Ian William Deavall · Prevention of Future Deaths report

On 26 January 2023 I commenced an investigation into the death of Ian William Deavall, age 65. The investigation concluded at the end of the inquest on 9 September 2024.

The conclusion of the inquest was:

Ian William Deavall died as a consequence of a naturally occurring cardiac arrest. There was an admitted failure to arrange for Mr Deavall to be sent to hospital for assessment between 20 and 24 January 2023, however this did not cause or contribute to death on the balance of probabilities.

The medical cause of death was:

1. Ischaemic heart disease.

The Deceased was remanded in custody to HMP Forest Bank on 7 January 2023. He had a known history of ischaemic heart disease and hypotension and was prescribed various medications for the same. The Deceased was housed on the induction wing throughout his time at the prison and shared a cell. Both the Deceased and his cell mate were believed to be at risk from other prisoners and were classed as vulnerable prisoners (‘VPs’) accordingly.

The inquest heard evidence that both VPs and non-VPs are housed on the induction wing and that the recognised risk to VP prisoners when co-located with non-VP prisoners is managed by operating two separate regimes to avoid the two groups of prisoners coming into contact with one another.

On 24 January 2023 the Deceased and his cell mate were locked in their cell when the Deceased suffered a cardiac arrest. His cell mate pressed the emergency cell bell whereupon a non-VP prisoner (Prisoner A), who was unlocked and conversing with two other prisoners on the landing adjacent to the Deceased’s cell, deactivated the cell bell on the panel outside the cell before resuming his conversation with the other prisoners. After approximately 1 minute Prisoner A walked down to the wing office and alerted officers inside, following which a medical emergency response was initiated.

The inquest heard evidence that when an emergency cell bell in the induction wing at HMP Forest Bank is deactivated on the panel outside the cell (i) this cancels the alert in the wing office; (ii) the only means by which staff can ascertain in which exact cell the emergency cell bell has been activated (the light on the panel outside the cell) goes off.

(1) The response to a medical emergency will generally be time critical.
(2) The risk that non-VP prisoners will victimise VP prisoners is a recognised one.
(3) That prison staff became aware of the medical emergency in the Deceased’s case was more by accident than design (depending as it did on the caprice of Prisoner A).

There remains a risk that future deaths could occur as it remains the case that emergency cell bells at HMP Forest Bank can be deactivated readily and altogether by other prisoners and no action to implement fail-safe measures is currently proposed.