Lessons learnt at HMP Highpoint after Joseph Bone left dead for hours before anyone noticed
PUBLISHED: 09:00 23 December 2014
Failures at HMP Highpoint Prison meant a man was dead for hours before any prison officers even noticed.
Lessons have now been learnt following the death of Joseph Bone, 44, who also suffered due to “inadequate healthcare”.
An inquest into the death of Mr Bone, held in Bury St Edmunds, heard that he had several health problems, including diabetes and a previous heart attack.
He died from a second heart attack on August 11, 2013, after being transferred back to HMP Highpoint, from the open prison at HMP Hollesley Bay, due to deteriorating mental health.
Referring to a report from an independent clinical review, written by Amanda Muter, Suffolk Coroner Dr Peter Dean, said: “The night care had been inadequate and there had been insufficient monitoring.
“(She) was unable to determine whether increased care would have reduced the risk of the death happening.
“The evidence we have suggests that Joseph Bone had not always been compliant with (taking) medication.”
Prison officers carrying out a roll check at 6.30am on August 11 and opening the cell doors at 9am failed to get a response from Mr Bone.
It was only at lunchtime, when Mr Bone failed to attend, officers discovered him in his cell.
Dr Dean said: “The officers in the morning did not follow the local and national guidelines.”
Giving evidence, Richard Lombardo, head of operations at the prison, said: “Following the death of Joseph Bone…the then governor issued a notice to staff that outlined the requirement to carry out an effective roll check.”
Talking about the changes to the provision of healthcare at the prison, Ashley Maund, healthcare manager, said that an electronic system and new policies meant the same failures would not happen again.
The changes included increased monitoring of patients that do not attend appointments and more awareness of those with long term medical conditions.
The family of Mr Bone, who lived in Billericay, welcomed the changes. His sister, Susan Pickett, said: “There will be other people in prison with similar health problems, it will save lives. It is something positive to come out of his sad death.”