Prisoner turned alarm off after inmate's collapse

Ian Deavall was on remand at HMP Forest Bank in Salford when he died

A prisoner was able to deactivate an emergency alarm triggered by the cellmate of a "vulnerable" inmate who had suffered a cardiac arrest, an inquest has heard.

Ian William Deavall, who was on remand at HMP Forest Bank in Salford, had a cardiac arrest and died on 24 January 2023.

The 66-year-old's cellmate pressed the emergency cell bell, but this was deactivated by another inmate who was standing outside on the landing.

Bronia Hartley, assistant coroner for Greater Manchester West, has filed a prevention of future deaths report after noting prison officers only learned of the medical emergency "more by accident than design".

While the inquest in Bolton concluded Mr Deavall had "died as a consequence of a naturally occurring cardiac arrest", Ms Hartley expressed concerns because it was recognised that "vulnerable prisoners" were at risk of being "victimised" in medical emergencies.

She also noted: "There was an admitted failure to arrange for Mr Deavall to be sent to hospital for assessment between 20 and 24 January 2023, however this did not cause or contribute to death on the balance of probabilities."

Ms Hartley said the medical cause of death was ischaemic heart disease and low blood pressure and he had been prescribed medications for these conditions.

The coroner said Mr Deavall and his cellmate were "believed to be at risk from other prisoners and were classed as vulnerable prisoners (VPs)."

She added: "The inquest heard evidence that both VPs and non-VPs are housed on the induction wing and that the recognised risk to VP prisoners when co-located with non-VP prisoners is managed by operating two separate regimes to avoid the two demographics coming into contact with one another."

'Risk remains'

Ms Hartley said Mr Deavall and his cellmate had been locked in their cell when he was taken ill.

The cellmate pressed the emergency cell bell but a non-VP (Prisoner A) talking with two other prisoners on the landing deactivated the bell on the panel outside the cell before resuming his conversation.

A minute elapsed before he alerted prison officers about the medical emergency.

Ms Hartley said staff were alerted "more by accident than design depending as it did on the caprice of Prisoner A".

Ms Hartley added: "There remains a risk that future deaths could occur as it remains the case that emergency cell bells at HMP Forest Bank can be deactivated readily and altogether by other prisoners and no action to implement fail-safe measures is currently proposed."

The coroner wrote to the operator of the private jail, Sodexo Justice Services, along with Spectrum Community Health CIC and Med-Co Secure Health Services Ltd stressing "urgent action should be taken to prevent future deaths and I believe your organisations have the power to take such action".

Her report was also sent to the Prison and Probation Ombudsman and His Majesty's Inspectorate of Prisons.

An HMP Forest Bank spokesman said: “Our thoughts and condolences remain with Mr Deavall’s family.

"Following the close of the inquest, we are working with His Majesty's Prison and Probation Service and the Ministry of Justice to review the coroner’s conclusions and recommendations."