There were failures in the lead up to the death of a Nottingham prisoner who suffered a heart attack in the toilets of the gym, an inquest has ruled. Masih Ullah was a serving prisoner detained at HMP Lowdham Grange when he suffered a myocardial infarction at 9.57am on August 5, 2019, following exercise.
Despite "prompt medical intervention", he was declared dead at 11.15am on the same day. Mr Ullah had a known heart condition which he declared on his gym induction process sheet. He had been transferred to HMP Lowdham Grange from HMP Full Sutton in Yorkshire, arriving 12 days before his medical emergency.
A jury found that there was a failure to properly arrange Masih Ullah's transfer to hospital for Cardiology and that there was also a failure to follow up and re-arrange the missed Cardiology review on April 11, 2019.
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When a prisoner declared medical issues as part of the prison gym induction process, it placed the onus on the prisoner to seek medical input. "There is no evidence that this system caused or contributed to Masih Ullah's death," the inquest found.
"Masih Ullah had arrived at Lowdham Grange 12 days earlier. Details of his medical condition and existing appointments were not provided by the sending establishment, including that he had not been able to attend an urgent cardiology appointment."
The jury also found that there was a failure to have in place a care plan relevant to his cardiology condition and a failure to provide the receiving establishment with an adequate healthcare handover.
It is not clear what Mr Ullah was in HMP Lowdham Grange for prior to his death.
Martin Booth, Serco Contract Director at HMP Lowdham Grange, said: “Any death in custody is a tragedy. As always we are working to ensure that we learn any lessons from the Inquest.”
A spokesperson from Spectrum Community Health CIC, which runs services for HMP Full Sutton, said: "We extend our deepest condolences to the patient’s family and those who knew him.
“As with all Death in Custody reviews Spectrum is fully committed to working closely with our employees, HM Prisons and Probation Service (HMPPS) and NHS England to ensure all recommendations outlined in the PPO report have been fully engaged with and implemented.”
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