Changes at Featherstone prison after inmate's death

Adam Williams collapsed while exercising at HMP Featherstone, near Wolverhampton, and died a day later at New Cross Hospital on March 6, 2013, Cannock Coroner's Court heard.

A postmortem examination revealed he had suffered a subarachnoid hemorrhage, bleeding in the area between the brain and the thin tissues that cover the brain, due to a ruptured blood vessel.

Pathologist Dr Alexander Kolar said there were also signs of a genetic condition.

The inquest heard that the Prisons and Probation Ombudsman for England and Wales made a series of recommendations to the prison after it was found there had been a delay in calling for an ambulance, although it was accepted this did not directly lead to his death.

Rob Del Greco (corr), senior investigator for the organisation, said one recommendation was that staff should be aware of their responsibilities during medical emergencies, including communicating efficiently, bringing relevant emergency equipment and calling an ambulance automatically when an emergency arises.

He said another recommendation was made that the risk assessments for escorts to hospital fully take into account the medical condition of the prisoner and should be reviewed after an emergency admission.

It followed concerns that Mr Williams was in left in restraints for around two hours after leaving prison.

Similar suggestions will be made to the prison in a report by Coroner Andrew Haigh, including whether there can be better communication by radio and if CCTV would be beneficial in common areas of the prison.

The inquest was told that another inmate had seen the 29-year-old collapse and prison officers responded after hearing an alarm and a 'code blue' message over the radio.

Prison officer Peter Docherty said he had been told that Mr Williams had suffered a fit.

Prison nurse Jennifer O'Connor, who responded to the alarm, told the inquest she assessed him and found he was breathing independently and his pulse was regular, but he appeared agitated.

She noticed his consciousness falling and asked an officer to call an ambulance.

Ms O'Connor said the control room should call an ambulance once hearing a 'code blue' but it was not done on this occasion, which resulted in a delay of up to 11 minutes before the call was made.

Governor Becky Wyatt, head of prison safety, said procedures for calling an ambulance had since been reiterated to staff and training had been given surrounding restraining prisoners when they are escorted from jail.

The inquest heard that the exercise room in which Mr Williams collapsed was not equipped with CCTV but Ms Wyatt said it may not have helped and costs would have to be considered before bringing in such a system.

The inquest heard the prison had not been aware of any healthcare concerns for Mr Williams but an incident where his head had been accidentally hit with a cell door at another prison in January last year had not been recorded.

However, the pathologist said trauma was unlikely to have caused his death.

The coroner, who concluded death was due to natural causes, said: "What has happened here is that Adam suffered the rupture of this vessel in his brain. That caused the collapse.

"It's the bleed on the brain that has led to his death."