Abul Kashem Miah died in hospital on April 21 last year, three days after suffering a heart attack in the prison yard.
A fatal incident report from the Prisons and Probation Ombudsman (PPO) has now revealed that staff did not have up-to-date first aid training and there was no oxygen in their emergency kit.
While the PPO, which investigates all deaths in custody, stressed that it could not say whether these factors affected Mr Miah’s chance of survival, it made five recommendations to ensure others are given the best possible chance of a positive outcome in any future incidents.
The Prison Service said it had acted on the recommendations.
The investigation report says Mr Miah, who had been handed a life sentence in November 2015, was transferred to HMP Stoke Heath, near Market Drayton, on March 14, 2022. Upon his arrival, no significant health needs were identified.
A matter of weeks later, on April 18, Mr Miah collapsed unexpectedly in the exercise yard at 2.45pm.
Other prisoners put him in the recovery position and ran for help – but did not use the panic alarm situated just metres from where Mr Miah had collapsed.
The report says: “Prisoners did not use the alarm to alert staff to the emergency, due to a culture of not wanting to be perceived as helping staff, and fears of being adjudicated for improper use.
“In practice, this meant that the prisoner who found Mr Miah had to travel to the staff office for support. This created a short delay of approximately two minutes in the emergency response to Mr Miah’s collapse.”
When staff arrived at the scene they began CPR and radioed for healthcare assistance.
The report says staff responded well to the emergency but officers later told investigators they “had not received refresher first aid training over a number of years”.
The first nurse arrived on the scene at 2.58pm, followed by another nurse soon after with emergency equipment – but it was discovered that there was no oxygen in the emergency bag.
This led to a delay of 12 minutes while oxygen was fetched.
The report says: “The clinical nurse manager told us that emergency equipment used for life support was checked daily. However, on July 28, the head of healthcare conducted an audit of the grab bags and identified that five out of seven bags had no oxygen in them.”
When oxygen was brought to the scene, it was administered by the first nurse, who told investigators they had felt “nervous and uncertain about this process”.
The report says: “The clinical reviewer was concerned that a senior nurse was present but did not lead the emergency response process.”
An ambulance arrived at the prison at 3.33pm and was taken to Mr Miah, arriving on scene at 3.40pm. Paramedics found a weak pulse and Mr Miah was taken to the Royal Stoke University Hospital Major Trauma Centre.
Three days later, following a visit from his family, Mr Miah stopped responding to treatment and died, aged 44.
The report says staff and other prisoners were notified of Mr Miah’s death and were offered support. Prisoners at risk of self harm or suicide were reviewed in case they had been affected.
As a result of the investigation, the ombudsman made five recommendations. They included asking the head of healthcare and the prison Governor to complete a review of the emergency response provided for Mr Miah, to ensure learning could be addressed, and ensuring all staff understand their responsibilities in a medical emergency.
The prison was also told to ensure all staff receive basic first aid training and that this is appropriately refreshed, and to ensure all emergency ‘grab’ bags are checked daily and any missing equipment replaced.
Finally, the prison was told to remind all prisoners to use the panic alarms in emergency situations.
The Prison Service confirmed it had begun delivering first aid refresher training to all staff.
A spokesperson added: “We have accepted all the recommendations made by the ombudsman and have introduced strict new processes to ensure emergency equipment is fully stocked at all times.”