Prison officer did not check on inmate’s welfare on day he died
A PRISON officer failed to check on the welfare of an inmate when unlocking his cell and the prisoner subsequently died.
Mark Shepherd, 42, died on Monday, January 22, 2018, at HMP Parc Prison in Bridgend, of an internal haemorrage.
A report by the Prisons and Probation Ombudsman published this week, said the care Mr Shepherd received was equivalent to that which he could have expected to receive in the community and his death was not foreseeable or preventable.
The report, however, found that the officer who unlocked Mr Shepherd’s cell on the morning of his death didn’t check on his wellbeing.
A spokeswoman for HMP Parc Prison said that subsequently every member of staff was issued a written notification by the director to conduct welfare checks on a daily basis, with regular reminders.
The ombudsman report said: “We made a recommendation to Parc about this in 2016 and it is disappointing that this issue has come up again.
“The director should ensure that officers understand their responsibilities for checking on the wellbeing of prisoners when unlocking their cells and ensuring that there are no immediate issues that need attention.”
Despite the fact the prison director issued a notice to staff after Mr Shepherd’s death instructing them to obtain a response from prisoners when unlocking their cells, the report continued, “more focus is required on this issue”.
Mr Shepherd – who was recalled to prison and admitted to HMP Cardiff on October 2017 – had a history of alcohol and substance misuse and was given opiate replacement medication while in prison.
He had hepatitis C and leg ulcers which required regular dressings.
Mr Shepherd was transferred to the category B prison in Bridgend on November 14, 2017.
The report said that on January 22 at 7am, “Officer A” looked into Mr Shepherd’s cell while completing an early-morning roll check, but he didn’t see anything untoward.
The officer returned to the cell at around 8.30am and unlocked the door, but he didn’t speak to Mr Shepherd “and went on to unlock other cells”.
“Shortly afterwards, Officer B began the process of re-locking cells after movements from the wing had taken place. When he went to Mr Shepherd’s cell he found him on the floor with blood around his face.
He checked for a pulse and tried to move him but Mr Shepherd did not respond.
“He called a code blue emergency on his radio (which indicates a medical emergency when a prisoner is unconscious, not breathing or having breathing difficulties).”
“Officer A” started CPR but didn’t give mouth-tomouth because there was “a lot of blood” around Mr Shepherd’s mouth, the report stated.
The officer said that Mr Shepherd was not cold and he thought that he might be able to save him.
The defibrillator advised that no shock be given but CPR continued until paramedics arrived at 8.50am, the report adds. Mr Shepherd was pronounced dead by paramedics at 9am.
The post-mortem report gave Mr Shepherd’s cause of death as gastrointestinal haemorrhage, ruptured oesophageal varices (veins) and cirrhosis of the liver due to hepatitis C.
Director of HMP & YOI Parc Janet Wallsgrove said: “Mr Shepherd’s family and friends remain in our thoughts at this difficult time.
“In line with the Prison and Probation Ombuds- man’s recommendations, every member of staff was issued a written notification by the director to conduct welfare checks on a daily basis, with regular reminders to staff.
“The duty director ensures that welfare checks are conducted effectively through daily CCTV monitoring. If any discrepancies are identified, guidance is provided and disciplinary action may be taken.”
Mr Shepherd was the 16th prisoner to die at HMP & YOI Parc since 2015, the report stated. There were four selfinflicted deaths during this time and Mr Shepherd was the 12th prisoner to die of natural causes.
Last month, a further two inmates died at the prison. The two inmates were found unresponsive inside their cells on separate days in less than a week, but officials have said their deaths were not connected.
Inquests for both men have been listed for May 10 and a spokesman for the Prisons and Probation Ombudsman confirmed two investigations were under way.
The men’s prison houses around 1,600 men and young adults, both convicted and on remand. It also has a unit for around 60 young people under 18, the report stated. The facility is managed by G4S on behalf of the prison service, and is the only private prison in Wales. It was ranked 11th worst out of the UK’s 117 jails earlier this year.
Last month it was revealed that Parc’s Young Offender Institution had the highest rate of selfharm incidents out of five comparable institutions in Wales and England. The figures, published by Cardiff University’s Wales Governance Centre, showed a total of 64 incidents took place in 2017.
G4S has been contacted for comment.