A coroner says staff failed to recognise the signs of a medical emergency
A man died in prison after staff failed to recognise he was experiencing “textbook” signs of a medical emergency, a coroner has said. Josh Tarrant, 34, was on remand at HMP Elmley on the Isle of Sheppey when he went into cardiac arrest and died in the early hours of November 1, 2023.
An inquest found the dad-of-five died as a result of cocaine toxicity following a lengthy and challenging restraint. During the proceedings at Oakwood House in Maidstone, headed by assistant coroner Scott Matthewson, it was concluded that Mr Tarrant was experiencing an acute behavioural disturbance which was not recognised by healthcare staff.
Their failure to provide sufficient medical treatment “at the earliest appropriate opportunity” was found to be “probably a significant contributing factor” in his death. Mr Tarrant had been charged with robbery, actual bodily harm and criminal damage after crashing a Nissan Qashqai in Sittingbourne on October 28, 2023 and was held in police custody for three days until he attended court.
He was remanded until his next court hearing and taken to prison in the early evening of October 31. Despite being searched by prison staff, he had managed to smuggle in cocaine. Mr Tarrant’s demeanour was initially calm and pleasant.
But during a call with his mother, he told her he could hear voices and spoke about suicide. This was relayed to the prison service by his mother after the call, as she became concerned. At around 11.30pm – an hour after he had likely ingested cocaine – staff visited his cell to talk to him. Mr Tarrant was standing up bare-chested, looking out of the cell window and was speaking incoherently and repetitively, saying “help me, help me, help me”.
He suddenly knocked a TV to the floor and tried to run out of his cell, resulting in him being physically restrained. During this, Mr Tarrant displayed unusual strength and at one point lifted several officers off the ground as he got to his feet. As a result, the nurse on duty was called, who made “little or no assessment” of Mr Tarrant, despite thinking he was having a psychotic episode.
She did not declare a medical emergency, which would have triggered a 999 call to the ambulance service, but decided he should be taken to the healthcare wing to be kept under observation. The coroner said the trip from Mr Tarrant’s cell to the unit would normally take five minutes, but ended up taking 30 minutes.
Once the door was locked in the new cell, he remained distressed, violent and began damaging his cell. It is noted that the force of his smashing the gate of his cell with his legs, arms and even his head shocked some of the officers who witnessed it, and Mr Tarrant seemed to be oblivious to the pain that he must have been experiencing.
Due to the damage, he was moved to a neighbouring cell. The coroner said as staff left, Mr Tarrant became unresponsive. When the final officer went to exit, he re-entered and saw the inmate was not breathing and did not have a pulse.
A “Code Blue” was called, meaning that any staff with medical training were summoned to the cell, and an ambulance was dispatched to the prison. CPR was started immediately, but healthcare staff made a number of basic errors in providing it, such as failing to use the correct equipment and inserting an i-Gel in Mr Tarrant’s airway the wrong way around, which blocked his airway.
Paramedics arrived at the scene at 1.44 am and took over, but CPR was unsuccessful, and Mr Tarrant was pronounced dead at 2.13am on November 1. Mr Matthewson has now written a Prevention of Future Death report, which says that from about 11.30pm until moments before his death, Mr Tarrant was displaying classic signs of Acute Behavioural Disturbance (ABD).
Those suffering ABD can display symptoms, including apparent psychosis, repetitive shouting, random violence against people or objects and be impervious to pain. According to the report, Mr Tarrant’s presentation made it obvious that he was experiencing ABD, and anybody who had been trained to spot the signs of it would have known in minutes.
At the time, neither healthcare staff or prison staff had any training in ABD. The report also notes that had treatment been initiated any time before 1am, Mr Tarrant would probably have survived. Mr Matthewson has expressed concerns that no training is provided to prison healthcare staff in relation to ABD and that if prison nurses remain unaware of ABD and the need to treat it as a medical emergency, then further deaths are likely in future.
The prison service has until April 6 to respond to the coroner’s concerns. A Prison Service spokesperson said: “Healthcare in prisons is the responsibility of the NHS – but we will carefully consider the coroner’s findings and will respond to the report in due course.”
Oxleas NHS Foundation Trust, which serves HMP Elmley, has been approached for comment.
