Inquest Concludes into death of Ryan McGrath

Before HM Assistant Coroner Rachel Galloway
Preston Coroner’s Court, 2 Faraday Drive, Fulwood, Preston, PR2 9NB

Tuesday 4 December – Wednesday 12 December 2018, lasting 7 days

Ryan McGrath was a loving father and best friend who had been trying to turn his life around so that he could make a new start and continue to provide for his two sons. Tragically, Ryan died whilst in his cell in HMP Wymott on 24 October 2016.

A jury concluded with a critical narrative stating there had been serious failures in Ryan’s care which possibly contributed to Ryan’s death.

Ryan had a family history of heart disease and regularly suffered from crushing chest pains accompanied by sweatiness and nausea. He had been resident in a number of prisons during his sentence. Whilst at HMP Parc, he was seen by health care staff on a number of occasions and his blood pressure was recorded as unusually high. Despite this and a family history of heart disease, Ryan was never formally diagnosed with high blood pressure or given any treatment for hypertension. The jury heard evidence from a medical expert that had Ryan’s hypertension been properly managed, he may have survived.

Ryan was then transferred to HMP Swansea, where the jury heard evidence that there was no record of his blood pressure being taken on his arrival, despite this being a requirement. Similarly, when Ryan arrived at HMP Wymott on 15 September 2015, he was seen by a nurse who did not note his blood pressure. Witnesses told the jury that healthcare staff did not consider Ryan’s previous medical records upon his transfer into the prison or at any time.

On 20 October 2016, Ryan told a nurse that he had had shoulder pain for a week, pins and needles, chest pains and felt clammy and nauseous all the time. His blood pressure was taken and was very high.  A nurse told the jury that these symptoms were “red flags” and so she arranged for blood tests and an ECG for a doctor to review.  Unfortunately, she was unable to obtain blood from Ryan.

The GP examined Ryan that day and told the inquest that he believed his pain to be muscular and considered Ryan to be at low risk of a heart attack. He said that the ECG did not show any abnormalities and it was not sent to be checked by an external company despite policy dictating it should have been. The jury heard evidence from medical expert that the GP had incorrectly read the ECG which did show signs of a heart attack. The GP claimed that he had requested blood tests be taken, despite two nurses confirming they had previously made him aware that they had already tried unsuccessfully to take blood, and referred Ryan to the chest clinic which had a two week wait for an appointment. The medical expert told Ryan’s inquest that he should have been sent to hospital at this stage.  Ryan’s family were not informed of his illness until after his death.  They are devastated that they were not given the opportunity to say goodbye to him, which may have been possible had he been taken to hospital.

Blood was finally taken from Ryan on the morning of 24 October 2016, however the incorrect test was ordered. Later on 24 October 2016, at approximately 2pm, Ryan collapsed in his cell. The emergency services were called but healthcare staff and paramedics were unable to resuscitate and revive Ryan. They pronounced him dead at 3.05pm.

The Prison and Probation Ombudsman report and Clinical Review have identified failures by the prison healthcare, advising in their findings that the care Ryan received in prison was not equivalent to that he could have expected to receive in the community. A witness for North West Ambulance Service also gave evidence that the call following Ryan’s collapse was not correctly dealt with and so there was significant delay in paramedics arriving at the scene.

During the inquest HMP Swansea and HMP Wymott admitted that they had failed to monitor Ryan’s blood pressure properly or to consider his family history and that Ryan should have been referred to hospital immediately on 24 October 2016. They also accepted that results from the ECG should have been sent for checking and the appropriate blood test carried out.

As a result of Ryan’s death HMP Swansea and Wymott have changed their procedures for screening new inmates so that their blood pressure and medical records are checked at this stage. Wymott now has a policy that all ECG readings are sent for analysis with swift feedback and anyone suspected of a heart attack should be transferred urgently to hospital.

The Coroner stated that she would refer the GP to the General Medical Council if he did not refer himself within 1 week. Bridgewater Trust, who are now responsible for healthcare at Wymott, indicated that they would review the situation in relation to the GP working for them again.

The jury concluded that:

• The failure of HMP Parc to adequately monitor Mr McGrath’s blood pressure in accordance with NICE guidelines possibly contributed to his death. This failure meant that the opportunity to be prescribed hypertensive medication was not afforded to Mr McGrath.
• There were further failures of the healthcare departments at HMP Swansea and HMP Wymott to appropriately monitor Mr McGrath’s blood pressure.
• There was a failure to refer Mr McGrath to hospital on 20 October 2016 when he presented at healthcare in HMP Wymott with a history of crushing chest pain and ongoing shoulder pain.
• There was a failure at HMP Wymott to interpret Mr McGrath’s ECG scan and a further failure to take a blood test for Troponin T levels which would have shown that Mr McGrath had a heart attack within the last 10 days.
• On the evidence, the GP who attended to Mr McGrath in HMP Wymott on 20 October was told by the nursing staff that they were unable to take blood from Mr McGrath in order to carry out the necessary blood tests.

Ryan’s family said:

“We are devastated by Ryan’s death.  Ryan was the kindest person and a fantastic father.  He would do everything he could to take care of his children. We are pleased that the jury have recognised the failures of the prison service in looking after Ryan.  He should not have died in HMP Wymott and the fact he was not taken to hospital when he should have been meant we were robbed of our final opportunity to say goodbye to him.  We hope that through the inquest process lessons will be learned and that no family will have to go through what we have been through.”

Alice Stevens, Solicitor at Broudie Jackson Canter Solicitors, said:

“This is a tragic case in which Ryan was failed by the people who were supposed to be responsible for his welfare. It was disturbing to see that the prison’s own GP was not concerned about Ryan despite his presentation and that he was not afforded appropriate medical care when he needed it the most. I hope that the three prisons involved in this inquest will carefully consider the jury’s conclusion and ensure that proper procedures for managing conditions such as Ryan’s are put in place as a matter of urgency. It is also reassuring that the Coroner has agreed to report the GP to the GMC given the gravity of the failures recognised by the jury.”