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Delay at HMP Chelmsford could have contributed to prisoner’s death

Crime / Wed 8th May 2024 at 12:07pm

CHELMSFORD prison has been criticised for a delay in responding to a collapsed 37-year-old inmate which could have contributed to his death reports the Local Democracy Reporter.

Ryan Flanagan died on March 23, 2021, in Broomfield Hospital, having collapsed in his cell on March 17 from heart failure.

A previous inquest held between April 15 and 26, 2024, concluded that Mr Flanagan died from natural causes but that the culture in Chelmsford prison around answering cell bells was not sufficiently prioritised.

It added this led to a delay which could have “possibly contributed to his death”.

The coroner added their concerns about culture in Chelmsford prison around entering cells in emergency situations.

It added this led to further delays to the start of resuscitation which “possibly contributed to his death.”

The Prisons and Probation Ombudsman has added its own concerns – highlighting that it has commented several times on staff failing to follow the correct emergency procedures in calling emergency codes.

It adds that it is “disappointing that once again we are commenting on the same issue.”

It adds it is also concerned that Mr Flanagan’s family were informed that he had gone to hospital by another prisoner and had to confirm this themselves with the prison.

Shortly before 8.30pm, Mr Flanagan’s cellmate raised the alarm he had collapsed. Mr Flanagan had a pulse but did not appear to be breathing.

Mr Flanagan’s cellmate said that he pressed his cell bell to attract staff attention. The Operational Support Grade (OSG) said in her police statement that she and the prison officer heard a cell bell, but attempted to finish a task they were involved in before the officer said that he needed to leave to respond to the cell bell. She said this was approximately two minutes.

But from the records, it seems that the officer arrived at the cell and answered the cell bell within three minutes of it being pressed.

The officer said in an interview that he did not know either prisoner and made a dynamic risk assessment that it was not safe for him to enter the cell at that stage.

The OSG joined him and used her radio to call a code blue emergency.

This was at 8.24pm. This prompted the control room to call an ambulance. The control room log does not record what time an ambulance was requested; Ambulance Service records showed that the call was received at 8.26pm.

The officer, who is first aid Prisons and Probation Ombudsman 7 trained, used his radio to reiterate that medical staff were needed.

Another officer arrived at the cell approximately two minutes after the OSG. She thought that the protocol was that three prison officers (not including OSGs) should be present to unlock a cell with two prisoners, but decided that in the circumstances they should enter the cell. As she was radioing for permission to open the door, she saw another prison officer arriving on the landing so she unlocked the door.

They started to perform cardiopulmonary resuscitation (CPR). The radio recordings indicate that the officer said that they were entering the cell two minutes from the OSG making the code blue call.

A nurse had responded to the emergency call, and the prison log showed that he arrived at the cell two minutes after the prison officers went into the cell. He could not detect a pulse nor any sign that Mr Flanagan was breathing.

They applied a defibrillator (a machine that monitors and, in some circumstances, can restart the heart).

He and the officers continued to attempt to revive Mr Flanagan until the ambulance crew arrived and took over. Having detected a pulse, they transferred him to the ambulance and on to Broomfield Hospital.

Mr Flanagan was put into an induced coma in the High Dependency Unit.

At approximately 10pm, a prisoner telephoned Mr Flanagan’s parents, telling them what had happened. They contacted the prison and, having been told where Mr Flanagan was, subsequently travelled to the hospital.

Mr Flanagan remained in a coma. His condition did not improve, and following a discussion between doctors and his family, the decision was taken to switch off life support. Mr Flanagan died at 12.45am on March 23. His family were with him.

A statement from the Prisons and Probation Ombudsman added: “We have commented several times in previous reports of investigations in Chelmsford on staff failing to follow the correct emergency procedures in calling emergency codes. In response to our recommendations, Chelmsford undertook a programme of training that involved an emergency scenario exercise to reinforce staff knowledge of what to do when faced with such a situation, including correct use of radios. This began in October 2019 and was scheduled to be an annual event. We acknowledge that the officer was a new member of staff, only completing his training and starting his role less than a month before the emergency with Mr Flanagan. It is, though, disappointing that once again we are commenting on the same issue.

It added: “The recorded timings for cell bells are not accurate. The CCTV footage was of poor quality and while we know in which order staff arrived, we were unable to accurately determine the time lapse between the cellmate raising the alarm and staff going into Mr Flanagan’s cell. While we do not know if the delay made any difference to the outcome for Mr Flanagan, it may do in other emergency situations.”

A Prison Service spokesperson said in response to the report: “Our thoughts remain with Mr Flanagan’s friends and family.

“We have accepted all of the Ombudsman’s recommendations and since this incident, HMP Chelmsford has upgraded its CCTV and improved the way staff respond to medical emergencies.”

