9.01pm.

The ombudsman report states: “The Healthcare Trust no longer employs the nurse as an agency nurse and has referred her conduct to the Nursing and Midwifery Council for an investigation into her clinical practice.

"Examination of the CCTV and body-worn camera footage shows that there was a seven-minute delay from the time the code blue was called to when CPR began. There was a further one-minute delay before a defibrillator arrived and a further two-minute delay before the emergency healthcare equipment arrived. This was wholly unacceptable.

“It is impossible to know, if CPR had started earlier, with medical equipment readily available, whether the outcome would have been different for Mr Hall. It is imperative that all staff respond to medical emergencies as quickly as possible, and that first aid is given at the earliest opportunity.”

Mr Hall’s death was the third drug-related death at HMP Ranby since 2015 and concerns over the emergency response had previously been raised by the ombudsman with regard to a death in 2017.

Mr Hall had a ‘significant’ history of illicit drug use and had refused offers of help from the prison’s substance misuse team. He also told staff on his arrival at HMP Ranby that he had schizophrenia and self-medicated with cannabis rather than taking prescribed drugs. He had spent time as an inpatient on mental health wards after being sectioned and regularly heard voices telling him to ‘do bad things’.

He was awaiting an appointment with a psychiatrist at the time of his death.

A clinical reviewer found Mr Hall’s care had been equivalent to that he would have received in the community prior to his collapse, but the emergency response was not up to standard

The report stated: “As Mr Hall was in the segregation unit because he had made threats to staff, we do not say that they should have entered the cell, but we are concerned that they believed they could not do so under any circumstances.

“The clinical reviewer found that the care provided to Mr Hall during the emergency response was not equivalent to that he could have expected in the community. The nurse who responded to the medical emergency code did not take the appropriate medical equipment with her and there was a delay before CPR was begun. We cannot say whether this made a difference to the outcome for Mr Hall.

“The post-mortem found that Mr Hall died as a result of using psychoactive substances. We are satisfied that there is nothing to suggest that this was anything other than an accident.

"Ranby has comprehensive policies to tackle the supply of illicit drugs in the prison. However, we are concerned that, despite this, Mr Hall was apparently able to access and use drugs in the segregation unit (where he had been located for the 15 days before his death).”

A post-mortem examination found that the cause of Mr Hall’s death was synthetic cannabinoid toxicity. Toxicology results showed that he had taken Spice before his death.

death.

The ombudsman made a series of recommendations to the prison including;

- that the Governor should ensure that the key drug issues at Ranby are identified and that the prison’s local drugs strategy addresses these key issues.

- that Governor should ensure that staff fully understand the expectation that preservation of life must take precedence when considering entering a cell

- that preservation of life should take precedence when entering a cell

Prison inspectors, who visited Ranby just five months before Mr Hall’s death, had raised the alarm over the prevalence and ready availability of illicit drugs, along with the associated issues of debt and violence. Incidents of psychoactive substances use were common. The were also concerned that the regime in the segregation unit was poor.

Psychoactive substances, which are also known as legal highs and have street names including Spice and K2 are a serious problem across the prison estate because they are difficult to detect. They can increase heart rate, raise blood pressure and reduce blood supply to the heart.