Thomas Black

On 2nd March 2015 ! commenced an investigation into the death of Thomas Byron Black (d.o.b. 28-02-86). The investigation concluded on 19"h November 2015. The conclusion of the inquest was Natural Causes. The medical cause of death being:- (a) Pulmonary thrombo-embolus (b) Vein thrombosis in a man with Factor V Leiden Mutation [heterozygous]

On 4th December 2014 Mr. Black was transferred to HMP Usk On Saturday 21st February 2015 Mr. Black collapsed. Officers took him to his cell and arranged a health care appointment for Monday morning, as health care staff are not on duty at the weekend: did not seek medical advice On Sunday 22nd February 2015 Mr. Black's cellmate reported he still felt unwell and had a tight chest Officers monitored Mr: Black but did not seek medical advice. On the morning of Monday 23r February 2015,a nurse examined Mr. Black and found no concerns, but arranged to carry out an electrocardiogram test later that afternoon. Just after 1.30 p.m: Mr: Black collapsed: He was conscious at first; but his condition deteriorated and he was conveyed to the Royal Gwent Hospital and he was pronounced dead at 3.21 p.m.

In my opinion action should be taken to prevent future deaths and believe you and your organisation have the power to take such action.