Derick James Stanmore · Prevention of Future Deaths report

On 14 July 2014 I commenced an investigation into the death of Derick James Stanmore. The inquest concluded on 30 April 2015. The conclusion of the inquest was

Natural causes

Cause of death
1a Acute myocardial infarction
1b Coronary artery atheroma

Mr. Stanmore was serving a life sentence for murder and was at the time of his death in HMP Gartree. He had a number of recognised medical conditions, including heart disease and diabetes mellitus type II. He complained of chest pains on 7th July 2014 and there were 3 encounters with healthcare over the next 3 days, none of which made a potential diagnosis of cardiac problems and none of which resulted in a referral for review. On 10th July 2014 Mr. Stanmore collapsed in his cell and despite prompt and effective CPR and paramedic assistance, he was pronounced deceased shortly after his arrival at Kettering General Hospital.

1. Observations were taken on the morning of Mr. Stanmore’s death by a registered nurse. The observations were abnormal and required further action to be taken but this was not recognised. A system similar to the hospital “Early Warning Score” (EWS) may assist the healthcare staff in recognising this and escalating care accordingly.

2. The nurse attending Mr. Stanmore did not access his healthcare records that were available and did not appear to have any information regarding the need for a healthcare assessment. He was therefore taking observations without the benefit of relevant clinical information in order to consider these in context. Consideration should be given to ensuring all staff have appropriate access whenever possible to information before conducting examinations or observations of prisoners.