‘Lessons learnt’ after death of elderly inmate at Norwich Prison

Norwich Prison entrance.

Norwich Prison entrance. - Credit: Archant © 2009

Healthcare officials at Norwich Prison said lessons had been learnt after a number of housekeeping errors were discovered following the death of a 92-year-old inmate.

A jury yesterday ruled that Ronald Sherlock, who was serving a life term, died at HMP Norwich on April 24 as a result of natural causes.

However, Norfolk coroner William Armstrong said he would be writing to the prison service and healthcare provider Serco to ensure they address the shortcomings found following an independent review into the prisoner's care.

Sherlock, who was jailed in 1979, was transferred to Norwich Prison in 2005 and was seriously ill with heart problems, prostate cancer, diabetes, chronic kidney disease, lung cancer and had developed Alzheimer's Disease, the inquest heard.

He was found dead in his cell by a healthcare worker at 11.30am on April 24, a few days after being put on the Liverpool Care Pathway end of life programme.


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Sandie Brown, a registered nurse, who reviewed his treatment, said Sherlock's treatment was equal to the standard of care expected in the community and prison staff had done 'sterling' work to ensure that he was able to attend hospital appointments for his renal failure.

However, she told the inquest that some 'housekeeping' issues had been found. She said the prison had no formal end of life programme, there was no evidence of a mental capacity assessment being carried out when Sherlock signed a 'do not resuscitate' form in December 2011, and no swallowing assessment had been performed.

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Cheryl Mortimer, matron at HMP Norwich, who works for Serco, said the prison had since put in place a formal end of life policy for dying inmates and mental capacity assessments were now formally documented.

However, she said the prison had no links to a speech and language therapist to determine whether a frail inmate can swallow food and drink.

Mr Armstrong said he would be writing to the authorities to ensure prisoners in Norwich did get access to a speech and language therapist.

'Lots of elderly people die as a result of swallowing difficulties and if someone at Norwich Prison does not have access to that facility, it is quite a serious issue.'

'Prisoners are entitled to the same medical care that the rest of us have - it is a basic human right. There seems to be a gap that needs to be filled,' he said.

The coroner added that the housekeeping issues had not contributed in any way to Sherlock's death.

A jury returned a verdict that Sherlock died of natural causes as a result of a chest infection, chronic kidney disease, diabetes and atrial fibrillation.

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