Inquest into the Death of Shane Reynold NARRIER

Contributing factors

• failure to recognize chest pain as urgent medical symptom requiring immediate assessment
• undue emphasis on communication method (CMS) rather than clinical content
• insufficient weight given to documented cardiovascular risk factors
• failure to arrange urgent medical examination despite clear chest pain complaint
• missed opportunity at failed appointment on 31 May 2020 with no follow-up
• lack of follow-up on outstanding ECG request from previous admission
• absence of cardiac care plan despite identified risk factors
• lack of annual ECG monitoring despite cardiac risk factors
• failure by Serco to implement disciplinary recommendations from Post Incident Review
• delayed family notification of death

Coroner's recommendations

1. Chest pain complaints in prison settings must receive urgent medical assessment regardless of reporting method
2. Clinical triage should prioritize symptom severity over communication medium
3. All documented cardiovascular risk factors must be reviewed when assessing chest pain complaints
4. When prisoners fail to attend medical appointments for potentially serious conditions, immediate follow-up and escalation must occur
5. Post-Incident Review recommendations, particularly regarding disciplinary action, must be properly implemented with documented decision-making
6. A Chronic Diseases Co-ordinator should identify prisoners with cardiac risk factors for placement on Cardiac Care Plans
7. Annual ECG monitoring should be implemented for prisoners with cardiac risk factors
8. CMS system should include clear messaging that urgent symptoms require direct notification to officers
9. CMS health requests should be reviewed and responded to multiple times daily with nurse triage protocols
10. Administrative procedures should ensure prisoners are clearly notified of scheduled medical appointments
11. Prison health services should maintain proper documentation of appointment follow-ups and clinical decision-making