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JURY CRITICISMS ON KYAL GAFFNEY DEATH AT HMP HEWELL: MISSED OPPORTUNITIES & EARLIER INTERVENTION COULD HAVE AVOIDED DEATH
15 March 2013
On 15 March 2013, the jury sitting with HM CoronerThe legal official who orders a post-mortem and who is in charge of the inquest procedure. Geraint Williams for the County of Worcestershire at Stourport on Severn returned their verdict following a five day inquest into death of Kyal Gaffney on 9 November 2011.
Kyal Gaffney was from Coventry and died from a spontaneous intracerebral haemorrhage as a result of clotting malfunction due to Acute Myeloid Leukaemia (AML) (promyclocytic variant). The jury found:
‘…It is the conclusion of the jury that, Mr Kyal John Gaffney, died at 13.20 hrs on 9 November 2011 at Alexandra Hospital, Redditch, of an intracerebral haemorrhage. It is also the conclusion of the jury that there were a number of missed opportunities for further intervention prior to 7 November 2011. The jury concludes that had further intervention occurred, then it is more likely than not, that an intracerebral haemorrhage could have been avoided.’
In July 2010, Kyal Gaffney was involved in a car accident in Leamington. He was the driver and one of his best friends died. Kyal sustained significant injuries leaving him disabled.
On 18 October 2011, Kyal Gaffney was sentenced to 21 months imprisonment having pleaded guilty to causing death by careless driving under the influence. He was immediately taken to HMP Hewell.
On 26 October 2011 Kyal tried to see a prison doctor but he was turned away as he did not have an appointment. On 31 October 2011 he saw a doctor who recorded that he had been bringing up blood for 5 days but who thought it was a chest infection. She later told the inquest that she did not consider a blood test that would have revealed the leukaemia. On 5 November 2011 Kyal saw another doctor who admitted that he did not read the earlier records and consequently did not ask about him bringing up blood, which the jury was told probably continued to occur. This doctor also failed to see extensive bruising on Kyal, and diagnosed oral thrush for what may have been the blood blisters that are common in leukaemic patients. The doctor did order blood tests, because Kyal seemed anaemic, but the tests were not ordered on an urgent basis.
When those tests were carried out on 7 November they showed that Kyal’s blood was severely abnormal. Kyal was rushed to hospital that night for treatment but very shortly thereafter he suffered the catastrophic bleed that killed him.
The jury heard that had Kyal been blood tested on 31 October, or urgently on 5 November, then he would probably have survived.
Kyal was 22 at the time of his death.
Kyal’s mother Mary Currie said:
“I wish to thank the CoronerThe legal official who orders a post-mortem and who is in charge of the inquest procedure. and his staff for their compassion and fearless investigation into Kyal’s death. My unfailing legal team for their guidance, support and expertise and INQUEST, who have been a pillar of strength.
“There was a catalogue of errors at the prison not only in relation to Kyal’s medical care but his disability. The jury’s verdict confirmed what we had always known, that despite our best efforts to alert the prison to Kyal’s deterioriating health, there were missed opportunities. If there had been earlier medical intervention, it is more likely than not that Kyal would be alive today. Our family feels vindicated by the jury’s verdict but devastated that Kyal’s death could have been prevented. We felt powerless watching him decline whilst at HMP Hewell. We can only hope that lessons are learnt and no other family has to endure this heartbreak.
“Following a death in custody, there must always be an inquest. The Prison and Trust, which provides healthcare at the prison, are both legally represented at the taxpayer’s expense. Yet I struggled to obtain funding for legal representation from the Legal Services CommissionThe organisation responsible for providing Public Funds for legal work. (LSC). Not only did it take months for a funding decision to be made but I was asked to make a financial contribution. Legal representation should be free for all families regardless of their finanical circumstances.”
Solicitor Anna Thwaites from Hodge Jones & Allen LLP, said:
“There were missed opportunities at HMP Hewell that led to Kyal’s tragic death. This case raises serious concerns about the care Kyal and other prisoners receive within the prison system. It is hoped that lessons are learnt from Kyal’s inquest and in the future prisons respond more effectively to prisoners’ health concerns.”
Deborah Coles, co-director at INQUEST said:
“This is a tragic case which raises serious concerns about the treatment of prisoners with disabilities and ongoing concerns about the quality of prison healthcare. Recommendations for learning must be implemented as a matter of urgency, not just in this one prison but across the board.”
Kyal Gaffney’s family is represented by INQUEST Lawyers Group member Anna Thwaites from Hodge Jones & Allen LLP and Counsel Nick Armstrong from Matrix Chambers.