Epileptic prisoner died in Pentonville Prison after nursing failures

12:04 18 June 2014

Pentonville in Caledonian Road, Holloway

Pentonville in Caledonian Road, Holloway


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.


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.”


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