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Investigation and inquest
On the 10th February 2015 I commenced an investigation into the death of Ian Paul Emsley, aged 50 years. The investigation concluded at the end of the inquest on the 3rd September 2015. The conclusion of the inquest was Natural Causes. The cause of death being:
1a – Metastatic Renal Cell Carcinoma
Circumstances of the death
PMH - Metastatic renal cancer. Prev IV drug use (on methadone) , alcohol excess
Diagnosed with terminal renal ca Sept 2013 whilst resident in HMP Dorchester. He was transferred to HMP YOI Portland on the 26th November 2013. Moved to palliative care wing HMP Exeter Nov 2014 with life expectancy in terms of weeks. Treatment consisted of steroids and analgesia. Mid Jan 2015 course of Radiotherapy to try and ease symptoms. 29/1/15 deterioration more pronounced and by 1/2/15 was unconscious for majority of the time. Family and Nursing staff were present at approx 1820hrs 1/2/15 when he stopped breathing. Prison Dr attended to confirm death 1930hrs 1/2/15. Police attended no sus circs.
An Investigation was opened on 10th February 2014.
Coroner’s concerns
During the Inquest into Mr Emsley’s death from Natural Causes in the palliative care wing at HMP Exeter, the care at HMP Exeter was highly proactive in the last 9 weeks of his life. The care given, in HMP YOI Portland was less so and subject to a number of resource based constraints in end of life care provision. The result being that transfer to HMP Exeter could have been much sooner.
The Clinical Reviewer found that overall it might be helpful for healthcare staff to be given formal guidance or training to assist them in making decisions regarding the assessment of the requirement of restraints and the assessment and decision making of release on compassionate grounds at Multi-Disciplinary Team Meetings involving prison (security) staff and healthcare staff.
With lack of formal guidance/or training on the subject healthcare staff were uncomfortable with making decisions on a prisoners risk of re-offending or escape. As a consequence there is a potential for delay in effecting transfer and/or compassionate release for prisoners who are terminally ill, which could also impact on the family.
When you have had an opportunity to review the current procedures I require a substantive response within the statutory 56 days.
Information checked against the published report and official responses