Inmate who died at Castlerea Prison did not receive CPR for seven minutes after collapsing
The prison authorities were also unable to contact a doctor to formally pronounce the prisoner dead following the incident
A 33-year-old inmate who died in custody at Castlerea Prison did not receive CPR for almost seven minutes after collapsing due to delays in retrieving a key to open his cell, an investigation has found.
The prison authorities were also unable to contact a doctor to formally pronounce the prisoner dead following the incident on July 14, 2020.
An investigation report by the Office of the Inspector of Prisons (OIP) noted that the importance of quick CPR intervention was “well established”, and brain damage begins to occur after four minutes.
It said it was unknown whether administering CPR immediately would have made any difference in this case, but recommended that “access to cells in any emergency situation should be in the shortest possible time”.
Mr G was a heavy smoker but no medical issues had been identified when he was committed to Castlerea Prison in November 2019.
He had not complained of any health concerns while in custody and appeared to be in good form on July 14, 2020, according to the report.
His cellmate told the investigation that Mr G began to feel unwell and reported being short of breath after his meal around 4.30pm.
Within 25 minutes, his condition deteriorated rapidly and he began vomiting before losing consciousness.
CCTV footage showed that the in-cell emergency call bell was activated at 4:57pm.
A prison officer responded within a few second and looked into the cell before immediately returning to an office to summon assistance.
However, the investigation established that it took six minutes and 50 seconds to access keys and open the cell door.
Access to the key room required biometric information from a prison officer, and the assistant chief officer in charge had to be notified.
Once the keys were obtained, the officer had to descend three flights of stairs and pass through two independent audiovisual gates, as well as two Atlas security doors.
It was therefore 5.04pm before nurse officers attended Mr G and commenced CPR.
They continued resuscitation attempts until 5.10pm, at which point they stopped as his vital signs indicated that he was deceased.
The report said the prison was unable to contact a doctor to formally pronounce Mr G dead, and noted that the unavailability of a medical professional at Castlerea had previously been raised in a report into the death of an inmate at the prison in 2015.
“Prison officers acted promptly and correctly but the location of the keys and the barriers it was necessary to navigate to open the cell diminished the potential opportunities for lifesaving interventions,” it said.
In its recommendations, the OIP said the Irish Prison Service should review the availability of a doctor for unexpected emergencies at Castlerea, and the viability of providing chest compression machines for CPR should be explored.
It also recommended that emergency access to cells should be examined to minimise the amount of time between a request for first aid and entry being made.
There should be oversight of this consideration during routine inspections by prison governors, it added.
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