Daniel Kernaghan was transferred to HMP Doncaster in November 2018 and had a “significant number” of long-term health conditions, including epilepsy, vascular dementia, heart disease, type 2 diabetes, high blood pressure, chronic kidney disease, pancytopenia (a low blood cell condition) and deafness. He was frail and used a walking frame or wheelchair to get around.
A report released last week shows that while the care he received in prison to manage these was appropriate, his health deteriorated and he suffered a number of falls and admissions and discharges between prison and hospital prior to his death on November 11, 2020.
On October 4, 2020, he was taken to hospital after falling and complaining of severe hip pain. X-rays showed he had not fractured his hip and he was discharged to Doncaster in the early hours of the following morning, despite hospital therapists stating this would not be a safe discharge.
Later that evening, he was taken back to hospital because he was in pain and his health had deteriorated. A CT scan did not show any injuries and he was discharged to Doncaster again early on the morning of October 6.
Mr Kernaghan was returned to prison a fortnight later and was back in hospital on October 30. He was discharged the next day with a recommendation for the prison to implement an advanced care plan as repeat trips to hospital were not in his best interests.
The prisoner, who had been serving his sentence since 2006, fell on November 3 and 6. Mr Kernaghan’s health continued to deteriorate and on November 9, he was admitted to hospital and died on 11 November.
A post-mortem found he died of pneumonia and had vascular dementia and a hip fracture which contributed to but did not cause his death.
In her report the Prison Ombudsman said while the care he received was akin to what would be expected in the community, “the clinical care in relation to Mr Kernaghan’s falls risk, advance care planning and end-of-life care was not equivalent to that which he could have expected to receive in the community.”
She added that HMP Doncaster should review its falls policy, end-of-life care for prisoners, dementia policy and staff should know when to review care if there is acute health deterioration.
It was also recommended that Doncaster Royal Infirmary should review the decision to discharge Mr Kernaghan against the advice of hospital therapists.
The report follows two other reports that were published in the same week regarding the deaths of two other prisoners at HMP Doncaster.
Russell Platts, 36, died in October 2020 of drug toxicity. The report into his death said more needs to be done to tackle drug supply into prison and extra monitoring should be in place over prisoners that are suspected to be under the influence - including recognising that snoring is a sign of drug overdose.
Ryan Lawrence was found hanged in his cell on January 20, 2021. There was a delay in the emergency response when the 25 year-old was found but, while it was noted it would not have affected the outcome, staff need to follow correct procedures.