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

Yesterday, 17:13

A British Transport Police officer was today fired for using “excessive and unnecessary force” on a member of public during an arrest at St Pancras station.

Yesterday, 15:06

Camden Passage neighbours have urged Islington Council to stop the “dismemberment” of the famous antiques street – after an upmarket deli called “Le Coq Epicier” applied to sell wine.

Yesterday, 11:06

Former council leader Terry Stacy is a loud Lib Dem activist, but also does a tonne of community work. The Gazette hears about his fascinating past.

Thu, 17:06

A scheme to boost the skills of people from black and minority ethnic backgrounds has set the foundation of 12 adult learners’ building careers.

Thu, 13:53

A dad accused of murdering his one-year-old boy and trying to kill his twin sister at their Finsbury Park home appeared at the Old Bailey today.

Thu, 10:18

Detectives investigating the killing of Jonathon “JJ” McPhillips in Upper Street have made a fourth arrest.

Thu, 07:00

‘Show some respect’ is the message from people on the Grade II-listed Golden Lane Estate to Islington Council and the City. The Gazette found out why plans for a school, private flats and a council tower block have angered them.

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