HMP Durham officers restrained prisoner who needed hospital treatment - despite him being paralysed
A sick prisoner who had signifigantly impaired movement and coordination was unnecessarily restrained when he required hospital treatment, a report into his death has found.
Simon Parkinson had no coordination or movement in his right arm and leg when he was restrained and transported to hospital from HMP Durham on July 2, 2023, following a stroke. However, he remained restrainted in hospital for two days before they were removed, by which time his right side was paralysed and he was unable to speak or swallow.
He died in hospital on July 7, 2023, of aspiration pneumonia, an infection of the lungs caused by inhaling fluids or food, caused by a stroke. The 60-year-old had been serving a four year and five month prison sentance at HMP Durham for sex offences since April 17, 2023.
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Now, a Prisons and Probation Ombudsman (PPO) report into his death has concluded that the decision to restrain Parkinson was not justified and it has called on the Governor to ensure that prison staff understand that medical information about a prisoner must be sought and properly considered when deciding whether to use restraints. It also asked that in cases where a medical objection is disregarded or is not obtained that the reason is documented.
A Prison Service spokesperson said: "HMP Durham has accepted the Ombudsman's recommendations and has reviewed risk assessment procedures around the use of restraints during hospital transfers."
It was around 8.30pm on July 1, 2023, when Parkinson's cell mate activated the emergncy call bell in his cell at the request of Parkinson, who had also asked his cell mate to help him back from the toilet. An Officer Support Grade (OSG) told the investigator that she responded to the call, during which Parkinson told her that he felt dizzy.
She said she told him to drink some water and rest. But at approximately 10.00pm Parkinson asked for help getting to the toilet, his cell mate told an invstigator. He said that Parkinson was sitting up in bed but could not move one side of his body and was not able to make it to the toilet, so wet himself and laid down on his bed.
He said that he pressed the call bell and told the officer what had happened but was told that the officer had not been able to contact the nurse. The OSG told the investigator that the call bell had only been activated once that evening at 8.30pm.
At approximately 4.00am on July 2, 2023, Parkinson's cell mate said he activated the call bell to find out what was happening and that Parkinson had wet himself again. The OSG said that she went to the cell, and she could see that Parkinson looked unwell and was unable to speak.
She activated medical emergency code blue at 4.16am, which triggers the control room to call an emergency ambulance and for healthcare and prison officers to attend as an emergency. It call was answered by the Custodial Manager (CM) in charge that night, who responded with two officers. She said it was obvious that Parkinson was unwell and needed to go to hospital. An ambulance arrived at approximately 4.38am.
The PPO report states that a medical examination found that Parkinson was very pale, had a clear droop to the side of his face, and he was cold to touch. It also noted that he was soaked in urine, was unable to speak in clear full sentences, and was unable to keep a thermometer under his tongue to record his temperature.
A nurse noted that Parkinson had no co-ordination or movement in his right arm and leg and was leaning to the right side when he was in the stretcher chair being transported to hospital, the report added.
But the CM told an investigator that she decided Parkinson should be escorted to hospital by two officers and restrained using a single cuff and escort chain. An escort chain is a long chain with a handcuff at each end, one of which is attached to the prisoner and the other to an officer. The PPO report found that the decision to restrain Parkinson was not justified.
It also found that a risk assessment document provided by the CM, which was wrongly dated April 12, indicated that a double cuff and escort chain was to be used. In this instance a prisoner's hands would be handcuffed in front of them, with one wrist attached to a prison officer by an additional set of handcuffs.The document also indicated a medical objection to the use of restraints.
In an email to the investigator, the CM said that she had reviewed the risk assessment document and noticed that she had ticked yes to medical objection, so she may have spoken to the nurse. However, while the form indicated that a double cuff was used, this was not correct, she added.
Later that day, a stroke consultant at the hospital told a prison nurse that Parkinson had suffered a stroke. And on July 4, it was confirmed that Parkinson had suffered multiple strokes, his right side was paralysed and he was unable to speak or swallow.
On the same day, an officer phoned a prison manager to report that doctors were concerned that Parkinson could have a cardiac arrest. It was during this conversation that the officer was told to remove Parkinson's restraints, the report added.
At 6.59pm on July 7, 2023, prison escort officers at the hospital with Parkinson contacted the control room to tell them that Parkinson had died. A doctor detrmined that the cause of death was aspiration pneumonia, an infection of the lungs caused by inhaling fluids or food, caused by a multifocal ischaemic posterior circulation stroke.
An inquest into Parkinson's death on September 5, 2024, recorded a verdict of natural causes. The coroner concluded that Parkinson's death was due to aspiration pneumonia, multifocal ischaemic posterior circulation stroke and clostridium difficile.
The full report can be found here.