Search

Epileptic prisoner died in Pentonville Prison after nursing failures

PUBLISHED: 12:04 18 June 2014 | UPDATED: 09:44 20 June 2014

Pentonville in Caledonian Road, Holloway

Pentonville in Caledonian Road, Holloway

Archant

An epileptic prisoner who suffered from schizophrenia was found dead in his cell after nursing staff failed to record that he should not be left on his own, an inquest heard.

David O’Garro, 34, was sent to Pentonville Prison, Holloway, after breaching a Sexual Offences Prevention Order in early 2012.

He died on June 2 that year in a suspected case of sudden unexpected death in epilepsy.

While nurses in charge of his care acknowledged that all patients with epilepsy should share a cell in case they have a seizure, nurse Adanma Obi failed to register this when she assessed Mr O’Garro, the inquest was told.

She said it would be assumed that he should not share a cell as he was epileptic, despite the fact that she had ticked a box saying he was fit for “any cell occupancy”.

At the hearing on Friday, Mary Hassell, senior coroner for Inner North London, said that while the nurse’s failings were the “most important” factor in Mr O’Garro being in a cell on his own, it could not be proved that having a cellmate would have prevented his death.

Medication

Referring to the form that Ms Obi said she did not remember filling in, the coroner said: “It seems to me wholly inaccurate, it says he is fit for any cell occupancy. It seems to me to be as wrong as it could be.

“But you haven’t said you’ve made a mistake, you’ve said you’ve done the right thing.

“If the question is, ‘Is he fit for any cell occupancy?’ the answer has to be no, which you could then go on to qualify by saying that he should share a cell.”

Ms Obi replied: “I can’t remember what happened.

“I take your point that if I was the person who did it I should have written it. I’m sorry for that omission.”

Mr O’Garro was sharing a cell but was moved to one on his own after a fight with an inmate.

Toxicological tests revealed that Mr O’Garro – who suffered a seizure the day before he was found dead – had not taken his anti-epilepsy medication,

But there was also no evidence that this would have helped prevent his sudden death.

Recording a narrative verdict, the coroner said: “If Mr O’Garro had been sharing a cell and a cellmate had been with him between 7.15am and 11.15am on the day he died, then his cellmate could have raised the alarm when Mr O’Garro became unwell.

“It is unclear whether immediate intervention would have changed the outcome.”

0 comments

Welcome , please leave your message below.

Optional - JPG files only
Optional - MP3 files only
Optional - 3GP, AVI, MOV, MPG or WMV files
Comments

Please log in to leave a comment and share your views with other Islington Gazette visitors.

We enable people to post comments with the aim of encouraging open debate.

Only people who register and sign up to our terms and conditions can post comments. These terms and conditions explain our house rules and legal guidelines.

Comments are not edited by Islington Gazette staff prior to publication but may be automatically filtered.

If you have a complaint about a comment please contact us by clicking on the Report This Comment button next to the comment.

Not a member yet?

Register to create your own unique Islington Gazette account for free.

Signing up is free, quick and easy and offers you the chance to add comments, personalise the site with local information picked just for you, and more.

Sign up now

Latest Islington News Stories

09:00

In a weekly feature, we profile a fascinating company doing business here in Islington. This week, we visit 308 Hobbies, which has been selling radio-controlled models in Holloway Road since 1946.

Fri, 18:09

A mystery spectator gifted £800 to a Newington Green marathon runner’s fundraising campaign after being inspired by her dash for the line, six minutes before the event’s cut-off.

Fri, 14:49

The town hall has started a £22million programme to deal with chronic damp problems in two of Islington’s biggest estates.

Fri, 11:03

A report published last year aimed to find a way to cure Islington of its chronic problems with damp and mould. Last night the council said the more radical recommendation were simply too expensive.

Fri, 07:53

Islington Council last night approved new policy to fight tax dodging contractors.

Thu, 12:45

Caroline Russell last night claimed she was the only realistic candidate to contest Jeremy Corbyn’s Islington North seat in June’s general election.

Thu, 11:00

In a weekly feature, we profile a fascinating company doing business here in Islington. This week, we re-visit Hammerton Brewery, which is expanding by opening a new pub in Holloway Road.

Thu, 10:41

Archway dwellers could soon be taking a stroll through Junction Square, Archway Plaza – or possibly Squarey McSquareface.

Education and Training

cover

Read the
Education and Training
e-edition today

Read Now

Newsletter Sign Up

Sign up to receive our regular email newsletter

Most read news

Digital Edition

cover

Enjoy the
Islington Gazette
e-edition today

Subscribe

Education and Training

cover

Read the
Education and Training
e-edition today

Read Now