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8 Comments for Delay at HMP Chelmsford could have contributed to prisoner’s death:

David Forman
2024-05-09 01:34:50

The problem with cell bell calls is that the first thought of prison officers is that it is an escape attempt. My experience of Chelmsford nick whilst on remand in 1989 in a similar scenario on a weekend is that three prison officers turned up to open the cell. Two were used to restrain me as the younger and fitter prisoner while the third officer attended to my very sick cellmate. It later emerged that my cellmate had suffered internal injuries after a fall down stairs during his arrest. Fortunately, my cellmate made a complete recovery. However, especially for first-time prisoners and those on remand, there is a lot of anxiety about getting sick in the cells. It is a really anxious time if you get sick at night or on weekends because there is less staff on duty than during the day. If you look at the picture above, you will see the round central hub which is where most prison officers are located out of hours, apart from those patrolling around the inner perimeter fence. Incidentally, the prison hospital is located in the middle left-hand corner of the prison campus. I'll never forget the morning when my cell door was opened and as the cell door opposite opened I could see a lifeless body hanging by a ligature from the cell's window bars. I'll also never forget the amount of prisoners I saw in the prison hospital who had slashed their wrists following receipt of a "Dear John" letter from their wife/girlfriend or succumbed to the pressure of bullying. Then of course there are those who got beaten up for not paying their debts or got a slap for not handing over their rations of tobacco or radio battery when bullied. I remember having to fend off three prisoners who wanted to beat up my cellmate. Those who say prison is a 'holiday camp' clearly haven't done time in one. Prison is mostly about punishment, very little about reform. The prison officers running physical training, the teachers and the prison chaplains do their best to help. Having a Bible in the cell also helped. Drugs were available both legitimately and smuggled in, but not my thing. Prison is not an experience I wish to repeat, but who knows what can happen in the future? One wrong move can land you there, so don't be so quick to denounce prison reform.

David Forman
2024-05-09 01:36:21

A shocking situation in the 21st century.

David Forman
2024-05-09 01:40:23

Just don't be sick.in your cell on nights or weekends as most of the prison officers are in the round central hub building. That is apart from the ones patrolling the inner perimeter fence. Plus, with two prisoners in the cell they like three or move prison officers to open the door. The reason for this is safety of prison officers and to stop escape attempts.

David Forman
2024-05-09 02:00:07

This is what the Prisons and Probation Ombudsman actually said in their action plan in relation to Mr Flanagan's demise: "HMP Chelmsford continue to regularly publish guidance surrounding medical emergencies. Guidance was republished in April 2022, specifically stating that staff should complete dynamic risk assessments and enter cells on their own if they deem it safe to do so. The Medical Response Code guidance was revised and republished in February 2022 and included a new paragraph focussing on carrying out dynamic risk assessments and entering a cell in life-threatening situations." See Action Plan at: https://cloud-platform-e218f50a4812967ba1215eaecede923f.s3.amazonaws.com/uploads/sites/34/2024/05/F5631-21-Death-of-Mr-Ryan-Flanagan-in-hospital-Chelmsford-23-03-2021-NC-31-40-37-AP.pdf

David Forman
2024-05-09 02:12:52

Here is what the Prison Reform Trust had to say in 2016: "There were wide-ranging reports that responses to medical emergencies were so poor that prisoners, particularly those who are older and have pre-existing health issues, were left with genuine fear for their lives. Those I spoke to attributed the poor responses to a number of factors. Anxieties particularly focussed on incidents occurring at times of low staffing such as during night state. Limited availability of staff authorised to unlock cells had led to long delays in accessing those in need of emergency assistance. There were complaints that some prison staff had made unreasonable judgements about the urgency of a person’s health need, sometimes with little interaction, which caused delay in getting help. Emergency services getting held up at the gate was also a recurring factor, regardless of time of day, with reports of ambulances stood at the gate for up to thirty minutes despite attending for a serious medical emergency." See this report at: https://prisonreformtrust.org.uk/emergency-response/

David Forman
2024-05-09 02:18:23

Of course nobody, especially the supercilious local politicians, give a monkeys about the welfare of prisoners. That is until one of them or their family gets banged up. The phrase "there but for the grace of God" should be in our minds. However, it demonstrates what a barbaric society we still have to endure in the 21st century.

David Forman
2024-05-09 03:24:37

The truly shocking thing is that after reading the Prison and Probation Ombudsman's report cover to cover it appears that Mr Flanagan was a remand prisoner, meaning that he had not been finally sentenced by a court. In paragraph 21 on page 5 it says: "On 18 January 2020, Mr Ryan Flanagan was remanded to HMP Chelmsford on charges of conspiracy to commit burglary". In paragraph 23 on page 5 it says: "After a court appearance in March, (2020) Mr Flanagan again complained of back pain." As no mention of a custodial sentence being applied one can only assume Mr Flanagan was still on remand. An absolute disgrace as well it taking almost 3 years for an inquest.

Gtgopher
2024-05-09 05:46:04

Hey ,here's one simple fact.... don't commit crimes! This never would have happened if he didn't choose to commit a crime.

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