Source · Prevention of Future Deaths

Gareth Warburton

Ref: 2019-0411 Date: 4 Dec 2019 Coroner: David Reid Area: Worcestershire Responses identified: 0 / 1 View PDF

Important letters from a clinician regarding a prisoner's prescription error and medication were neither acknowledged by the Governor nor passed to the prison healthcare team, posing a risk to prisoner welfare.

Date 4 Dec 2019
56-day deadline 28 Jan 2020
Responses identified 0 of 1
State Custody related deaths

Coroner's concerns

AI summary
Important letters from a clinician regarding a prisoner's prescription error and medication were neither acknowledged by the Governor nor passed to the prison healthcare team, posing a risk to prisoner welfare.
View full coroner's concerns
(1) Letters dated 16.10.17 and 27.11.17 from Mr. Warburton's treating clinician at the Queen Elizabeth Hospital, Birmingham to then Governor of HMP Hewell Gareth Sands, highlighting concern about the prescription error; asking for more information about the error; and seeking assurances that Mr: Warburton continue to receive all required medication, were neither acknowledged nor answered by the Governor; (2)_Furthermore,although such letters ought to have_ been passed on to the prison To and being: my would healthcare team, the evidence suggested that this was not done: Investigations carried out by current Governor Anthony Morrow failed to establish what had happened to these letters; (3) As to the suggestion that perhaps these letters were never received by the prison, it was apparent that the same letters had been sent to, and received by , members of Mr: Warburton's family; (4) Accordingly, am satisfied that it is probable that these letters did reach the prison, but were not dealt with satisfactorily; (5) am concerned that; as long as there is a risk that letters which seek or contain important information about a prisoner's health and welfare are not dealt and go unanswered, there remains a risk to prisoners' lives at HMP Hewell:

Report sections

Investigation and inquest
On 18th April 2018 | commenced an investigation into the death of Gareth Wycliffe WARBURTON; then aged 58. The investigation concluded at the end of the inquest on 3r December 2019. The jury returned a narrative conclusion; with the medical cause of death Ia Bronchiolitis Obliterans Syndrome; 1b Interstitial lung disease transplant )
Circumstances of the death
Mr. Warburton had undergone a double lung transplant in 2005,and at the time of his arrival at HMP Hewell on 1.4.17 was in good health, although taking a number of different medications to ensure that his body did not reject the transplanted lungs; (2) Due to a prescription error by a member of the prison healthcare team, Mr. Warburton was incorrectly prescribed half his usual dose of an important anti-rejection medication for the period 1.7.17 - 25.8.17 This error probably led to the chronic rejection of his transplanted lungs, resulting in his death on 1.4.18; (3) In addition, the jury found that: A failure in the system in place for writing and screening those prescriptions which were sent out to an external pharmacy probably contributed to Mr. Warburton's death; (ii) Inadequacies in staffing; role allocation and time management within the prison healthcare team in mid-2017 possibly contributed to Mr. Warburton's death; and (ii)Had opportunities to pick up on the prescription error on 14.7.17 and 27.7.17 been taken, it was "highly possible" that the chronic rejection of the transplanted lungs would not have occurred
Action should be taken
In my opinion action should be taken to prevent future deaths believe you have the power to take such action:

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Report details

Reference
2019-0411
Date of report
4 December 2019
Coroner
David Reid
Coroner area
Worcestershire

Responses identified

Responses identified 0 of 1
1 response not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 28 Jan 2020.

Sent to

HMP Hewell

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