A second officer who later found him did not immediately call for emergency assistance, says the independent investigation into the death of Gareth Brear, a prisoner at HMP Garth.
Brear, who had been addicted to heroin and alcohol, died of heart disease on December 29 2020 at HMP Garth. He was 42 and serving a life sentence for the murder of 20-year-old Joe Cook in his student accommodation in Leeds in August 2009.
Prison services were aware that he had had a heart attack in November 2008. He was referred to hospital specialists and, in May 2010, he was diagnosed with an abnormal fast heartbeat. After he received hospital treatment, his condition improved, and he was discharged from hospital care in November 2011 and continued to receive regular reviews by prison healthcare staff.
In September 2018, he was transferred to HMP Garth and referred to substance misuse services.
Sue McAllister, of the Prisons and Probation Ombudsman, said: "The clinical reviewer did, however, identify some shortcomings in Mr Brear’s care in relation to his medication. Although these did not contribute to Mr Brear’s death, they are of concern because of his history of substance misuse."
In her summing up she stated concern over officer conduct, which while it did not affect the outcome for Brear, it could for future prisoners.
The sequence of events reveals that at about 8.30am on November 29, 2020, an officer carrying out the morning welfare check saw Brear apparently sitting on his bed. He assumed he was alive and did not try to obtain a verbal response from him.
At 8.55am, another officer went into his cell and found him sitting on his bed with no trousers on. She spoke to him, but he did not respond, so she asked another officer to check on him and at 9am the other officer entered the cell and checked for a pulse, but there was none.
He immediately radioed a medical emergency code to summon help. A nurse responded immediately and considered Brear had been dead for some time so she did not attempt CPR. Paramedics arrived at the cell at 9.10am and confirmed Brear had died.
The post-mortem report gave cause of death as left ventricular hypertrophy (a thickening of the wall of the heart's main pumping chamber).
Ms McAllister added: "I am concerned that the officer who conducted the welfare check on the morning of 29 December did not realise that Mr Brear was dead, and that the officer who later found him, did not immediately call a medical emergency code. These failings did not affect the outcome for Mr Brear as he had been dead for some time but could make a critical difference in other cases."
During the 2010 court hearing, where Brear pleaded guilty to murder, it heard that Brear broke into the property on Ebberston Terrace, in the Hyde Park area of the city in August 2009, and stabbed Mr Cook, who was originally from Newcastle, 15 times with a kitchen knife before ransacking the house and stealing a BMX bike which he later sold for £10.
Mr Cook was due to begin his second year of a fine art degree at Leeds Metropolitan University.
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