HMP Forest Bank didn't 'understood needs of prisoner' with no spleen

A man on remand at Forest Bank prison in Salford died aged 50 from septicaemia. Russell West - who had been in prison before and was said to have had a history of using illegal drugs behind bars - had his spleen removed in 2003.

A coroner recorded a verdict that he died of natural causes following an inquest, but the prisons watchdog has now told Forest Bank to comply with a series of recommendations concerning inmates with no spleen.

A now published report by the Prisons and Probation Ombudsman (PPO), which investigates deaths in custody, revealed a clinical reviewer 'was not satisfied that healthcare staff understood the needs of a prisoner who had undergone a splenectomy and that Mr West was at an increased risk of developing a serious infection' because of it.

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Healthcare staff at the prison, added the report, 'did not recognise the importance of the need to establish if Mr West had been fully vaccinated and if he was taking prophylactic antibiotics'.

The body's spleen fights infections, with anyone having a splenectomy open to an increased risk of severe infection for life.

The report said: "The clinical reviewer found that while Mr West was offered and refused vaccinations when he arrived at Forest Bank, there is no evidence that healthcare staff investigated if he was fully vaccinated in accordance with NHS England recommendations. Mr West was not prescribed prophylactic antibiotics at Forest Bank.

"Healthcare staff did not recognise the importance of the need to establish if Mr West had been fully vaccinated and if he was taking prophylactic antibiotics. The clinical reviewer concluded that Mr West's post-splenectomy care at Forest Bank was not equivalent to that which he could have expected to receive in the community."

Healthcare staff also didn't obtain his GP medical records, and therefore 'failed to establish his ongoing clinical care needs', said ombudsman Sue McAllister in her report.

Mr West died on July 8, 2018. He was remanded to the prison in the February for drug-related offences, the report said.

A month before his death, he is said to have complained of neck pain and was prescribed painkillers together with a referral to a physiotherapist.

On the morning of July 4, he complained of felling unwell and was moved to the prison's healthcare unit. But nurses went on to assess he had a 'moderate to high risk of developing sepsis' and he was taken to hospital. The report says he had a cardiac arrest on July 6 in hospital and died two days later without regaining consciousness.

The ombudsman added: "A post mortem report gave Mr West's cause of death as pneumococcal septicaemia and meningitis in a male with asplenism (the absence of a spleen) after trauma. The head of healthcare [at the prison] should ensure that healthcare staff are aware of and understand the clinical needs of a prisoner who has undergone a splenectomy."

Forest Bank in Pendlebury holds 1,460 remanded and sentenced men and is managed by Sodexo Justice Services. Sodexo also provides primary health care services.

Mr West was said to be the third prisoner to die of natural causes at HMP Forest Bank since January, 2016.

An HMP Forest Bank spokesperson said: "Our thoughts continue to be with Mr. West's family and friends. A full coroner's inquest has been held which examined all relevant matters. While many changes and improvements have been made in the prison over the course of the six years since Mr. West's death, we have considered the jury’s findings and conclusions with great care and continue to build on progress made."