Verdict on prisoner found dead in cell

A PRISONER found dead in his cell at a Northumberland prison three days after his transfer from another facility died from natural causes, an inquest heard.

Brian Milburn, 69, died at HMP Acklington on January 9, 2009, after his transfer from HMP Holme House in Stockton-on-Tees on January 6.

At the inquest at Berwick Town Hall, the jury returned a verdict of natural causes, and a post mortem suggested the cause of death was a combination of coronary artery atharoma, or furring of the arteries, and chronic obstructive pulmonary disease, which affects the alveoli in the lungs. It also revealed that Mr Milburn had previously suffered a heart attack.

Mr Milburn was known to be suffering from these conditions and had a variety of inhalers and medications. Upon arrival at HMP Acklington, he was suffering from shortness of breath, anxiety and doubt.

But a Prison and Probation Service Ombudsman report after his death raised two issues regarding the management of ill prisoners. The report author Paul Cotton recommended that HMP Holme House should review the process for obtaining a prisoner’s prior medical records from GPs and the process for transferring prisoners with illnesses, ensuring that the full medical records are available.

Jo Thurston, now responsible for healthcare at the prison, said that the reception nurse used to be responsible for requesting medical records from GPs.

“I don’t believe that was a fool-proof system,” she said. “Since then, that task is now done by dedicated administration staff.”

Regarding the transfer of medical information she said that the system is now fully computerised so that all prisons can access prisoners’ medical records from a central ‘spine’.

She also confirmed that if the prisoner had been too ill to be transferred the details would have been noted on his Prisoner Escort Record.

On January 8, 2009, an operational support grade (OSG) member of staff at HMP Acklington found Mr Milburn alive at 8.55pm when he did a roll check and ‘in a relaxed sleeping position’ at 10.45pm, although he did not disturb him for a response.

John Ellison, a prisoner in a neighbouring cell said he ‘heard a bang which came from Milburn’s cell’ at 1am while another prisoner, Jeremy Hicks, said that he spoke to Mr Milburn around 4am.

At a 5.47am check, the OSG could not see him and called another prison officer.

On entering the cell, Mr Milburn was found dead in a slumped sitting position on his toilet, fully-clothed in his pyjamas.

During the following investigation, nothing suspicious was found at the scene, and no internal or external injuries were found at the post mortem.