Wayne Bayley: Jury Finds Neglect Contributed To The Death Of Black Man From Sickle Cell Disease Complications And Restraint At Hmp Pentonville

This is a media release by Hickman and Rose, reshared by INQUEST

Before HM Senior Coroner Mary Hassell
At Bow Coroner’s Court, Bow Road, London E3 3AA
17 to 31 October 2024

An inquest jury considering Wayne Bayley’s death in HMP Pentonville on 17 May 2022 has returned a narrative conclusion highly critical of both prison and healthcare and found that gross failures in basic medical attention contributed to his death.

Wayne was a 43-year-old Black man who had diagnoses of sickle cell disease, epilepsy and delusional disorder. He was found unresponsive in a cell on the healthcare unit at HMP Pentonville on the evening of 17 May 2022, having been subject to restraint by prison officers ten hours earlier.

The jury found that Wayne died of acute chest syndrome - the most common fatal complication of sickle cell disease – caused by the restraint.

Wayne had been remanded to HMP Pentonville on 11 May 2022 and moved into a cell in the main prison on 16 May 2022. Shortly after midday on 17 May 2022, Wayne was restrained by officers after raising concerns about the unclean state of his new cell. While being conveyed under restraint to the segregation unit, he collapsed to his knees and told officers that he could not breathe.

Despite this, Wayne was subject to a forcible strip search in which his clothes were cut off him and he was left naked in a segregation cell. The nurse responsible for monitoring his physical health during and after the restraint failed to address his stark deterioration and in particular did not take vital observations which an expert haematologist considered would have confirmed that the restraint had triggered a sickle cell crisis requiring urgent hospital treatment which would have saved his life. Instead, without considering Wayne’s medical records which clearly identified his sickle cell disease, she referred him for assessment by a mental health nurse.

After seven hours in segregation, Wayne was conveyed to the prison’s healthcare for a mental health assessment. On the way, Wayne was so frail he collapsed to his knees and had to be transported in a wheelchair. On arrival, despite telling healthcare staff he could not breathe and asking to see a doctor, vital observations were again not taken in breach of protocol and no other care was rendered. Three hours later, Wayne was found unresponsive and, following attendance of paramedics, he was pronounced dead at 23.46.

The jury found a litany of failures that caused Wayne’s death:

1. The interpretation of non-engagement as non-compliance;
2. A lack of accurate communication between prison officers and healthcare staff;
3. Failure to monitor closely enough Wayne’s physical condition or recognise any deterioration;
4. Failure to undertake physical observations;
5. Failure to immediately consult the medical records;
6. Failure to adhere to medical protocol, instead placing mental health over physical health.

Furthermore, the jury found that Wayne’s death was contributed to by neglect.

Wayne was part of a large and very loving family. He is survived by his parents, his six siblings, his grandmothers, stepmother and aunts, uncles and cousins. In life he endured many challenges, including experiencing mental ill health in addition to his chronic physical health conditions, but his family describe how, to them, he was always protective, loyal and loving, putting them before everything else. They remember him for his big heart and his big smile.

They have said: “In the two and a half years since Wayne passed, we have lived with the knowledge that Wayne spent much of his last day not believed, naked, alone, unwell and without any medical treatment, despite having well-documented serious chronic health conditions. We experienced additional trauma and anxiety from an initial post mortem, which gave the medical cause of death as unascertained because sickle cell disease and its complications are still not properly understood. We therefore had to fight even to get that fundamental question answered and it was only in the course of the inquest itself that we got confirmation of what we always suspected: that the restraint by prison officers caused Wayne to suffer a sickle cell crisis which he would have survived if he had received the most basic care. We very much hope that lessons learned from Wayne’s death lead to meaningful changes in the way that vulnerable people with long term health conditions are cared for whilst in prison, both generally but particularly in circumstances involving restraint, so that others do not have to experience the pain of knowing their love one’s death could have been so easily avoided.”

Ellie Cornish of Hickman & Rose, who represent the family, said: “On the day he died, the treatment Wayne received from prison and healthcare staff was characterised by a profound lack of professional curiosity, common sense and humanity. As a result, warning signs of what was in fact a medical emergency were disregarded, unnoticed or unidentified. A sickle cell crisis can be entirely treatable but, as the jury found, multiple failures by prison and healthcare meant that, in this instance, it proved fatal. Wayne’s family have shown extraordinary dignity and resilience throughout his inquest and the damning conclusion that his death was contributed to by neglect is an important step forward in their ongoing pursuit of justice for Wayne.” 

Selen Cavcav, Senior Caseworker at INQUEST said: “This inquest conclusion is a damning indictment of our prisons today. The fact that a vulnerable black man died a preventable death in the circumstances he did is utterly shameful. We call upon the Ministry of Justice and Department of Health to publicly respond to the shocking evidence that has come out of this inquest.” 

The family are represented by Ellie Cornish and Daniel Machover of Hickman & Rose Solicitors and Raj Desai of Matrix Chambers.

Other Interested Persons represented at the inquest were HMP Pentonville, Practice Plus Group and Barnet Enfield and Haringey Mental Health NHS Trust.