Source · Prevention of Future Deaths
Ronald Sherlock
Ref: 2013-0181
Date: 9 Aug 2013
Coroner: William Armstrong
Area: Norfolk
Responses identified: 0 / 1
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Older prisoners lacked appropriate access to speech and language therapists to assess and manage swallowing difficulties, including recommendations for diet and fluid intake.
Date
9 Aug 2013
56-day deadline
4 Oct 2013 est.
Responses identified
0 of 1
Coroner's concerns
Older prisoners lacked appropriate access to speech and language therapists to assess and manage swallowing difficulties, including recommendations for diet and fluid intake.
View full coroner's concerns
The MATTER OF CONCERN is as follows. –
Prisoners accommodated in the Older Prisoners Unit of HM Prison Norwich do not have appropriate access to speech and language therapists who can provide assessments to those with swallowing difficulties and make necessary recommendations as to their medical management including the regulation of fluid and food intake and the provision of a soft diet.
This omission was acknowledged at the hearing by a professional witness for the health service provider of Norwich Prison SERCO.
Prisoners accommodated in the Older Prisoners Unit of HM Prison Norwich do not have appropriate access to speech and language therapists who can provide assessments to those with swallowing difficulties and make necessary recommendations as to their medical management including the regulation of fluid and food intake and the provision of a soft diet.
This omission was acknowledged at the hearing by a professional witness for the health service provider of Norwich Prison SERCO.
Report sections
Investigation and inquest
On the 30th of April 2012 I commenced an investigation into the death of Ronald Sherlock, Aged 92. The investigation concluded at the end of the inquest on the 2nd of August 2013. The conclusion of the inquest was
Ia Chest infection Ib Chronic Kidney Disease Ic Diabetes Mellitus
II Atrial Fibrillation
NATURAL CAUSES
Ia Chest infection Ib Chronic Kidney Disease Ic Diabetes Mellitus
II Atrial Fibrillation
NATURAL CAUSES
Circumstances of the death
Ronald Sherlock was a prisoner serving a sentence at HM Prison Norwich. He had been sentenced to life imprisonment in 1979 and been at HM Prison Norwich since April 2005. Mr Sherlock suffered from a number of natural medical conditions including heart problems, high blood pressure, lung disease, prostate cancer, diabetes and Alzheimer’s disease. He was being closely monitored and was resident on the older prisoners unit. His health had been deteriorating for some time and he was diagnosed with a chest infection on the 5th of April 2012. On the 24th of April 2012, a healthcare assistant entered his cell to carry out a check and found him unresponsive. Medical help was summoned but he could not be revived and was pronounced dead. No post mortem was carried out and I accepted at the inquest the evidence of the treating doctor that the cause of death was:
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Report details
- Reference
- 2013-0181
- Date of report
- 9 August 2013
- Coroner
- William Armstrong
- Coroner area
- Norfolk
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: 4 Oct 2013 (estimated).
Sent to
- Serco