Death sparks changes

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PROCEDURES have changed at a Northumberland prison after an inmate died, an inquest heard.

Mark Anthony Bernard Mulgrew, 44, was serving an eight-year sentence at HMP Acklington when he complained of chest, back and left arm pains before suddenly dying from a heart attack on November 25, 2008.

At the two-day Morpeth Town Hall inquest this week, a jury heard that communications procedures at the prison were changed after an out-of-hours doctor was unable to return a call to prison staff because a daytime switchboard had not been changed to night-time operations. This led to a delay in calling for an ambulance.

Paul Cotton, a senior investigator for the Prison and Probation Ombudsman Service, said there were ‘several important issues’ arising from an investigation into Mr Mulgrew’s death.

He said: “There was a significant delay in calling the emergency services that may have affected the outcome. I am critical of the management and decision-making in response to Mr Mulgrew’s request.”

Officer Kyle Shaw visited Mr Mulgrew at 2.57am. He told the inquest that the prisoner complained of chest pain.

“He was fairly distressed, holding his chest and coughing a lot. I could tell he was genuine at that point.

“I did all I could do in that situation and got assistance,” he said.

But when senior officer Brian Robinson attended the cell with officers Stephen McKenna and Andrew Robinson, Mr Mulgrew had calmed down.

Senior officer Robinson said he did not think the inmate’s concerns were ‘urgent’. Officers left the cell at 3.20am while senior officer Robinson called the out-of-hours doctors’ service.

The jury heard that Dr Christopher Moll tried to call the prison five times but received no response.

Senior officer Robinson said that at the time calls during the day went to administration staff but in the evening a switch was flicked which diverted calls to the control room.

He said: “My assumption is that that switch never got switched over. But that system has now changed.”

Mr Mulgrew, from Stockton, was left in his cell until around 4am when officers Shaw and McKenna found him. They checked for a pulse but there was none and an ambulance was called.

CPR was performed to no avail and paramedics pronounced him dead at 4.40am.

In recording a narrative verdict, the jury found that calling the out-of-hours doctor was not the only option available to prison staff and added that failed attempts by the on-call doctor to contact the prison led to a delay in treatment.

However, it was agreed that it was impossible to say whether Mr Mulgrew would have recovered if treatment had been received earlier.