Jury conclude that death of Stephen Coates at HMP Preston was contributed to by neglect

Mr Coates’ wife and children were represented by Kelly Darlington in the inquest proceedings.

Stephen Coates, aged 39, was found dead in his cell at the morning unlock on 9th April 2016.  He had been attended on by a nurse 3 times during the night.  Autopsy revealed his cause of death as

1a. Peritonitis

  1. Perforated Chronic Duodenal Ulceration

The inquest into his death was opened and took place on 16th – 24th November 2017 in front of HM Senior Coroner in the Coroner’s Area for Preston and West Lancashire, Dr James Adeley.

At the time of our instruction the inquest was listed for a 3 hour hearing, without a jury, as it was deemed a natural causes death and thus Article 2 was not engaged.

The Coroner accepted submissions on behalf of the family that on the evidence culpable human failure may have played a part in Mr Coates’ death. The Coroner accepted submissions that expert evidence was required from

  1. a nurse, to consider the actions of the nurse attending Mr Coates

  2. an upper GIT surgeon to consider Mr Coates likely presentation and progression through the night.


Factual circumstances

Mr Coates had been in custody for 3 days.  He was dependant on opiates and benzodiazepines. He had not received any methadone in the 3 days prior to entering HMP Preston.

At the initial health screen the prison GP referred Mr Coates to the substance misuse team and he placed on the IDTS Standard Protocol 5-day methadone maintenance titration programme and had received 20mls of methadone, as prescribed, in the 24 hours prior to his death. Mr Coates was prescribed medication to help with common side effects during withdrawal including cramps and diarrhoea, although it was not clear whether these were prescribed prophylactically or had he reported symptoms.

On 8th April a COWS score was used to assess the severity of Mr Coates’ withdrawal symptoms. He was in the mild category. He was noted not to be showing any signs of opiate withdrawal.

In the late evening of 9th April Mr Coates was woken by the sudden onset of severe abdominal pain.  The timing of this was difficult to establish.  Mr Coates did not think that was a symptom of ‘rattling’ and he asked his pad-mate to press the cell call button.  The attending prison officer requested the attendance of a nurse.

Nurse Makoni attributed the onset of the stomach pain to withdrawal/methadone.  She did not ask Mr Coates if he felt these were symptoms of withdrawal.  She prescribed and administered paracetamol and gaviscon tablets to Mr Coates.  Mr Coates moved to the bottom bunk.

Nurse Makoni returned to Mr Coates’ cell approximately one hour later and again two hours later. On neither occasion did she ask for the cell to be opened and her assessment took place through the observation hatch of the cell door, with just the cell night light turned on. Nurse Makoni’s evidence was that on the first visit Mr Coates indicated that his pain was easing. On the second occasion he gave the ‘thumbs-up’.  The surgeon expert was at a loss to explain the apparent lessening of pain.

Nurse Makoni informed the wing officer that it was not necessary to attend his cell again, she planned to inform the unit’s healthcare team of events during the morning handover.

At approximately 8:25 hrs Mr Coates’ cell was unlocked and he was found lying on the floor of the cell.  Resuscitation was commenced. Paramedics arrived shortly after and took over emergency treatment. At 09:30 hrs Mr Coates was declared dead.


Expert evidence

The Court heard that Nurse Makoni deviated from an acceptable range of practice for a registered nurse and failing to follow organisational guidance, including the NHS Trust’s escalation guidance. The experts were critical of Nurse Makoni’s actions that night including, but not limited to,

  1. a failure to carry out the full complement of observations necessary to calculate a NEWS score

  2. a failure to carry out a NEWS score

  3. a failure to review the System One records prior to attending Mr Coates or shortly thereafter when the record of the attendance ought to have been entered (there was a 6 hours delay)

  4. a failure to carry out a second set of observations when she first returned to the cell an hour later. The evidence of the prison was that there would have been no issue with re-opening the cell had Nurse Makoni requested it.

Had Nurse Makoni reviewed Mr Coates’ medical entries she would have or ought to have recognised that there had been a significant drop in Mr Coates’ blood pressure from that recorded since his arrival at HMP Preston and a significant increase in his heart rate, and that the observations recorded by her were quite abnormal.  The evidence was that a full set of basic observations should have been repeated within one hour.

The jury heard evidence from the expert surgeon that Mr Coates observations would have continued to deteriorate and heard evidence that had Mr Coates’ observations been repeated within one hour, and protocol followed, an emergency ambulance would have been called taking Mr Coates to Preston Royal Infirmary, a very short distance away. This led to a missed opportunity for Mr Coates to receive timely medical assessment

The jury concluded that;


  1. The jury has arrived at a unanimous decision, based on the evidence and timing given by expert witnesses that Stephen Coates would have arrived at Accident and Emergency within two hours of his first observations being taken.

  1. On the balance of probabilities Stephen Coates would have survived. The decision was arrived at by accepted expert witness evidence.

  1. The jury agrees that there was a gross failure to provide basic medical care to Stephen Coates.

  1. The jury have come to the conclusion that by the nurse not taking a full set of observations and a subsequent second set with follow up actions when the opportunity arose Stephen Coates ‘ basic medical care was not met. And from that Stephen Coates’ subsequent death was contributed to by neglect.


The Coroner confirmed in open court in front of the jury of his intention to refer Nurse Makoni to the General Nursing Council.

This is a clear case of what appears on the face of it to be a classic natural causes death that would have been prevented by following basic healthcare practice. It further highlights the importance of families being legally represented to ensure all the issues are thoroughly explored and scrutinised.

The jury did not agree.



Kelly Darlington, Associate Partner

Counsel – Andrew Bridgman St John’s Buildings