Darren Adams · Prevention of Future Deaths report

On 15th November 2017 I commenced an investigation into the death of Darren Adams (DOB 30th March 1962). The investigation concluded at the end of the inquest on 28th April 2021. The conclusion of the inquest was suicide, the medical cause of death was 1a Hypoxic Brain Injury 1b Hanging.

On 7th November 2017 Darren Adams was transferred from HMP Garth (HMPG) to HMP Lindholme (HMPL). It appears he believed, incorrectly, that there was a Vulnerable Prisoner Unit (VPU) at HMPL. Staff at HMPG accepted Mr Adams had asked about a VPU but the fact there was no such unit at HMPL was not relayed back to him. There was no evidence to say that he would have been placed on a VPU even if there had been one at HMPL. Mr Adams had a history of being unsettled when moved, even within a prison. The jury found that there was insufficient information regarding Mr Adam’s on his transfer and arrival at HMPL. Within 24 hours of arrival his mental health deteriorated to such an extent he was placed on an ACCT. There were insufficient records of his behaviour in the ACCT and a full picture of his mental health was not recorded. Darren was alive at 0641 hours on 12th November 2017 but discovered ligatured in his cell at 0738 hours. The officer discovering Mr Adams waited for additional staff assistance before attempting to enter the cell however Darren had erected a barricade at his door which caused an additional slight delay in accessing him. Once the door was opened and barricade removed nursing staff from prison healthcare entered the cell. The nursing staff carried out a clinical assessment but misdiagnosed him, believing him to have hypostasis and rigor mortis. They decided not to commence CPR. The nurses had previously been advised by the Prison Service and Probation Ombudsman against commencing CPR when someone is obviously deceased. They referred to the guidance “Guidance to support the decision-making process of when not to perform Cardiopulmonary Resuscitation in prisons and immigration removal centre (IRC)”. When paramedics arrived their clinical assessment found no hypostasis, no rigor mortis and they also stated he was still warm. They commenced CPR and obtained a return of spontaneous circulation 4 times, the last as he was conveyed to Doncaster Royal Infirmary (DRI). Once at DRI, after a period of observation and tests Mr Adams was declared dead at 13th November 2017.

1. The Nursing Staff misdiagnosed hypostasis. It was apparent in evidence that they did not have a sufficient understanding of the process and how to identify it.
2. The Nursing Staff misdiagnosed rigor mortis. It was apparent in evidence that they did not have a sufficient understanding of the process and how to identify it.
3. Management of the nurses accepted in evidence that more focus on the identification of those conditions should have been covered in better depth during the nurse’s life support training.
4. It was seen during the evidence that definitions in Annex A of the document “Guidance to support the decision-making process of when not to perform Cardiopulmonary Resuscitation in prisons and immigration removal centre (IRC)” could be confusing, for example the word “mottling” was interpreted by different people in different ways (both lay and medical).