Terrance John Madden - Death in Custody

The jury have returned their verdict following the Inquest into the Death of Terrence John Madden.

The jury found that Mr Madden was experiencing severe alcohol withdrawal symptoms and that although prison staff recognised that his condition was deteriorating and that he was becoming more confused and distressed, he received no further medical intervention before he was found in his cell having sustained a serious head injury.

The jury had heard evidence that non of the healthcare staff in prison had had any specific training in the assessment and treatment of alcohol withdrawal. Staff gave evidence that although Mr Madden was suffering from auditory and visual hallucinations and he was plucking imaginary objects off the walls in his cell, this behaviour was normal for prison inmates undergoing alcohol withdrawal at HMP Liverpool.

The jury found that the significances in his deteriorating condition had not been appreciated by the healthcare staff.

Following his injury, Mr Madden was taken to University Hospital Aintree where there was a delay in his treatment, he became unconscious and died in Ormskirk Hospital on the 20th March 2005.

Petra Blanksby - Womens Death in Prison

Farleys Solicitors represented the family of Petra Blanksby a young woman who died in HMP New Hall prison. 

Petra had a long history of self-harming and had been arrested following an attempt to kill herself by setting her bed on fire.  Whilst an inmate at HMP New Hall for 130 days she self-harmed on 92 occasions. She was described by one prison officer as a 'death in custody waiting to happen'. 

This case highlighted the issue of the lack of suitable places for young women who self-harm and following the Inquest, the Coroner indicated his intention to write subject to Rule 43 of the Coroners Rules to both the Prison Service and the Department of Health.

Gareth Price - Juvenile Death

Farleys acted for the family of Gareth Price a 16 year old who died in HMP Lancaster Farms. The Inquest lasted 3 months and evidence was heard from over 60 witnesses.  Having heard all the evidence the jury returned a detailed narrative verdict which included some of the following comments:-

• County Durham Engagement Service (CDES) took the decision to derogate from their National Standards, however failed to communicate this decision adequately to key agencies resulting  in a poor standard of service being delivered.
• There was a failure by CDES to engage in meetings, in particular Gareths initial remand planning meeting. Documentation was incomplete and there were inappropriate assessments and only intermittent communication with Gareths family.
• The jury found that there was a serious omission in that incidents of Gareths self harm were not communicated to the family and other agencies.
  The visiting Psychiatrist who assessed Gareth in prison should have ensured that the contents of her report were shared with other agencies instead of anticipating that they would be.
• The Prison Psychologists Report was not dealt with adequately, the report contained important information regarding Gareths self harm and was sent via the Prison internal mail. However the report did not reach the Prison Governor who had requested the same.
• The Personal Officer system within the Prison was ineffective.
• After 3 incidents of self harm Gareth was not seen by a qualified health practitioner.
• The jury found that the Youth Offending Team of Lancashire County Council  employed untrained temporary staff, had confused lines of management and unclear job descriptions. Paperwork was not always completed correctly or on time, record keeping was poor and communication between agencies was haphazard. The overall running of the department was intermittent and casual.

In conclusion the jury stated that, "the complexity of this case and the evidence heard the jury finds that all agencies dealing with Gareth Price provided a most inadequate and negative input to his needs and ultimately contributed to his death."

Kurt Howard - Death in a Psychiatric Hospital

Six years after he died the Inquest recently concluded into the death of Kurt Howard who died in Cefn Coed Hospital, Swansea.

The Inquest lasted 5 weeks and amongst their findings the jury concerned that,

• The care plan and risk assessment in relation to Kurt were inadequately completed.
• There was a lack of communication and training between the hospital staff.
• Kurt was subject to an excessive and prolonged restraint in the prone position.
• There was a delay in the staff calling the Ambulance.
• The environment that the restraint took place was inadequate and unsuitable.