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A prisoner at HMP The Verne died from congestive heart failure after delays in receiving his prescribed diuretics, the senior coroner for Dorset has found.

Coroner Rachael Griffin wrote in a report to prevent future deaths that George Haldenby, who had hypertensive and ischaemic heart disease, died in Dorset County Hospital on January 29, 2022 aged 56 having collapsed in prison.

Mr Haldenby was not prescribed his usual furosemide by the prison healthcare team from January 10-26. On Friday January 21 he was taken to Dorset County Hospital after presenting to the prison doctor with deteriorating heart failure.

Clinicians at the hospital upped his furosemide prescription from 20mg to 80mg per day, issuing the FP10 prescription after the hospital pharmacy’s Friday closure time of 6pm.

The prescription was therefore taken back to the prison, but because the GP had left for the weekend it was not actioned until Mr Haldenby’s next doctor review on Wednesday January 26.

He took the medicine at the higher dose the following two days, and on the morning of January 29 after defecating in his cell was moved to the Care and Separation Unit (CSU) where he collapsed, with the healthcare team performing CPR nine minutes later. He was taken back to Dorset County Hospital where he died that day.

The impact of his medication regimen and the exertion of his move to the CSU “contributed more than minimally to his death,” wrote the coroner.

Commenting on the lack of weekend care that was available to Mr Haldenby, she wrote: “In prisons without 24 hour healthcare provision, if a prisoner receives treatment at a hospital and is issued with a medication prescription on a FP10 form, this cannot be processed at the prison in the absence of a doctor or prescribing nurse, and pharmacies in hospitals are not always open 24 hours a day for it to be dispensed as TTO medication.

“This means there will be a delay in prisoners receiving necessary and lifesaving medication over a weekend or bank holiday period until staff are in the prison who can action the prescription.”

She found that although there is now a duty doctor at The Verne to progress out-of-hours prescriptions, there is a lack of local policy to ensure prison staff can deal with prescriptions when a prescribing healthcare professional is not available, also noting that furosemide was not included as a “critical” drug in the prison’s medicine cabinet.

The coroner also identified a lack of CPR training for prison staff, which could lead to delays in performing effective CPR.

Responding to the coroner’s report, NHS England said that while not all prisons have 24-hour healthcare the provider is expected to “arrange and use a process for the dispensing of urgent medication from local pharmacies, or other urgent care or OOH primary care services, outside of core hours”.

NHSE noted that the healthcare provider at The Verne has changed since Mr Haldenby’s death.

In its response, Oxleas NHS Foundation Trust said it planned to recirculate its out-of-hours medicines management SOP to all healthcare teams to “reinforce staff understanding and compliance”.

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