The inquest was originally listed for 9 days, but overran by two weeks, following an application for an adjournment, an application for discharge of the jury and re-start of the inquest, two applications for separate representation and IP status, arrangements for the issuing of a witness summons by UK Border Force at Heathrow airport, preparatory arrangements for the arrest of a witness, numerous whistleblowing claims, and an admission of neglect by those representing the healthcare Trust on Day 10 of the inquest. The inquest heard evidence from over 30 witnesses.
The jury found failures by staff employed by Nottinghamshire Healthcare NHS Foundation Trust in medical assessment, documentation, escalation of concerns, escalation of medication withholding, absence of clinical observations, absence of capacity assessments, inadequate communication of symptoms to hospital staff, and failure to call an ambulance. The jury found failures by prison officers employed by Serco including the photocopying of observation sheets, the failure to open relevant Logs, and the destruction/loss of key documents.
The jury was invited to consider a number of systemic concerns in relation to the healthcare Trust and found that staffing levels were unsafe, staff were inadequately trained, the Trust did not have adequate policies in place, staff did not understand the policies in place, there was a failure of leadership, and there was a systemic failure in the duty of candour.
The jury considered that CS’s death had been contributed to by neglect.
Assistant Coroner Laurinda Bower indicated that she would be issuing a wide-ranging Regulation 28 report criticising what she described as “serious failings” in disclosure, inquest preparation and the duty of candour by the healthcare Trust to the Trust’s Chief Executive, Minister for Prisons Damian Hinds MP, the CQC, and NHS Commissioners. She also indicated she will be referring every single healthcare Trust clinician (17 in total) to their professional regulator.