06 Dec Alex Braund inquest: jury finds continuous failure to provide adequate healthcare contributed to death at HMP Nottingham

The inquest into the death of 25-year-old Alex Braund concluded on 30 November, with the jury finding that neglect contributed to Alex’s death.

Alex was remanded to Nottingham Prison on 15 February 2020, fit and well. He became unwell around 6 March and on Saturday 7 March Alex pressed his emergency cell bell and asked to see healthcare. He was seen in his cell by a nurse. Alex reported having a bad chest bringing up brown phlegm, which healthcare staff knew to be a possible symptom of chest infection or pneumonia.

Alex was sharing a cell with a friend, Tom Hill, who told the inquest that Alex’s condition worsened over the coming days.

The emergency cell bell was activated again at 10.22pm on 9 March. Prison Officer Binns was responsible for around 75 prisoners on Alex’s wing. There was one nurse, Cynthia Bailey, to cover the whole of the prison (over 800 prisoners), assisted by a senior healthcare assistant.

Officer Binns responded to the cell bell and called for healthcare to attend. Nurse Bailey and her assistant arrived. An officer told the inquest that Alex looked scared and panicked and was struggling to breathe. She heard Alex ask to go to hospital but Nurse Bailey refused. Nurse Bailey failed to read Alex’s medical notes, take a full set of observations or ask any probing questions. She told Alex she would make an appointment for him to see a doctor in the morning. Tom challenged this as he could see that Alex was obviously very unwell and needed treatment.

Dr Soar, a consultant in intensive care, told the inquest that had a full set of observations been conducted and a NEWS2 score generated it is more likely than not that this would have prompted the need for further monitoring or emergency treatment that might have saved Alex’s life.

Officer Binns told the inquest he checked Alex every hour overnight. When told by the Coroner that CCTV showed this not to be the case he at first challenged the accuracy of the CCTV before accepting that he hadn’t checked every hour. The CCTV showed that he looked though the cell door hatch only once overnight, at 5.26am. At this time Alex was on the phone to his girlfriend. She told the inquest Alex was struggling to breathe and couldn’t finish his sentences. He told her he was scared and that staff were dismissing him.

Tom told the inquest he was woken by Alex coughing and being sick. He was burning up and very pale. Tom pressed the emergency cell bell at 5.35am He told the inquest Alex was slumped against the cell door.

Officer Binns responded to the cell bell. He told the inquest that he spoke to Alex who has standing at the door Officer Binns left to call for Nurse Bailey. The two met a short time later in the wing office but the nurse refused/declined to go to see Alex. Dr Soar told the inquest that by this time Alex would have been much worse and would have required oxygen (which might have delayed or prevented the cardiac arrest) and emergency life-saving treatment.

Tom activated the emergency cell bell again at 6.55am after Alex collapsed and hit his head. Officer Binns responded, remained outside the cell and called for healthcare. Staff responded but didn’t immediately enter the cell. The cell door was opened 5 minutes after the cell bell had been activated and CPR started a minute later.

Alex was taken to hospital but died a few hours later. The inquest heard that pneumonia had caused his heart to stop, causing irreparable brain damage.

Questioning at the inquest revealed that after Alex had been taken to hospital on 10 March Nurse Bailey amended her record made at 6.46am that morning detailing her observations of Alex the night before so as to include two readings which were said to be in the normal range. She also changed the plan for his treatment.

The Coroner was told that in light of the evidence heard the NHS Trust has severed ties with Nurse Bailey and reported her to the Nursing and Midwifery Council. The Coroner intends to refer her to the police in relation to possible offences of falsifying medical records and perjury. Officer Binns has been removed from night shifts and a disciplinary investigation is to be launched.

The Coroner intends to make a report to prevent future deaths in relation to the use of NEWS2 and emergency response codes because she is “tired of doing inquests involving the same organisations and the same issues coming up time and time again”.

The jury found shortcomings in the healthcare assessment on 9 March and the failure to review Alex on 10 March contributed to his death. As did the unreasonable delays in entering Alex’s cell after 6.55 and calling a code blue emergency response. The jury said there was a continuous failure to provide adequate healthcare and an unreasonable reaction to provide prompt assessment after 6.55.

Alex’s family said:

“Our family and Alex’s friends have had to endure over two and a half years of waiting to find out how Alex died on that morning of 10th March 2020. On every single one of those days since, Alex is never far from our minds and our hearts. The loss we have suffered is utterly incalculable, compounded by a deep sense of unfairness in such a young life being needlessly lost.”

Jo Eggleton of Deighton Pierce Glynn solicitors said:

“The inquest has been extremely difficult for Alex’s family. They were entitled to expect, at the very least, that witnesses would tell the truth on oath. This is not the first time that those working at the prison have tried to cover up their failings with lies. This inquest has shown that they are prepared to alter records to hide their incompetence. It’s shocking that this was not picked up by the Trust’s own investigation or by the PPO.”

Alex’s family are represented by INQUEST Lawyers Group members Jo Eggleton from Deighton Pierce Glynn and Nick Stanage from Doughty Street Chambers.

You can read more about the case here (The Guardian).

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