James Reilly died aged 60 on September 26 last year, the day after being taken to hospital by ambulance as a result of vomiting an excessive amount of blood.
A report from the Prisons and Probation Ombudsman, which investigates all prisoner deaths, has now criticised the decision to restrain Mr Reilly with an escort chain, and leave it on while he received emergency treatment including being anaesthetised.
Concerns were also raised that no care plan was in place to manage swelling Mr Reilly had been experiencing in his legs.
The ombudsman made two recommendations, which the Prison Service said had already been acted on.
The report says Mr Reilly arrived at HMP Stoke Heath, near Market Drayton, in 2018, having been jailed for 15 years for robbery four years before.
He was known to have type two diabetes and liver cirrhosis caused by a history of alcohol misuse.
In May 2022 Mr Reilly went to hospital because of swelling in his legs, and returned in June as the swelling had got worse. The hospital said he had cellulitis caused by liver disease.
The report says: “The clinical reviewer found no record that healthcare staff created a care plan to manage his fluid retention or cellulitis.”
After a further trip to hospital in July he was given a wheelchair.
Around the same time Mr Reilly was undergoing tests for unexplained weight loss.
He began vomiting blood on September 17 and was admitted to hospital. A scan on September 22 found he had lesions on his liver, and he returned to Stoke Heath the following day.
At 12.35pm on September 25, Mr Reilly pressed his cell bell and when officers arrived they found a large amount of blood. Mr Reilly was dizzy, had low blood pressure and was “very pale”, the report says.
An ambulance was called and paramedics arrived at 2pm.
Prison staff completed an escort risk assessment, which judged that he posed a low risk of escape but a high risk to the public and hospital staff. The decision was made to restrain him with an escort chain while he was escorted to hospital in the ambulance.
The report says: “He remained restrained in hospital, including during an anaesthetic and endoscopy procedure.
“When Mr Reilly came round from the anaesthetic, his health deteriorated and at around 5.45pm, he haemorrhaged.”
Hospital staff told prison officers it was a life-threatening situation and the chain was removed.
Mr Reilly was placed in a coma but died the following day.
An inquest concluded on April 13 that he had died of natural causes.
The report says the ombudsman’s clinical reviewer found the care Mr Reilly received at the prison “was partially equivalent to that which he could have expected to receive in the community”.
It says: “The clinical reviewer considered that Mr Reilly should have had a care plan in place to manage the fluid retention and cellulitis in his legs which were ultimately caused by his liver cirrhosis.”
The ombudsman recommended that the prison ensure care plans are created for prisoners with symptoms related to long-term or chronic conditions.
Turning to the use of restraints, the report references a High Court judgement from 2007 which ruled that medical opinion about a prisoner’s ability to escape should be taken into consideration in such situations.
The report says: “The judgement found that using handcuffs or other restraints on terminally ill or seriously ill prisoners was inhumane, unless justified by security considerations.”
It says Mr Reilly was using a wheelchair, had lost a lot of blood, and there “was sufficient opportunity to involve healthcare staff in the assessment” before the ambulance arrived.
The report adds: “We are particularly concerned that Mr Reilly remained restrained in hospital, including when hospital staff anaesthetised him and completed an endoscopy procedure.
“We are shocked that it was only when Mr Reilly haemorrhaged after his procedure and hospital staff indicated that it was a life-threatening situation that escort officers removed his restraint.
“This was undignified and unacceptable.”
The ombudsman recommended that the prison ensure all staff are aware of the legal position on restraints and that risk assessments for patients being taken to hospital “are based on the actual risk the prisoner presents at the time”.
A Prison Service spokesperson said: “Our sympathies remain with Mr Reilly’s family and friends.
“HMP Stoke Heath has already implemented the ombudsman’s recommendations – reviewing risk assessment processes for escorting prisoners to hospital and hiring more healthcare staff to ensure prisoners with long-term health conditions have care plans in place.”