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Jury finds that neglect by prison and healthcare staff at HMP Nottingham significantly contributed to a black prisoner’s death
A Jury has returned a critical narrative conclusion following the inquest into the death of 29 year old Shalane Blackwood, who died from a burst duo-denal ulcer on 5 August 2015, at HMP Nottingham. The inquest was held at Nottingham Coroner’s Court from 25 April-5 May 2016.
The Jury heard that Shalane had been moved onto the Segregation Unit in HMP Nottingham on 7 July 2015 and remained there until his death nearly a month later. He appeared to experience a serious deterioration in his health from 21 July 2015 and officers had doubts that he was eating, drinking or sleeping. It was documented that he was behaving strangely, crying out and responding to things that weren’t there.
Shalane had a history of stomach complaints from his previous prison, HMP Liverpool, although officers and health care staff at HMP Nottingham denied that he had ever explicitly told them about any stomach pains. However, Shalane’s mother Linda Blackwood told the Jury in her evidence that when she spoke to her son on 21 July he told her that he was dying and referred to his stomach pains. This would be the last time Mrs Blackwood would speak to her son before his death.
On 21 July it was decided that Shalane should be placed under a four man unlock which meant that at least four officers had to be present in order for his cell to be opened. Due to staffing levels the jury heard that sometimes this meant that medical professionals were assessing Shalane through a hatch from behind a closed door.
On 4 August Shalane was found with blood in his cell. He was restrained whilst a physical examination was carried out. The jury heard how the source of the bleeding was not identified. During the course of the inquest a member of healthcare staff admitted that Shalane should have been taken to hospital at that point. However, Shalane was not transferred to hospital and the following morning, on 5 August, he was found dead in his cell.
In their narrative conclusion, the jury found that Shalane died from a burst duodenal ulcer- a condition that should have been diagnosed and treated. They went on to say that systemic failings amounting to neglect by prison staff and Nottinghamshire Healthcare NHS Trust healthcare staff significantly contributed to Shalane’s death.
Shalane’s mother, Linda Blackwood said:
“I couldn’t be happier with the Jury’s conclusion and I want to thank Lester Morrill Solicitors and my barrister Ifeanyi Odogwu for their help throughout the Inquest. I also want to thank my family and friends for their support throughout.
As a mother I knew something was wrong with my son when he was in HMP Nottingham - I just wish my concerns had been listened to at the time when I raised them. I feel Shalane’s death could have been prevented.”
Rebecca Treece, solicitor representing Shalane’s family said:
“This inquest has highlighted failures within HMP Nottingham and wider issues concerning the standard of healthcare in prisons. It is deeply concerning that Shalane was found with blood in his cell and, even though the source was not identified, further investigations were not sought. Shalane’s family were particularly shocked by this.
Whilst I am pleased that the Jury have recognised that systemic failings contributed to Shalane’s death, urgent action is needed to address the issues which this inquest has uncovered.”
Deborah Coles, Director of INQUEST said:
“The jury rejected the prison’s claim that they did not know Shalane was in need of medical assistance. Instead they concluded that neglect by both prison and healthcare staff significantly contributed to his death. It is shocking that someone in need of medical care was kept in segregation.
The prison attempted to rely on the possible side effects of a ‘legal high’, black mamba, found in his body - despite him being in segregation for a month - as justification for why they were unaware of his deteriorating health. Concerns about the prevalence of ‘legal highs’ in prisons must not deflect attention away from deteriorating regimes and conditions in prisons and systemic failings in the treatment and care of vulnerable prisoners.”
INQUEST has been working with the family of Shalane Blackwood since August 2015. The family is represented by INQUEST Lawyers Group member Rebecca Treece from Lester Morrill Solicitors and Ifeanyi Odogwu from Garden Court Chambers.
‘My congratulations to all involved in this 30 year battle for disclosure [of the Cass report on the death of Blair Peach] … it was this awful state of affairs which led those of us who founded INQUEST to set it up. But it is mind-boggling to think that we were still arguing over this report 30 years later.’
– Terry Munyard, barrister at Garden Court Chambers and founding member of INQUEST