Ombudsman Criticizes Emergency Care Following Inmate’s Death

The emergency medical attention provided to an inmate who collapsed and subsequently died has been criticized by an ombudsman. This criticism arose after an ambulance was cancelled because healthcare personnel erroneously thought the prisoner had consumed drugs. Thomas Simmons, 45, experienced a seizure in his cell at HMP Humber on 19 April 2022. The seizure was linked to a prior head injury sustained during an assault before his imprisonment. Mr. Simmons passed away in hospital the following day. The Prison and Probation Ombudsman’s report indicated that it held “concerns about the way in which the emergency response was managed” following the dismissal of an ambulance, as staff members believed Mr. Simmons was “under the influence of an illicit substance.” The healthcare provider for the correctional facility stated its inability to release specific information regarding Mr. Simmons’ medical treatment. Mr. Simmons, who had a record of intermittent incarceration, also had a background of substance misuse and was under observation for potential suicide and self-harm due to his mental health conditions. On 19 July 2021, he received an 11-month custodial sentence for possessing a bladed article. This occurred three months after he had been assaulted and sustained a significant head injury. Approximately one year later, at around 15:30 BST, correctional staff discovered the inmate collapsed on his cell floor, leading them to initiate “a medical emergency code,” according to the report. He was placed in the recovery position, and within eight minutes, a nurse determined that the ambulance was no longer necessary. Subsequently, medication intended to counteract opioid effects was administered to him, as staff suspected he had consumed “illicit drugs.” However, Mr. Simmons’ condition worsened, and he began experiencing a seizure and vomiting, the report indicated. The nurse then requested an ambulance once more but departed the cell due to feeling unwell, leaving an untrained staff member to “manage the emergency situation, with a suction machine that did not work.” Approximately 15 minutes elapsed before a different nurse arrived with a functional suction machine and assumed control of the emergency. Mr. Simmons subsequently experienced a cardiac arrest. The ambulance arrived just before 17:00, and paramedics performed resuscitation. Nevertheless, he passed away in hospital during the early morning hours. An inquest conducted on 19 November 2024 determined that his death resulted from a brain injury induced by a seizure. However, the report noted that the delay in providing medication during his seizure was a contributing factor to his demise. Prisons and Probation Ombudsman Adrian Usher stated in his findings: “The clinical reviewer concluded that Mr Simmons’ mental health and substance misuse care was of a good standard and equivalent to that which he could have received in the community. “However, the clinical reviewer considered that the level of care given during the emergency response was inadequate.” Usher also identified “some failings in the ongoing family liaison from the prison” and advocated for an adequate number of trained family liaison officers. City Health Care Partnership CIC, the entity responsible for healthcare services, issued a statement saying: “We were deeply saddened to hear of the death of Mr Simmons and our thoughts are with his family and friends. “City Health Care Partnership CIC cannot disclose any details about the care of individual patients as this would be a breach of confidentiality but if any serious incidents occur in our services we do thorough and detailed reviews of what has happened and put any recommended improvements in place.”