Inquest into the Death of Frank Kenneth MAJOR
Deceased
Frank Kenneth MAJOR
Demographics
75y, male
Date of death
2021-10-10
Finding date
2023-07-25
Cause of death
complications of metastatic prostate cancer and end-stage chronic obstructive pulmonary disease, with terminal palliative care
AI-generated summary
Frank Kenneth Major, a 75-year-old prisoner with metastatic prostate cancer and end-stage COPD, died of natural causes in October 2021. The coroner found his overall medical care during incarceration was excellent and comprehensive, with timely transfers to tertiary care. However, a significant systemic failing was identified: despite medical certificates and TOMS alerts indicating he should not be restrained due to his terminal illness, frailty, and mobility issues, Mr Major was inappropriately restrained with handcuffs and leg irons during three hospital transfers in September-October 2021. He had reported finding these transfers traumatic. The coroner recommended amending TOMS to default restraints to 'No' for terminally ill prisoners, ensuring active consideration before restraints are applied. The Department's initial response via broadcast and emails was deemed insufficient.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Contributing factors
- metastatic prostate cancer
- end-stage COPD
- urinary retention and recurrent urinary tract infections
- hospital-acquired pneumonia
- dehydration
- frailty and mobility issues in final weeks
Coroner's recommendations
- Amend the 'Transfer and Discharge' module in TOMS so that the 'Restraints Required' field defaults to 'No' for all prisoners being managed on the Terminally Ill register. This ensures movements officers will be required to carefully review TOMS to determine whether a terminally ill prisoner should be restrained before they leave prison for external appointments.
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