Coroner calls for CPR training at Yorkshire prison after inmate death
Lewis Johnson, 34, was found unresponsive in his cell at HMP Wealstun, shortly after 4.40am on December 12 in 2019.
Prison officers took him down but no one attempted CPR for several minutes. Paramedics managed to re-establish a pulse, after arriving in the cell at 5.18am, but Mr Johnson died later that day at Leeds General Infirmary.
A recent inquest heard the paramedics had been delayed as the prison’s electronic gate malfunctioned and it had to be opened by hand.
Before his death, Mr Johnson, who had a history of mental health issues and substance abuse, told his family he feared for his safety due to drug debts.
Kevin McLoughlin, Senior Coroner for West Yorkshire, has written a report which states the Prison Governor and the Ministry of Justice should take action to avoid future deaths at the Category C men's prison in Wetherby.
No healthcare staff were on duty on the night Mr Johnson was found hanged, but the coroner said prison officers “should be trained to respond effectively” to self harm incidents and suicide attempts.
He wrote: “The four prison officers present in the cell did not discuss the need for CPR. The possibility of using a defibrillator was not mentioned.
“Mr Johnson was left in the cell in a seated position without the wisdom of placing him in the recovery position being considered.
“The medical evidence available at the inquest indicated effective CPR more than doubles the chance of someone surviving a cardiac arrest.”
He also stated prison officers should be provided with CPR training and taught how to use a defibrillator.
The Prisons & Probation Ombudsman, which also conducted an investigation into the death, has criticised the emergency response and the standard of the mental health care Mr Johnson received at the prison.
In a report, Prisons and Probation Ombudsman Sue McAllister wrote: “There were significant delays in the emergency response when staff found Mr Johnson hanging.
"I cannot say whether the delays made a difference to the eventual outcome but we know that in an emergency situation, a delay of a few minutes may be critical.”