Wayne Anthony BAYLEY · Prevention of Future Deaths report

On 25 May 2022, one of my assistant coroners, ████████ commenced an investigation into the death of Wayne Bayley, aged 43 years. The investigation concluded at the end of the inquest earlier today.

The jury made a narrative determination at inquest, which I attach. You will see that this includes a finding that death was contributed to by neglect.

Mr Bayley died in HMP Pentonville, some ten hours after a restraint.
His medical cause of death was:

1a acute chest syndrome
1b hypoxia and chronic sickle cell lung disease
1c sickle cell disease and restraint.

In attempting to learn lessons from Mr Bayley’s death, a great deal of work has been done by the primary healthcare provider in HMP Pentonville, Practice Plus Group, in liaison with the mental healthcare provider, Barnet Enfield & Haringey NHS Trust, and the prison itself.

This work has covered the assessment, treatment and medication of all prisoners, from healthcare planning on arrival in prison, through any control & restraint, to the entering of a cell in an emergency, all particularly in the context of any underlying health conditions – including, but not limited to, giving staff a proper understanding of the identification of and risks associated with an acute sickle cell crisis.

However, I am not at all clear that this work has been replicated nationally. Whilst PPG provides healthcare in 57 prisons, I understand that there are over double that number in England & Wales. I did hear evidence of the work of University College London Hospital in setting up an innovative outreach pilot. Nevertheless, my concern remains that learning and improvements in practice may not have been shared across the country.