Colin John Ireland · Prevention of Future Deaths report

On 28th February 2012, I commenced an investigation into the death of Colin John Ireland (aged 57). The investigation concluded at the end of the inquest on 24th October 2014. The conclusion of the inquest was:

1a Pulmonary Thromboembolism
b Deep Venous Thrombosis of the left leg
c A Fracture to the left hip (operated).

Jury’s narrative conclusion

Having considered the evidence, we the Jury find Mr Ireland’s death was accidental in nature and not caused by the action or inactions of any other person or persons at Pinderfields Hospital, Wakefield or HMP Wakefield.

On the morning of 11th February 2012, Colin John Ireland accidentally fell while taking routine exercise in the yard at HMP Wakefield. Mr Ireland was then transferred to Pinderfields Hospital, Wakefield and was diagnosed with a fracture of the left femur. On 13th February 2012, Mr Ireland underwent full hip replacement surgery and was discharged on 17th February 2012 to HMP Wakefield’s Health Care Centre. On 21st February 2012, Mr Ireland was found collapsed in his cell, after attempts of resuscitation, he was pronounced dead at 0924 hours.

1. Colin John Ireland had been sentenced to life imprisonment with a whole life tariff in 1993. He had been at HMP Wakefield since March 2008.

2. He was a diabetic and there were times when he ignored medical advice in respect of this which led to complications arising from poor management of his diabetic condition and him suffering with poor vision.

3. During icy weather on 11th February 2012 and whilst taking exercise in the exercise yard, Mr Ireland slipped and fell fracturing his left hip.

4. Despite verbal advice from a GP to an experienced nurse that this was a life-threatening condition and that Mr Ireland should have been sent to hospital immediately, there was a delay of three and a half hours whilst a Governor Grade Officer insisted on the attendance of a GP and having made several attempts to obtain permission from the Prison Service Directors for him to leave the Prison having regard to his high security status.

5. Mr Ireland’s surgery, which was uneventful, did not take place until Monday, 13th February 2012. He was given the appropriate anti-coagulant drugs to reduce the risk of deep vein thrombosis and pulmonary embolism although there were missed doses which according to Expert evidence on balance of probability did not cause or contribute to his death.

6. He was discharged to the Prison’s Healthcare Centre at approximately 5.00 pm on 17th February 2012. He needed considerable assistance with mobility of the activities of daily living. He was meant to receive continued anti-coagulant medication but there were missed doses which according to Expert evidence on balance of probability did not cause or contribute to his death.

7. On the morning of Monday 21st February 2012, whilst using the toilet he was found in a collapsed state. Resuscitation attempts were unsuccessful and his death was confirmed by paramedics at 09.24 hours on 21st February 2012.

1. That a Governor Grade Officer who had sole responsibility for the running of the Prison challenged the clinical judgement and decisions of both an experienced nurse and an on-call GP who believed that Mr Ireland had fractured his hip and that this was a potentially life-threatening condition and that he should be sent to hospital as an emergency.

2. That the same Governor Grade Officer had difficulty in contacting by telephone the on-call [████████] for the High Security Prison Group to seek permission for Mr Ireland to be sent to hospital. Apparently, [████████] was not responding to her calls. I request that the Director of the High Security Prison Group specifically address this issue in response to this report. Fortunately, the Governor had through his own dealings with [████████] who was then the Director of High Security Prisons, his contact details who was then able to give the relevant permission. I understand that this was an unofficial approach which I do not criticise but would point out that other Duty Governors may not have had access to [████████] number, which would have lengthened the delay. It occurs to me that the on-call system is flawed and should be reviewed.

3. That the Governor Grade Officers who gave evidence had differing views as to the action to be taken, in particular in relation to seeking approval from the High Security Prisons Group regarding release to hospital in such circumstances. I consider that there should be an agreed protocol for this and that all on-duty Governors should receive appropriate training regarding responding to medical emergencies of all types to ensure a speedy release to hospital when necessary, obviously without prejudicing appropriate security issues. Although the Duty Governor claimed to acknowledge that preservation of life was paramount, he appeared to be more motivated by Mr Ireland’s notoriety than to the serious issues of his condition which created an unacceptable delay.