Darren McGuin · Prevention of Future Deaths report

On the 1st March 2018, I commenced an investigation into the death of Darren McGuin. The investigation concluded at the end of the inquest on 26th June 2019. The conclusion of the inquest was the Mr McGuin died from :

1(a) Pulmonary embolism
1(b) Deep vein thrombosis
(2) Obesity

A short form conclusion of Natural Causes was recorded in Box Four and Box three completed in the following term:

Mr Darren McGuin died on the 22nd February 2018 at HMP Lindholme due to the detachment of a deep vein thrombosis, which caused a massive pulmonary embolism. It is more likely than not that Mr McGuin died in his sleep.

Mr McGuin (D.O.B 01.01.1980) was a serving prisoner at HMP Lindholme, Doncaster. On the 22nd February 2018, Mr McGuin was found laid unresponsive on the top of his bed in his cell by a Prison Officer who was unlocking the door that morning. The Prison Officer made a “code Blue” emergency call to Healthcare for their urgent assistance. The Prison Officers who were on duty and in attendance that morning had not been trained in basic life support and therefore cardio-pulmonary resuscitation did not commence until a member of health care attended on the wing. Healthcare staff continued with CPR until the emergency services attended who later pronounced Mr McGuin deceased.

1) There was clearly a delay between Mr McGuin being found unresponsive by the prison officers and the commencement of CPR by members of the healthcare staff. Although, earlier CPR would not have altered the outcome in this particulate set of circumstances, it may on a different occasion.

2) Prison officers will usually be first on scene, particularly if a prisoner is found in their cell and this lack of basic life support training is leading to a delay in the commencement of CPR. The evidence before the Court was that prison officers who’s employment either started prior 2005 or after 2017, completed a compulsory three-day Basic Life Support and First Aid course as part of their mandatory training. However, at a date unknown at this time, this training requirement ceased. This inquest has highlighted that there are a number of staff working within the prison service who have never received basic life support training. It is my understanding that there are no efforts being made to identify and provide retrospective training to those members of staff who were appointed during this period of time where basic life support training was not provided.

The Ministry of State for Prisons is asked to consider whether it is appropriate for a review to take place to identify and subsequently provide appropriate basic life skill training to all prison staff, who have not received if as part of their mandatory training.