A man died in immigration detention after medical staff “dismissed” signs that he was having a stroke because they wrongly presumed that he had taken spice, an inquest has concluded.
Jamaican national Carlington Spencer, 38, died in hospital on 3 October 2017, after medical staff in Morton Hall took more than 48 hours to treat his condition as an emergency despite warnings he was “fire hot” and one side of his face was drooping, the jury heard.
In an unusual move, the coroner said he was preparing a report to send to Morton Hall and Nottingham NHS on how to improve their response to such warnings and to prevent “confirmatory bias” by staff.
Mr Spencer grew up in Jamaica and had a number of successful businesses, but after moving to Derby with his wife in 2010 suffered a series of difficult bereavements and developed a troubled relationship with alcohol.
After separating from his wife, he became homeless for periods and struggled with mental and physical ill health. In April 2016, he was imprisoned for drug-related offences and a year later, after serving his sentence, was detained in Morton Hall IRC under immigration powers.
The jury found healthcare staff and officers were “dismissive” of repeated warnings from fellow detainees in the days before Mr Spencer's death that he was suffering from a stroke or another physical ailment, and that there was a lack of communication between staff about his health.
Detainees told the inquest Mr Spencer was slurring his words, was “fire hot” and dribbling, and had been found collapsed on the floor twice and complained of a headache and pain in his eyes.
But healthcare staff did not assess him for stroke-related symptoms, despite him having pre-existing conditions, and told the inquest that they believed he had been suffering from a physical attack related to spice.
They opened an illicit substances log at on the afternoon of 28 September and placed the 38-year-old under regular observation for the next five hours, before closing the log without reviewing Mr Spencer’s wellbeing, and without carrying out welfare checks overnight, the inquest heard.
The next morning, Mr Spencer's condition had deteriorated further and detainees set off the emergency alarm and banged on the healthcare centre's windows at around 12.45pm until staff arrived.
Around 25 minutes later, staff at the detention centre called a “non-emergency” ambulance which arrived more than an hour later, after taking some time to get through security at Morton Hall, which the jury found amounted to a failure to follow correct emergency procedures and causing unnecessary delays in arranging an ambulance.
Mr Spencer arrived Lincoln County hospital at 3.32pm and died three days later at Queens Medical Centre in Nottingham on 3 October 2017.
Despite the belief of staff that Mr Spencer had consumed spice, the jury found there was no evidence to prove that he had taken the substance in the days before his death.
They concluded that the interpretation by the healthcare staff of his presenting condition was “not reasonable” and on multiple occasions healthcare staff “failed to assess the situation correctly, resulting in confirmatory bias, non-consideration of differential diagnoses”.
The jury found “inadequate” management of Mr Spencer’s type 1 diabetes, “numerous” missed opportunities by discipline staff to sufficiently monitor and a “failure” of medical staff to identify symptoms of stroke and take appropriate actions in a timely manner.
Mr Spencer's sister, Shameika Spencer, thanked the jury on behalf of the family, saying their attitude towards “Jammy” – their nickname for him – and their reasoning, “far surpassed that of the actual medical professionals at Morton Hall detention centre”.
She added: “Special thanks to Carlington’s friends and fellow detainees who showed how much they cared and valued him by showing up at the hearing to be his voice from the grave. Things would have been so difficult, if not for them.
“Our lives will never the same again, because in spite of this success Carlington is still not here. Nevertheless we find some peace in knowing his death was not in vain.”
Mr Spencer was one of 11 people to die in immigration detention in 2017 – a record high.
Deborah Coles, director of the Inquest charity, which investigates state-related deaths, said: “Carlington’s death once again exposes the fatal consequences of a culture of dismissal and disbelief in immigration detention.
“Serious warning signs indicated that he was in need of urgent medical attention, yet were repeatedly ignored by detention and healthcare staff, despite the persistent efforts of fellow detainees.
“Successive inquests have highlighted fundamental failings in treatment and care as well as unsafe systems and practices. These deaths are at the sharp end of the harm and anguish caused by immigration detention and illustrate the human cost of UK immigration policies."
A Home Office spokesperson said their thoughts and sympathies were with Mr Spencer’s loved ones and that the department awaited the findings of the coroner's Regulation 28 report.