An investigation into the death of an inmate at Leeds prison has raised concerns about the care he received while in custody.
Anthony Alexis was found slumped on his bed in his cell at HMP Leeds. It was found that he had died of a heart attack, aged 54.
Now a report by the Prisons and Probation Ombudsman has highlighted some concerns about how he was cared for leading up to his death on September 26 2021. The report says that Mr Alexis had been sentenced to life imprisonment in March 1990, having been convicted of murder.
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He transferred to Leeds prison on May 18, 2021. He was suffering from high blood pressure and was on medication for high cholesterol and heart failure. He also had a history of paranoid schizophrenia. Healthcare staff at the prison recorded that he refused to take his medication 13 times.
The Ombudsman's report states: "The clinical reviewer was concerned about the lack of a timely care plan for Mr Alexis’ heart disease and the lack of a formal mental capacity assessment. She was also concerned about staff’s failure to act with sufficient urgency when reviewing the Do Not Attempt cardiopulmonary resuscitation order, and that changes were not formally recorded, meaning they were not easily accessible to staff."
The report made a number of recommendations for improvements and concluded: "The clinical reviewer found that some of the care that Mr Alexis received was not equivalent to that which he would have received in the community. She was concerned about the lack of a timely care plan for Mr Alexis’ heart disease, mismanagement of the Do Not Attempt cardiopulmonary resuscitation order and a lack of a formal mental capacity assessment."
The report noted the emergency response that followed after an officer looked through Mr Alexis' cell observation panel and saw him slumped on the bed. She radioed a 'code blue' and waited one to two minutes for two more members of staff before she opened the door.
The report added: "The officer said that she weighed the risk to Mr Alexis against the risk to herself.
"She considered Mr Alexis’s recent aggressive and threatening behaviour towards staff including herself. Since she was aware of Mr Alexis’ unpredictable behaviour, she decided to wait for extra staff. She also said that she would always make a dynamic risk assessment if she ever found an unconscious prisoner who required a three-officer unlock.
"We are satisfied that the officer made a dynamic risk assessment and that waiting for officer support was an acceptable decision in the circumstances."
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