Karl Reavy was found unresponsive in bed
HMP Liverpool(Image: Liverpool Echo)
An investigation has been launched after a prisoner was found dead in his cell at HMP Liverpool. The Prison and Probations Ombudsman (PPO) announced a probe was underway into the death of prisoner Karl Reavy, 53, who was found dead in his cell on February 15, 2023, after staff failed to complete a welfare check that morning.
A post-mortem examination revealed that Reavy, who had a “complex medical history,” overdosed on his prescribed medication. Reavy died from ischaemic and hypertensive heart disease with citalopram toxicity.
According to the report published on July 18, Reavy was jailed between April 2021 and October, when he was released on licence after serving a sentence for arson. In November, he was recalled to prison and taken to HMP Liverpool.
The prisoner was prescribed citalopram, an antidepressant, codeine for abdominal pain and medication to manage his other clinical conditions, all of which he kept in his cell. He saw healthcare staff regularly.
On January 19, 2023, a nurse noted that Reavy had asked for more codeine and that he might not have been adhering to his prescribed dose. Due to his complex medical history, the long-term conditions nurse reduced Reavy’s dose of codeine, however on January 25 a GP at the prison increased the dose after Reavy complained of nerve pain.
Reavy was taken to hospital by ambulance on January 29 and February 8 with chest pain. He was diagnosed with angina and advised a referral to a heart specialist if the pain continued.
At around 8pm on February 14, an operational support grade (OSG) staff member locked Reavy in his cell. It is understood Reavy was watching TV and there was “no concerns” regarding his health. At 11pm, Reavy rang his cell bell because he felt lightheaded. He then rang his cell bell again at 1am on February 15, however went back to sleep.
The OSG completed a routine check at 4.40am and did not “notice anything unusual”. The prison was on a restricted regime due to a staff training day on February 15 and Reavy remained in his cell on the morning and prison staff did not complete a morning welfare check.
PPO says despite Liverpool operating a restricted regime, all prisoners should have been subject to a welfare check on the morning of February 15. Reavy was not checked between the early hours of the morning and 11.23am.
At 11.23am a prison officer unlocked Reavy’s cell for lunch and found him unresponsive on the bed. Staff began CPR and paramedics arrived at 11.30am. However, at 11.35am it was confirmed that Reavy had died. A post-mortem examination revealed that Reavy died from ischaemic and hypertensive heart disease with citalopram toxicity.
After Reavy’s death, the Governor issued a notice to staff about completing prisoner welfare checks and the action that must be taken if a prisoner is unresponsive. PPO were told that the officer responsible for welfare checks on Reavy’s wing on February 15 was redeployed and the wing did not have any detailed staff that morning.
The clinical reviewer noted that the lead pharmacist for Spectrum CIC, that provides quality healthcare interventions for people in vulnerable circumstances, had agreed to audit all patients within Spectrum CIC prisons, including HMP Liverpool, who were prescribed citalopram to ensure that a robust process for monitoring these patients was in place.
PPO recommend the head of healthcare at HMP Liverpool should ensure that regular medication in possession risk assessments (MIPRA) are undertaken when there are changes in patient’s circumstances or there are concerns regarding the compliance and adherence of medications, in accordance with the Spectrum CIC Medicines In-Possession Policy 2022.
A spokesperson from Spectrum Community Health CIC said: “Spectrum Community Health CIC acknowledge your query in response to the recently published PPO report relating to the very sad death of a patient at HMP Liverpool.
“We extend our deepest condolences to Mr Reavy’s family and those who knew him. Spectrum accept the findings detailed in the Prison Probation Ombudsman report and clinical review report and all recommendations outlined have been fully engaged with and implemented and we are unwavering in our commitment to learning from every Death in Custody review.
“Alongside our partners, we remain focussed on continuously improving the care and support provided to patients on entering and throughout their time in the prison system. Together with our dedicated staff and partners, we strive to ensure the highest standards of healthcare and wellbeing in these challenging environments.“