A west London prison has been told to review how it shares information on prisoners with serious medical conditions after a 32-year-old man died of sudden death in epilepsy.
A Prisons and Probation Ombudsman (PPO) investigation found Darren Boamah died in his cell in HMP Wormwood Scrubs last January with wing staff not knowing he was epileptic.
While it may not have changed the outcome, PPO Adrian Usher wrote in a report that “more should be done to make prison staff aware of prisoners with serious, potentially life-threatening medical conditions, particularly if they are not taking their medication”.
A spokesperson for the Prison Service said all of the Ombudsman’s recommendations have been accepted and steps have been taken to improve how medical information is shared.
Mr Boamah was remanded to HMP Wormwood Scrubs on December 28, 2023 for alleged indecent exposure and possession of cannabis.
He told the nurse during his initial health screen that he had epilepsy and had had a seizure two weeks prior. He also disclosed he was not taking his medication.
At 1.45am on January 3 Mr Boamah pressed his emergency cell bell due to a flood coming from the pipe under his sink. He remained in his cell and was checked throughout the night, with the last recorded officer visit at 5.16am.
According to the report: “The officer said she checked on him again at around 6.50am, before she went off duty, and recorded this in the observation book but the CCTV shows she did not. The observation book, along with other documentation relating to Mr Boamah, has been lost according to the prison.”
Two managers visited the cell at around 7.55am when they found Mr Boamah lying on his bed unresponsive. Healthcare staff were called and, having attempted CPR, found him to be showing signs of rigor mortis.
According to the PPO report, the clinical reviewer found the care Mr Boamah received at the prison “was equivalent to that which he could have expected to receive in the community”.
Healthcare in prisons is the responsibility of NHS providers, which in this case was Practice Plus Group.
On the officer’s claim that she checked on Mr Boamah at 6.50am, the PPO wrote: “It is possible that the officer misremembered the time of her check. If she did record a check at 6.50am that she did not do, that would be a serious conduct matter. We have been unable to check what she recorded as the observation book, along with other documentation relating to Mr Boamah, has been lost according to the prison. This is unacceptable and should be investigated.”
Two recommendations were outlined, firstly that the Governor and Head of Healthcare should review protocol for sharing information on prisoners with serious medical conditions, with wing staff reportedly unaware Mr Boamah had epilepsy, and secondly that the Governor should investigate what led to the documentation being lost and ensure in the future it is retained and stored securely.
It is understood action has been taken since Mr Boamah’s death, including information about prisoners with serious conditions being flagged on prison systems and all wings having hardback observation books which are accounted for to improve documentation.
A spokesperson for Practice Plus Group said: “We extend our sincere condolences to the family and loved ones of Darren Boamah. As the Prisons and Probation Ombudsman recommended, since Mr Boamah’s death we have worked closely with the prison to ensure wing staff are aware of prisoners with serious medical conditions, particularly if they are not taking their medication.
“We remain committed to providing safe, responsive, and compassionate care to everyone we support.”
A Prison Service spokesperson said: “Our thoughts remain with Mr Boamah’s friends and family.
“We accepted all of the Ombudsman’s recommendations last year and have taken steps to improve how we share medical information about prisoners with serious conditions. The prison has also strengthened its processes for securely storing observation records to prevent future loss.”
