Two nurses have been sanctioned by the Nursing and Midwifery Council following the death of a patient at a Lancashire prison more than six years ago.

Failings in assessments, refusals to see the prisoner and cancelled GP appointments led to Patient A’s death at HMP Garth in Ulnes Walton in January 2017, despite inmates repeatedly banging on their cell doors telling staff that ‘Patient A is dying’.  

A misconduct hearing held by the Nursing and Midwifery Council (NMC) in October found the actions of nurses Odette Benatar and Julie Warmington had amounted to misconduct and as a result their fitness to practice was found to be impaired.

A report from the hearing explained that in March 2016 Patient A was transferred from HMP Durham to HMP Garth, near Leyland.

He was medically assessed and found to have no physical health conditions and no outstanding medical appointments.

Two months later Patient A made his first complaint to the medical team complaining of having sharp abdominal pains and headaches on opening his bowels.

He continued to complain of pain right through to July, but was never seen by a GP.

On November 6, he experienced vomiting, was seen by a nurse and told to see a GP the following day but this did not happen.

It was heard that wing officers approached Warmington the following day to express concerns that Patient A was being sick.

She saw him and told him to apply for a GP appointment and declined a sick note, but then asked him to leave when he became agitated.

On November 24 he complained again of being sick and Warmington told him to stay in his cell and use his bell if he needed anything.

He was diagnosed with an ulcer on caused by a bacterial infection on December 2 and was prescribed medication.

On December 29 Patient A had triage over the phone with Benatar where she advised him to stay in his cell as he was still vomiting.

There was no record of a follow up, but it was recorded his condition was causing him to contemplate self-harm and suicide.

As a result, the following day, a care plan was made up and he was booked in to see the GP, but this was cancelled and rearranged for January 6.

On January 5, wing officers again expressed concerns as Patient A had pain in his side and could not get out of bed.

Warmington is alleged to have said he should wait for his GP appointment and stay in his cell and use his cell bell if needed.

At his GP review it was found Patient A had lost 11.6kg over the last 24 months and was referred to gastroenterology.

The following day, Benatar was called to see Patient A as part of a code blue emergency, which indicates a patient is unconscious or not breathing.

He was given paracetamol and in records written by Benatar she described him as ‘drug seeking’.

Three days later another code blue emergency was made, and witnesses said prisoners were banging on their cell doors reporting that Patient A was dying. Warmington went to his cell but refused to treat him as he had become aggressive.

The report noted that Warmington left his cell, but prisoners became concerned and refused to go to work unless he was seen to. A GP later prescribed him antacid, but he never collected it.

The next day, January 11, Patient A was checked on and was found to have trouble breathing. Advice was given and it seemed to help but in the next round of checks, he was found slumped behind the door, not breathing and with no pulse.

Both Warmington and Benatar had heard the code blue call but had hesitated to head to the cell because of Patient A’s previous behaviour.

Paramedics arrived but Patient A was pronounced dead some 40 minutes after being found. The post-mortem concluded the cause of death was peritonitis caused by a perforated ulcer.

It was alleged by the NMC, that Benatar’s actions on December 29 in terms of the phone triage and her entries of drug seeking on January 8 were failures, and that these contributed to the death or a loss of a chance of survival.

It was alleged by the NMC, that although neither nurse was responsible for every failing in Patient A’s history, they were responsible for their own failings, and that one or more of their alleged failings contributed to Patient A’s death, or alternatively, to the loss of chance of survival.

Benatar admitted five charges, and Warmington admitted eight, with the NMC finding them both to be guilty of misconduct.

Benatar received a caution order for 18 months, and Warmington was suspended for six months.

The report concluded: “The panel considered that it was important for a proper understanding of the circumstances that led to the death of Patient A, to note that he had been subjected to systemic failings by the prison health service and that your failings were only a part of the much wider picture.”