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Investigation and inquest
On 2nd March 2015 I commenced an investigation into the death of Thomas Byron Black (d.o.b. 28-02-86). The investigation concluded on 19th November 2015. The conclusion of the inquest was Natural Causes. The medical cause of death being:-
1. (a) Pulmonary thrombo-embolus
1. (b) Deep Vein thrombosis in a man with Factor V Leiden Mutation [heterozygous]
Circumstances of the death
On 4th December 2014 Mr. Black was transferred to HMP Usk. On Saturday 21st February 2015 Mr. Black collapsed. Officers took him to his cell and arranged a health care appointment for Monday morning, as health care staff are not on duty at the weekend. They did not seek medical advice. On Sunday 22nd February 2015 Mr. Black's cellmate reported he still felt unwell and had a tight chest. Officers monitored Mr. Black but did not seek medical advice. On the morning of Monday 23rd February 2015, a nurse examined Mr. Black and found no concerns, but arranged to carry out an electrocardiogram test later that afternoon. Just after 1.30 p.m. Mr. Black collapsed. He was conscious at first, but his condition deteriorated and he was conveyed to the Royal Gwent Hospital and he was pronounced dead at 3.21 p.m.
Coroner’s concerns
Prison staff did not seek medical advice when it was apparent that Mr. Black was unwell.
Information checked against the published report and official responses