Michael Lavin died two weeks after being found unresponsive in his cell
HMP Altcourse, Liverpool(Image: Liverpool Echo)
A man died while serving time at HMP Altcourse after being found collapsed in his prison cell. Michael Lavin, 52, was found on the floor of his cell at around 7.40am on October 28 2020.
Prison officers making the breakfast round called out to him, then attended to other prisoners to “give him a few minutes to sort himself out”. But when they returned to his cell at 7.45am, they found him collapsed and unresponsive.
The officers called for help from the prison nurses, Michael Walsh and Joan Southern, who were both tending to other patients at the time. However, an inquest heard the call had not been registered as an emergency, and so both nurses continued their activities.
A prison officer saw Ms Southern and called her to Mr Lavin’s cell, where the 52-year-old was found on the floor. She suspected he had suffered a hypoglycaemic collapse (collapse due to low blood sugar) due to Type 2 diabetes, which Mr Lavin was known to suffer from.
As the incident had not been called in as an emergency, the nurse did not have any equipment with her, and so she had to go and collect a blood sugar test kit. The test found Mr Lavin had a blood sugar level of just 0.9, well below the normal level of between 4 and 7.
A “code blue” emergency was issued at 7.56am, and ambulance services were called to the prison. Paramedics arrived at 8.11am and treated Mr Lavin at the scene until 8.54am, when he was taken to Aintree Hospital.
He was transferred to intensive care, where he was placed in a coma. His condition did not improve and he died two weeks later at 8.35am on November 12 2020.
At Mr Lavin’s inquest today, April 28, his sister Paula Lacey said: “Michael was one of four siblings. Our mother called him ‘our red-headed tearaway’ as he always kept her on her toes. Michael came from a loving family, but became addicted to drugs at a young age.
“Out mother’s death in 2018 had a deep impact on Michael. He was mum’s favourite and didn’t have a partner or children of his own. The grief seemed to send him off the rails.”
A CT scan carried out at Aintree Hospital revealed a jaw fracture and brain swelling. However, pathologist Dr Christopher Johnson said the fracture was “likely months or years old” and “didn’t relate to any incident shortly before or running up to his admission to hospital”. He also said there was “no evidence” of a brain bleed.
He said: “The autopsy showed the fracture to be old and unrelated to the time frame leading to this man’s admission to hospital. There is also, in my opinion, no evidence of head trauma that might have contributed to this man’s death.”
He found Mr Lavin’s cause of death was hypoglycemic encephalopathy – low blood sugar resulting in brain injury – and bronchopneumonia.
Mental health support
Helplines and support groups
The following are helplines and support networks for people to talk to, mostly listed on the NHS Choices website
- Samaritans (116 123) operates a 24-hour service available every day of the year. If you prefer to write down how you’re feeling, or if you’re worried about being overheard on the phone, you can email Samaritans at jo@samaritans.org.
- CALM Campaign Against Living Miserably (0800 58 58 58) is a leading movement against suicide. It runs a UK helpline and webchat from 5pm to midnight 365 days a year for anyone who has hit a wall for any reason, who need to talk or find information and support.
- PANDAS (0808 1961 776) runs a free helpline and offers a support service for people who may be suffering with perinatal mental illness, including prenatal (antenatal) and postnatal depression plus support for their family or network.
- Childline (0800 1111) runs a helpline for children and young people in the UK. Calls are free and the number won’t show up on your phone bill.
- PAPYRUS (0800 068 41 41) is an organisation supporting teenagers and young adults who are feeling suicidal.
- Mind (0300 123 3393) is a charity providing advice and support to empower anyone experiencing a mental health problem. They campaign to improve services, raise awareness and promote understanding.
- Students Against Depression is a website for students who are depressed, have a low mood or are having suicidal thoughts.
- Bullying UK is a website for both children and adults affected by bullying.
- Amparo provides emotional and practical support for anyone who has been affected by a suicide. This includes dealing with police and coroners; helping with media enquiries; preparing for and attending an inquest and helping to access other, appropriate, local support services. Call 0330 088 9255 or visit www.amparo.org.uk for more details.
- Hub of Hope is the UK’s most comprehensive national mental health support database. Download the free app, visit hubofhope.co.uk or text SHOUT to 85258 to find relevant services near you.
- Young Persons Advisory Service – Providing mental health and emotional wellbeing services for Liverpool’s children, young people and families. tel: 0151 707 1025 email: support@ypas.org.uk
- Paul’s Place – providing free counselling and group sessions to anyone living in Merseyside who has lost a family member or friend to suicide. Tel: 0151 226 0696 or email: paulsplace@beaconcounsellingtrust.co.uk
- The Martin Gallier Project – offering face to face support for individuals considering suicide and their families. Opening hours 9.30-16.30, 7 days a week. Tel: 0151 644 0294 email: triage@gallierhouse.co.uk
- James’ Place – supports men over 18 who are experiencing a suicidal crisis by providing quick access to therapy and support. Call 0151 303 5757 from Monday to Friday between 9.30am and 5.30pm or visit https://www.jamesplace.org.uk/
The inquest heard Mr Lavin, who was serving time for theft, had a long and difficult history of mental health problems, drug abuse and self harm. He also had a “complex” medical history including pancreatitis, alcoholic liver disease and type 2 diabetes.
He was prescribed medication for his diabetes, but the court heard he struggled to comply with the treatment, and would sometimes neglect to take his insulin.
Dr Deborah Faint, lead GP of Brownlow Health’s homelessness service, said the 52-year-old lived a “complex and chaotic” life, and could be “very aggressive” towards healthcare staff. She said: “He always presented as being very vulnerable. We struggled to engage with him in the last year of his life.”
Mr Lavin had been remanded at HMP Altcourse on September 1 2020, having been released from the prison just two weeks earlier. The prison noted he suffered several health problems, including diabetes, and he was prescribed medication, which he was given daily.
He was placed on an Assessment, Care in Custody and Teamwork (ACCT) process designed to support individuals at risk of self-harm and was due to have an assessment on September 2, but he “refused to engage”. Coroner Anita Bhardwaj said: “It was noted he was shouting from his cell and demanding medication.”
During September he made several “superficial” acts of self harm, but was removed from the ACCT on September 29 “when he said he would not harm himself again”.
Ms Bhardwaj said: “Staff said he was erratic and unpredictable at times. He could be aggressive and would swear and spit at them.” She added: “Officers used force on several occasions from October 12 to October 26.”
Mr Lavin, from Toxteth, was placed on an ACCT again on October 22 after showing officers several “superficial” cuts to his arm which he said he had done. However this was closed the following day when Mr Lavin expressed he regretted his actions and did not want to die.
On October 24, four days before he was found collapsed, prison staff found him fitting on the floor of his cell. Nurses confirmed his blood sugar was low, and he was given glucose, after which he recovered and became aggressive, and was restrained.
He was restrained again later that day after smashing a kettle against the door of his cell, and was taken to the prison’s Correctional Facility Unit.
The coroner said the last time Mr Lavin was restrained was on October 26, after he became agitated and threw water in a nurse’s face when she tried to give him his medication.
On October 28, a female officer checked in on Mr Lavin at 7.10am and said he was still sleeping. She looked in on him again at 7.40am while making the breakfast round with another officer and a prison chaplain.
Five minutes later, the group returned to his cell and found Mr Lavin unresponsive, and raised the alarm.
The inquest, which is being held before a jury at the Gerard Majella Courthouse in Kirkdale, is expected to last nine days. The hearing continues.