A report into a man who died just a week after arriving at HMP Forest Bank found received at the prison was equivalent to that which he could have expected to receive in the community.
37 year old Dean Leach died from peritonitis – inflammation of the inner abdominal wall – caused by a perforated duodenal ulcer after being charged with assault and being remanded at the Salford prison in December 2022
Two days later a nurse recorded on Mr Leach’s medical record that she had been asked to urgently examine him due to concerns raised by officers.
Mr Leach had been vomiting and refusing food for three days and could not sit up in bed. When the nurse arrived at Mr Leach’s cell, he immediately sat up in his bed.
The nurse said his immediate presentation contradicted the telephone call she had received.
Mr Leach told her that he had not been eating anything and had been vomiting. She told Mr Leach to take regular sips of water, to stay hydrated.
Mr Leach asked for medication, but she said it was not necessary at that point. Mr Leach became verbally abusive, started swearing and made threats that he would stop eating. In response, the nurse commenced a food refusal care plan, which involved keeping a food diary, daily visits by a nurse and regular GP appointments.
The following day after discussion with officers on Mr Leach’s wing, the nurse established that he had been eating biscuits and drinking tea with other prisoners.
She considered that Mr Leach was just angry in the moment when he threatened to refuse food, so chose not to continue with the food refusal care plan.
The nurse advised officers to contact the healthcare emergency responder or use the healthcare triage system if they had any concerns.
On the morning of 3 January, prison officers asked healthcare staff to urgently examine Mr Leach. Officers had found Mr Leach grunting and rolling around in his cell, holding his stomach.
Mr Leach told a nurse that he was supposed to be on omeprazole (a medication taken for gastritis, inflammation of the lining of the stomach) but that he had not taken it for some time because he had been “on the run” while resisting police arrest in the community.
Mr Leach explained that the pain was worse if he ate, so he had not eaten for a few days. The nurse assessed Mr Leach and found that he was breathing quickly and had a fast pulse.
At around midday, officers escorted Mr Leach to the healthcare centre for an appointment with a GP. Mr Leach reported that he was suffering from indigestion, burping, and vomiting.
He explained that he had a history of stomach ulcers for which he had been prescribed omeprazole in the past, however he had not taken it recently.
The GP noted that Mr Leach had lost 3kg in weight since his arrival. He completed a thorough examination of Mr Leach and checked for signs of serious illness. He did not find any issues of concern, other than Mr Leach’s trouble opening his bowels.
The GP noted that Mr Leach’s breathing, blood pressure and temperature were within the normal ranges. He diagnosed Mr Leach with gastritis and created a care plan to monitor his treatment, which included a prescription for omeprazole. The GP explained the red flag symptoms Mr Leach should look out for and refer to staff, using his emergency cell bell where necessary
At 3.05pm, a nurse noted in Mr Leach’s medical record that he had returned to the wing and should be reviewed by a night nurse later in the evening.
At 6.05pm, a nurse attended Mr Leach’s cell to check on him and noted that he was fully alert and orientated, lying on his bed. Mr Leach reported ongoing abdominal pain but said it was less severe. He said he had not vomited again.
The nurse recorded that Mr Leach had eaten a bowl of cereal and a warm drink. She administered his medication and completed a set of checks on the severity of illness and risk of deterioration, which indicated a low risk.
Shortly before 10.00pm, an operational support grade (OSG) completed a routine check of prisoners on Mr Leach’s wing. He had a brief conversation with Mr Leach and did not raise any concerns.
At around 4.45am the following morning a duty nurse called the OSG to ask if he could check on Mr Leach during his early morning routine check. Mr Leach had been sick the previous day and the early morning roll check was due in 15 minutes.
They found that Mr Leach was semi-naked on the cell floor, banged on the door and called Mr Leach’s name, but he was unresponsive.
They then radioed a medical emergency ‘code blue’, and officers and healthcare staff, including the duty nurse, responded quickly. The code blue triggered a call for an ambulance.
At interview, the nurse told us that Mr Leach’s body was rigid, cold to the touch and had no pulse. He noted that rigor mortis was present. As there were no signs of life, cardiopulmonary resuscitation (CPR) was not started.
Paramedics arrived at the cell and confirmed that Mr Leach had died.
