A NURSE WAS forced to watch helplessly as a 59-year-old inmate died in his cell because prison officers could not locate the keys, according to a damning investigation report that branded the circumstances of his death “unconscionable”.
An investigation into the death at the Midlands Prison in August 2021 by the Office of the Inspector of Prisons (OIP) exposed a chaotic 14-minute delay in retrieving the keys to the man’s cell as he suffered a medical emergency.
The delay occurred during a lunchtime staff crossover, leaving a total of 297 prisoners across two wings completely inaccessible in the event of an emergency because the master keys had been removed from the landing.
The deceased prisoner, who was identified in the report only as Mr D, was serving a five-year sentence with a remission date of 16 February 2022.
The emergency began at 12.11pm when Mr D activated the alarm in his cell. A dinner guard attended the cell at 12.30pm and observed the inmate standing inside holding a handwritten note that read, “I had a reaction to antibiotics.” His face and tongue were visibly swollen.
The guard immediately called for medical help, prompting a nurse to run to the landing. Through the observation flap, she saw that Mr D was distressed and had severe difficulty breathing.
The inmate then lay down on his side on his bed and stopped responding. The nurse was forced to stay outside the locked door, shouting down the corridor for the keys while preparing medical equipment for suspected anaphylaxis.
The fatal delay was caused by a total breakdown in communication regarding the secure E and G division key room, according to the report. The investigation established that the official dinner guard post for the key room had previously been cut as a cost-saving measure.
Instead, keys were supposed to be returned to the central internal Keys Office during staff breaks. However, on the day of the incident, a prison officer had remained on the landing during lunch to do paperwork and locked the key room with the keys in his possession.
When prison staff arrived to take up duty and found the internal Keys Office empty, he scrambled across the complex trying to find the master key for Mr D’s cell. After making several radio calls and searching the complex, the prison officer was found in a staff tearoom.
The cell door was eventually opened at 12.38pm, 27 minutes after the initial emergency call had been activated. Nurses immediately entered and administered an EpiPen, but Mr D had no pulse.
Despite CPR, 15 litres of oxygen, and a second EpiPen dose, he could not be resuscitated. A doctor subsequently attended the cell and pronounced Mr D dead at 2.59pm.
The OIP report also highlighted significant failures in medical record-keeping and continuity of care leading up to the tragedy.
The investigation found that a locum doctor had prescribed the antibiotics Augmentin and Flagyl to Mr D on 25 July 2021 but failed to log any explanatory notes or patient allergy information in the healthcare system.
While a nurse had spotted the lack of documentation on 1 August and marked the antibiotics as “prescribed in error,” Mr D demanded them “as chartered” the following morning.
Another nurse confirmed the prescription on the system and administered the antibiotics at 12pm, just 11 minutes before Mr D triggered his emergency cell bell.
The locum doctor had requested a formal prison doctor review for Mr D on 26 July, but the prison service failed to act on the request and Mr D was not seen by a doctor before his death.
The OIP described the circumstances of the man’s death as “unconscionable” in the report.
It issued four core recommendations, demanding that the Irish Prison Service implement system-wide measures to ensure cells can always be rapidly unlocked during medical emergencies.
It also directed the IPS to conduct a full clinical review into the locum doctor’s unrecorded prescription and the failure to follow up on the medical review request.