Shalan Blackwood · Prevention of Future Deaths report

Shalan Blackwood died at HMP Nottingham on 5th August 2015. An investigation was begun, an Inquest opened and heard from 25th April 2015 to 3rd May 2015 before a Jury. The Jury concluded that the duodenal ulcer should have been diagnosed and treated and that systematic failures amounting to neglect by prison and healthcare staff significantly contributed to his death.

Mr Blackwood died as a result of a bleed from a duodenal ulcer. His case was complex and his presentation challenging due in part to his being unable to communicate effectively. At the time of his death he was on a “four person unlock” in the Segregation Unit and had been referred for specialist mental health opinion. There was evidence that he had bled, for a reason unknown at the time, on 4th August but that no GP or hospital referral was made following the blood being observed.

1. That there is no proper provision for the care and supervision of prisoners who present with complex physical and/or mental health needs. It is understood that such a provision could be provided by means of an inpatient unit within the prison, such as for example is the case at HMP Liverpool.

2. That at present, if a prisoner is assessed as needing a four person unlock, and is within the Segregation Unit, there are insufficient prison staff to provide him with a proper regime and to unlock him after lunchtime, for example to allow

3. That the use of New Psychoactive Substances (NPS) remains rife within the prison, and presentations such as Mr Blackwood’s are not diminishing, and that the Substance Misuse Team requires further staff to be effective in future.

4. That the documentary tool for decision making between prison staff and healthcare staff, as to whether a prisoner is fit to remain in Segregation and should do so, is unclear in or in use.

5. That healthcare staff are insufficiently alert to the issue that physical symptoms which require urgent medical attention may be occluded by mental health issues.