A prisoner with epilepsy and depression has died after an automated healthcare system failed to flag that he wasn’t taking his medicines.
John Joseph Singleton was serving a 10-month sentence for attempted burglary at HMP Risley near Warrington.
He died at Warrington Hospital on 10 September, following an attempt to take his own life on 1 September.
Singleton, 42, was prescribed medicines for epilepsy and depression.
According to the coroner Kate Ainge, while the lack of medicine did not cause or contribute to Singleton’s death, the “importance of consistent medication, and early identification of prisoners who do not comply, was an issue”.
Ainge said the SystmOne electronic patient system that was used by the prison was not able to flag a warning when prisoners did not receive their medicines.
In the report, Ainge said: “Singleton was a reclusive loner with a history of depression following significant family bereavements and epilepsy secondary to a head injury.”
It added that Singleton’s compliance with medications was sporadic and he failed to collect a number of prescriptions.
This was put down to “anxiety in attending to collect his medications and periods of self-isolation”, which lead to a decline in his mental health.
Ainge concluded there was a risk of future deaths at the prison if the system for monitoring those who do not collect their medicines was not resolved.
She said an automated flag alert on the system would be a more “efficient and effective way in which prisoners failing to comply with medications could be identified and actioned quickly”, adding that this could allow future deaths to be prevented.
Singleton’s death is the nineteenth death of a prisoner with epilepsy that Epilepsy Action is aware of since 2005.
In 2021, Trevor Monerville, aged 33, died from sudden unexpected death in epilepsy at HMP Lewes in Sussex.
The coroner found that “insufficient and unacceptable management” of care had contributed to his death.
Trevor had been prescribed and administered medication, but 40 days’ worth, unused, was found in his cell after his death.
In 2014, Mohamoud Ali died from SUDEP at Parc prison in February 2014.
Despite hospital appointments made for him to see a neurologist, transport for his appointments was not provided because of staff shortages. An inquest into his death identified unacceptable failures in his care.
Earlier this year, Epilepsy Action joined Inquest’s No More Death’s Campaign.
The campaign is calling for a National Oversight Mechanism – an independent public body responsible for collating, analysing and following-up on recommendations arising from state-related deaths.
If you have been affected by the issues raised, or would like to support our work to improve epilepsy awareness in prison settings, please contact us here.
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