Adetokunbo Ohisaga Ajakaiye · Prevention of Future Deaths report

On 14/12/2010 I commenced an investigation into the death of Adetokunbo Ohisaga Ajakaiye, 28 . The investigation concluded at the end of the inquest on 27 May 2016. The conclusion of the inquest was (see attached questionnaire).

1. Mr Ajakaiye was arrested when he entered the UK through Heathrow Airport, on 13th November 2010. He was seen by a doctor at Heathrow Airport Police Station and was then transferred to Lawcroft House Police Station, Bradford, later that same Day. Mr Ajakaiye was seen by nurses at Lawcroft House Police Station on both 13th November 2010 and 14th November 2010. On all of the above mentioned occasions when Mr Ajakaiye was seen by healthcare staff, he raised the possibility that he was suffering from malaria. On each occasion observations were taken.

2. Mr Ajakaiye was remanded into custody on 15th November 2010 and was transferred to HMP Doncaster. He was seen by a nurse who carried out the first reception health screen using the standard pro forma which, it was said in evidence, followed a model prepared by ████████ Mr Ajakaiye again mentioned malaria.

3. Mr Ajakaiye was seen by a doctor at HMP Doncaster, on 16th November 2010.

4. Mr Ajakaiye remained at HMP Doncaster until 24th November 2010, on which date he was transferred to Doncaster Royal Infirmary. On the evening of the 24th he was transferred to the Royal Hallamshire Hospital, where he died, of malaria, early on the morning of 25th November 2010.

1. It became apparent, from the evidence, that none of the healthcare staff who dealt with Mr Ajakaiye at HMP Doncaster, had, prior to November 2010, any practical experience of dealing with a patient suffering from malaria and that there was a lack of knowledge and understanding of the signs and symptoms of malaria and of tropical diseases generally in circumstances where, in an era of increased foreign travel and inward migration, the incidence of malaria is likely to increase.

1. When Mr Ajakaiye arrived at HMP Doncaster on 15th November 2010 it appears that his medical records from Heathrow Airport Police Station and Lawcroft House Police Station did not accompany him. The doctor who saw Mr Ajakaiye, on 16th November 2010, stated, in her evidence, that it would have assisted her in her diagnosis had she had those medical records available to her at that appointment. The court heard that, whilst the medical records from previous custodial establishments sometimes accompanied the Prisoner Escort Records, it was not infrequently the case that they did not.

2. It became apparent, from the evidence, that none of the healthcare staff who dealt with Mr Ajakaiye at HMP Doncaster, had, prior to November 2010, any practical experience of dealing with a patient suffering from malaria and that there was a lack of knowledge and understanding of the signs and symptoms of malaria and of tropical diseases generally in circumstances where, in an era of increased foreign travel and inward migration, the incidence of malaria is likely to increase.