Ronald Sherlock · Prevention of Future Deaths report

On the 30th of April 2012 I commenced an investigation into the death of Ronald Sherlock, Aged 92. The investigation concluded at the end of the inquest on the 2nd of August 2013. The conclusion of the inquest was

Ia Chest infection
Ib Chronic Kidney Disease
Ic Diabetes Mellitus

II Atrial Fibrillation

NATURAL CAUSES

Ronald Sherlock was a prisoner serving a sentence at HM Prison Norwich. He had been sentenced to life imprisonment in 1979 and been at HM Prison Norwich since April 2005. Mr Sherlock suffered from a number of natural medical conditions including heart problems, high blood pressure, lung disease, prostate cancer, diabetes and Alzheimer’s disease. He was being closely monitored and was resident on the older prisoners unit. His health had been deteriorating for some time and he was diagnosed with a chest infection on the 5th of April 2012. On the 24th of April 2012, a healthcare assistant entered his cell to carry out a check and found him unresponsive. Medical help was summoned but he could not be revived and was pronounced dead. No post mortem was carried out and I accepted at the inquest the evidence of the treating doctor that the cause of death was:

Ia Chest infection
Ib Chronic Kidney Disease
Ic Diabetes Mellitus

II Atrial Fibrillation

Prisoners accommodated in the Older Prisoners Unit of HM Prison Norwich do not have appropriate access to speech and language therapists who can provide assessments to those with swallowing difficulties and make necessary recommendations as to their medical management including the regulation of fluid and food intake and the provision of a soft diet.

This omission was acknowledged at the hearing by a professional witness for the health service provider of Norwich Prison SERCO.