A quicker response from prison staff may have saved the life of an inmate who was found unconscious in his cell, an inquest heard.
Paul Johnstone, 37, who had a long history of drug misuse, was found unconscious at 1.40pm on January 2, 2019. He was lying motionless on the top bunk-bed when the alarm was raised at Strangeways prison.
Cellmate Derek Hulme called for help after he didn't respond when nudged. Prison officer Paul Thompson told Manchester Coroners' Court he answered the alarm and was asked by Mr Hulme: "Can you check on him?"
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Giving evidence during a three-day inquest, Mr Thompson added: "I checked his neck for a pulse and thought I felt one but it might have been adrenaline." He then ran downstairs and alerted other members of staff to assist him.
The officer explained he had worked at the prison for 15 months on the drugs and detox wing and had received 10 weeks training on emergency response codes. The court heard how a 'code blue' meant there is an urgent medical emergency.
Mr Thompson described how he and other officers struggled to assist Paul due to his size as he was 91kg and classed as obese, and his position on the top bunk. They called for a nurse - known as a Hotel One call - and she responded and attempted CPR.
She herself issued a 'code blue' after the officers brought him down to the floor - meaning an ambulance and emergency crew were called. He was pronounced dead in his cell at 2.46pm.
When asked by coroner Zak Golombek if he himself should have issued a 'code blue', he said: "Yes". When challenged why he hadn't, he said: "Inexperience. This was my first experience of this and I was in panic."
Giving evidence, nurse Danielle Spirou, who attempted CPR on Manchester-born Mr Johnstone, said she had never issued a 'code blue' before and "would have expected an officer" to do so. She described Mr Johnstone as having "fixed pupils" and "being blue in colour".
Robert Downs, Head of Health Care at the prison, described how Nurse Spirou had climbed on to the top bunk to try to administer CPR. He said this "Would not have been affective in any circumstances".
Giving evidence, prison officer Scott Wardle, who was one of five officers who removed Mr Johnstone from the top bunk to the floor, said he was approached by colleague Paul Thompson, who asked him to "come up here a second". The court heard how he told the ombudsmen that this did not appear to be urgent.
He said he entered the cell and tried to get a response from Mr Johnson by shaking him and calling his name. The court heard he told the ombudsmen that he used his fingers to check for a pulse and thought he could feel it faintly.
He said: "When we realised that we needed to get him from the bunk, we went to get more staff and a hotel one had been called." Mr Golombeck suggested "panic and distress played a part in decision making," in that the officers did not call a code blue.
A post-mortem examination of Mr Johnstone, who had been diagnosed with paranoid schizophrenia, revealed he had cocaine and cannabis in his system along with prescription drugs.
Consultant cardiologist Professor Nicholas Curzen said, based on the statements from two police officers, Mr Thompson and Mr Wardle, where they both thought they may have felt a pulse, it was likely he was still alive at the time they entered the cell.
He said: "The balance of probability is that he was alive when they first arrived in the cell. It seems likely he was experiencing some kind of important event like a cardiac arrest.
"The evidence suggests that when the Hotel One nurse arrived, as he had fixed pupils and she described him as blue and could not find a pulse he had passed away. It's likely he would have passed from being extremely unwell to passing away."
Professor Curzen, who explained survival rate decreases by seven percent every minute without effective defibrillation, said Mr Johnstone's position on the top bunk, before he was brought down by five officers to the floor, will have been problematic.
He said: "To perform chest compressions on a soft surface is very difficult." Professor Curzen commented on the further delay getting Mr Johnstone on to the floor of his cell and getting the defibrillator sorted out.
He said: "It might have had a different outcome if he had had access to a defibrillator and chest compressions more quickly. I think it's likely that if he had successful defibrillation and compressions earlier he would have had a lot more chance of survival. The balance of probabilities the delay will have contributed to Mr Johnstone's death."
Prof Curzen added: "That is not a direct criticism of the prison staff it is more difficult than it is in hospital. I have to conclude that a quicker response could have saved this man's life."
Speculating that Mr Johnstone suffered from ventricular tachyarrhythmias and went into cardiac arrest, Professor Curzon said the chances of resuscitating someone is extremely high but reduces very quickly.
Also giving evidence, Custodial Manager Garey Atton confirmed policies are explained at induction and there is provision of an ERIcard, which provide guidance on initial actions, for prison officers to carry as well as notifications around the prison. He said officers also attend a heart start first aid course.
Coroner, Zak Golombek recorded that Mr Johnstone suffered a cardiac event. Delayed attempts to resuscitate him were unsuccessful and he was pronounced dead at 2.46pm.
Giving a narrative conclusion, Mr Golombek said: "There was a failure to call a code blue when the deceased was discovered and this possibly contributed to his death."
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