The inquest into the death of JE concluded on 14th August 2024 before HM Assistant Coroner for Kent, Mr Ian Brownhill. The inquest was heard over three days.

JE was a serving prisoner at the time of his death in November 2022. His health had deteriorated in 2022 and he was treated for recurrent sepsis. The root cause of his sepsis was not identified. The coroner found that there were missed appointments for lymphoma investigations which JE was entitled to, though it is speculation to say whether this contributed to the death.

JE had been discharged from Medway Maritime Hospital to prison on 26th October 2022, despite objections being raised by a nurse at the prison as JE was a high falls risk. The nurse gave evidence at the inquest that she told the hospital that they couldn’t meet JE’s needs in prison. The nurse also raised her concerns with the Head of Healthcare at the prison. A doctor from the hospital gave evidence that he had not been told of the concerns raised about discharge. The coroner found that this discharge was unsafe, though was unable to say that it was contributory to the death.

On 31st October 2022, JE was readmitted to Medway Maritime as his health had deteriorated. Between his discharge and re-admission, JE had two falls whilst in prison and had not been eating or drinking.

Following admission to hospital, JE died in November 2022 from pneumonia. At the time, he had liver disease which had not been identified.

The coroner is issuing a Prevention of Future Deaths Report to Medway Maritime as he found a risk of future deaths in respect of their discharge of patients from acute care back to prisons. Medway Maritime have been directed to provide a policy to address these issues, to inform the content of the Coroner’s Prevention of Future Deaths Report.

Interested Persons (IP) for the inquest included:

  1. The family

  2. Ministry of Justice

  3. Oxleas NHS Foundation Trust, healthcare provider at the prison

  4. Medway NHS Foundation Trust – following submissions made by representatives for the family at a previous pre-inquest review hearing, the coroner included Medway as an IP

The family were represented by Alice Wood and David Corrigan at Farleys Solicitors and Anna Moradi at 12KBW.

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