Leeds Prison inmate with cancer died in ambulance 'effectively trapped' at gate

Senior West Yorkshire east coroner Kevin McLoughlin sent the regulation 28 report to the governor of the jail at Armley following an inquest into the death of 73-year-old Guy Clifton Paget.

The inquest, which was held at Wakefield Coroner's Court, heard that serving prisoner Mr Paget was diagnosed with terminal cancer of the oesophagus in December 2020.

Mr Paget was found in a confused state in his cell in the prison's hospital wing at around 1pm on March 16 this year.

Mr McLoughlin wrote in the report: "The clinicians responsible for his care decided he should be taken to an outside hospital for treatment.

"An ambulance was duly brought into the prison.

"The ambulance could not convey Mr Paget to hospital, however, due to incorrect paperwork being available at the prison gate, which delayed the authorisation for it to leave the prison.

"In addition, the vehicle gate in the prison malfunctioned and could ot be opened.

"Mr Paget's condition deteriorated and he was pronounced dead at 3.06pm that day in the ambulance, which was effectively trapped at the prison gate."

Mr McLoughlin said that he believes there is a risk that future deaths could occur unless action is taken and outlined his concerns.

He wrote in the report: "The prison should have effective systems to facilitate the exit of an emergency ambulance from the prison.

"In this case a decision was made shortly after 1pm that Mr Paget needed to be taken to hospital.

"It should have been made clear to the prison managers that the necessary authorisation to exit needed to be prepared as a matter of urgency.

"At approximately 3pm, however, this was not in place.

"It is foreseeable that prisons nationally will need to admit paramedics and ambulance vehicles to attend to prisoners at times of emergency - and may then need to leave with the prisoner in the ambulance.

"An efficient and tested system to manage this process is essential , in order that serving prisoners are provided with an equivalent level of care to that which they could expect in the community."

A Prison Service spokesperson said: “Our sympathy goes out to Mr Paget’s family and friends and we will respond to the coroner’s recommendations, in detail, shortly.”