Prisoner died after 'unsafe' nursing, report says

The report looked into the death of a remand prisoner in 2022

A prisoner who had a rare form of pneumonia died after "poor and unsafe" nursing caused delays in him being assessed and treated, a report says.

Marc Uzzell, 42, had been charged with violent offences and was on remand at HMP Bristol when he became unwell on Christmas Eve 2022. He died in hospital four days later.

The Prisons and Probation Ombudsman found Mr Uzzell reported coughing up blood but the agency nurse who assessed him did not record his observations or mention them during morning handover.

A spokesperson for the prison service said it had since made "significant improvements" and taken action to ensure staff properly record decisions.

Mr Uzzell was the seventh prisoner at Bristol to die since December 2019 and there have been a further seven deaths since, the report added.

He first became unwell in the early hours of 24 December 2022 and was assessed by Nurse A.

Mr Uzzell remained unwell and his symptoms got worse. At about 09:00 GMT another nurse reviewed him and found he needed to be assessed by a critical care team in hospital.

She also notified the prison's head of healthcare about Nurse A's failure to record his assessment or hand over properly.

Mr Uzzell did not recover and at an inquest in June the coroner for Avon concluded he died from natural causes, adding the delay in hospital admission increased the speed and severity of the illness and accelerated his death.

Nurse A's actions remain under investigation by the Nursing and Midwifery Council, the report adds.

Marc Uzzell was being held on remand when he fell ill in December 2022

The report said Nurse A initially failed to engage with the ombudsman's investigation and maintained he had provided a statement to the prison's head of healthcare, who disputed this.

In a statement submitted to the clinical reviewer, Nurse A said Mr Uzzell was alert and said he advised him to contact prison healthcare if his symptoms persisted.

The report adds: "He also said that he had spoken about Mr Uzzell during the handover to healthcare day staff, but we found no evidence to corroborate this."

The report recommends agency staff are "clinically competent" to be assigned to the role of lead emergency nurse and that improvements are made to the documentation of interactions and decisions.

It also said record keeping when dispensing medication should be improved, as Mr Uzzell was given over-the-counter painkillers three times from 19-20 December but the reason for this was not recorded.

In 2023, a damning report into HMP Bristol said there were "chronic and intractable" problems, which led to HM Chief Inspector of Prisons Charlie Taylor describing it as "one of the most unsafe prisons in the country".

A spokesperson for HM Prison Service said: "We accepted all of the ombudsman's recommendations and took action in 2023 to ensure staff properly record key decisions and preserve important documents after a death in custody.

"Since 2023, HMP Bristol has made significant improvements including boosting security, expanding support services, and improving rehabilitation to help reduce reoffending and make the prison safer."