Hayden Meirion NORTON · Prevention of Future Deaths report

On 10 January 2014 I commenced an investigation into the death of Hayden Meirion NORTON, otherwise known as Haydn Meirion EVANS, aged 77 years. The investigation concluded at the end of the Inquest on 11 March 2015.

The conclusion of the Inquest was Natural Causes, with the Cause of Death being 1a. Ruptured atherosclerotic abdominal aortic aneurysm.

Mr NORTON was a prisoner in HMP Dartmoor. On 6th January 2014, Mr NORTON was making baskets in the day (over 50% working normal working day). No problems have been reported throughout the day. In the evening of 6th January 2014, Mr NORTON was in his cell (single occupancy cell) when complained of feeling unwell; believed he was complaining of pain in his left flank. A doctor was called. Mr NORTON became very short of breath afterwards and an ambulance was called at 22:47 hrs. Mr NORTON was with prison staff when he collapsed. CPR was commenced by Prison staff. On collapse, Mr NORTON hit his head. On the arrival of the paramedic crew at 23:12 hrs it was described that Mr NORTON had been complaining of pain his right flank, became agitated and fidgety, hot and sweating. Paramedics have arrived when Mr NORTON was in cardiac arrest (asystole) with CPR ongoing by Prison staff. On examination Mr NORTON’s pupils were fixed and dilated, there was no pulse or respiratory effort. Mr NORTON had vomited and had been incontinent of urine. Advanced life support (ALS) was commenced at 23:15hrs; airway inserted with BVM ventilation. Mr NORTON was given adrenalin but was asystolic throughout resuscitation attempts. Death was confirmed at 23:35hrs by paramedic.

It is believed that male was taking folic acid for low iron levels and had previous heart related problems.

The Deceased was medically assessed whilst an inmate of HMP Albany (now part of HMP Isle of Wight) on 28 September 2006 and known to have extensive and well documented history of high cholesterol, ischaemic heart disease with episodic angina, two previous myocardial infarctions, blood pressure 220/100. But after arrival at HMP Dartmoor on 15 March 2013,

(1) there was no record that his blood pressure was monitored; or

(2) that he had been informed of a screening test for aortic aneurysm.

He died on 6th January 2014 from a ruptured aortic aneurysm at HMP Dartmoor.

(3) There was a delay in calling an emergency ambulance because HMP Dartmoor did not have an emergency code (unlike HMP Exeter) protocol.

There was insufficient evidence to say the above were causative of Mr NORTON’s death but there would have been an awareness of possible problems to come.