Inquest into the Death of Matthew John PICKIN

Contributing factors

• Stage IV metastatic lung adenocarcinoma with brain metastases
• Staphylococcus aureus bacteraemia and sepsis
• Left leg/hip infection developing during palliative cancer treatment
• Immunocompromised state secondary to cancer treatment
• Comorbidities including COPD, history of smoking, diabetes

Coroner's recommendations

1. Addition of terminal illness medical alert within Total Offender Management System to be completed by medical staff and visible to all users
2. Mandatory field to be added to prisoner movement forms to record whether prisoner is being transported for palliative care and whether they are likely to return to prison
3. Amendment to COPP 12.3 Policy to explicitly state that Stage Three or Stage Four terminally ill prisoners shall not be placed in restraints unless there is a requirement following an appropriate risk assessment
4. Inclusion of explanatory note within COPP 12.3 clarifying that prisoners in specified cohorts (including Stage Three or Four terminally ill) should not be restrained without documented risk assessment justification
5. Amendment of Prisoner Movement Risk Assessment, External Movement Risk Assessment, Offender Movement Information, and Hospital Admission Advice processes to require staff to specifically consider significant medical conditions or mobility issues and justify any restraint usage