DAVIN PAUL SHORT · Prevention of Future Deaths report

On 6 October 2011 an Inquest into the death of DAVIN PAUL SHORT aged 46 years was opened. The Inquest concluded at the end of the inquest on 25 June 2015. The conclusion of the inquest was that Davin Short died from natural causes with the medical cause of death being 1a Ac ute Lobar Pneumonia.

Mr Short had been diagnosed and treated for a chest infection on 21 September 2011. At a review appointment on 28 September 2011 it was considered that his infection had resolved. Expert evidence from ████████ confirmed that Mr Short received appropriate treatment and that his presentation on 28 September 2011 was of a resolved pneumonia. Mr Short rang his cell bell at 03:00 on 4 October 2011 and was spoken to by an officer when he complained of leg pain. He appeared to take advice and get some rest. He was discovered unresponsive in his cell at about 08:15 hours on 4 October 2011. CPR was commenced but he was sadly pronounced deceased by attending ambulance service at 08:43. In the opinion of the pathologist ████████ Mr Short was deceased when his discovery was made.

(1) During the course of the hearing I heard evidence that the prison did not have electronic system for recording cell bells and it was left to the discretion of individual officers whether to record a cell bell call in the Wing Record. I am therefore concerned that without guidance as to the making of a record of a cell bell call of medical nature an important matter may be overlooked with risk to life.

(2) I also heard evidence that although there were now adequate radios for all three healthcare staff it was not made clear that if a single member of healthcare were on duty he or she must have a radio. I am therefore concerned that without a specific guidance, there is a risk that a single member of healthcare may not have a radio causing delay in responding to an emergency call and possible risk to life.