HMP Nottingham: Prisoner died after neglect from staff, inquest finds

A prevention of future death report was made by the coroner

An inmate who died after being taken ill in his cell was neglected by nursing and prison staff, an inquest has found.

Alexander Braund, 25, was taken from HMP Nottingham to the city's Queen's Medical Centre on the morning of 10 March 2020, where he died.

A jury at Nottingham Coroner's Court found there was "an unreasonable delay" in providing emergency treatment.

The Ministry of Justice (MoJ) said training had since been stepped up.

'Probing questions'

In a narrative conclusion, the court heard Mr Braund was remanded into custody on the evening of 13 February 2020, and was described as being "fit and well" apart from a documented shoulder injury.

He first became unwell on 6 March, which was not reported to prison staff, but the following day he told a nurse he was "coughing all night, producing brown phlegm, generally feeling unwell and had a bad chest".

The nurse examined his medical records, completed a sepsis screening, with a diagnosis of a common cold made, but his chest was not examined with a stethoscope "and probing questions were not asked".

His condition deteriorated over the next two days, and the court heard an emergency bell from Braund's cell was called at about 22:20 GMT on 9 March.

Mr Braund was taken to the Queen's Medical Centre

A prison officer told a nurse the inmate was "having difficulty breathing and had been vomiting", with a cellmate providing a similar account to the nurse examining him.

Braund's pulse and oxygen levels were checked, but the nurse did not carry out blood pressure, respiration or temperature checks, and his chest was not examined and no specific diagnosis was made.

The court heard staff were planning to refer him to a GP in the morning, but at 05:35 on 10 March the emergency bell was activated again as Braund and his cellmate "were becoming increasingly concerned about Alex's deteriorating condition".

Despite requests to see a nurse he was not reassessed, and at 06:55 the emergency bell was rung again after Braund collapsed.

A prison officer arrived but did not enter the cell. Then a colleague arrived and at 07:01 an ambulance was called.

Braund died at the hospital's intensive care unit at 11:44.

'Continuous failure'

The medical cause of death was given as hypoxic ischaemic brain injury, cardiac arrest "with long down time" and atypical pneumonitis.

A jury said in its conclusion Braund "had been suffering from an atypic[al] pneumonitis that was not detected", and found there was "continuous failure to provide adequate healthcare".

It said there was a failure by a nurse to re-review the patient on the morning of 10 March, as well as an "unreasonable reaction to provide prompt assessment" after he had collapsed.

Assistant coroner Laurinda Bower said she would make a referral to the Nursing and Midwifery Council regarding the conduct of a nurse both in the lead-up to Braund's death and during the inquest, and write to HMP Nottingham regarding a member of prison staff.

She also issued a prevention of future death report to HMP Nottingham, which has been heavily criticised in recent years and was the first in the UK to be issued an urgent notification letter over self-inflicted deaths.

"It's clear that changes, whether they have been made, aren't having the desired effect," she said.

An MoJ spokesperson said: "Our thoughts remain with Mr Braund's family and friends.

"Since this tragic incident we have introduced extra training for staff responding to medical emergencies.

"We will consider the jury's findings and respond to the coroner's recommendations in due course."