Response delay at HMP Chelmsford could have contributed to prisoner’s death

Chelmsford Prison has been criticised for a delay in responding to a collapsed 37-year-old inmate which could have contributed to his death.

Ryan Flanagan died on March 23, 2021, in Broomfield Hospital, having collapsed in his cell on March  17 from heart failure.

A previous inquest held between April 15 and 26, 2024, concluded that Mr Flanagan died from natural causes, but that the culture in Chelmsford Prison around answering cell bells was not sufficiently prioritised.

It added this led to a delay which could have “possibly contributed to his death”.

The coroner added their concerns about culture in Chelmsford Prison around entering cells in emergency situations.

It added this led to further delays to the start of resuscitation which “possibly contributed to his death.”

The Prisons and Probation Ombudsman has added its own concerns – highlighting that it has commented several times on staff failing to follow the correct emergency procedures in calling emergency codes.

It adds that it is “disappointing that once again we are commenting on the same issue.”

It is also concerned that Mr Flanagan’s family were informed that he had gone to hospital by another prisoner and had to confirm this themselves with the prison.

Shortly before 8.30pm, Mr Flanagan’s cellmate raised the alarm he had collapsed. Mr Flanagan had a pulse but did not appear to be breathing.

Mr Flanagan’s cellmate said that he pressed his cell bell to attract staff attention. The Operational Support Grade (OSG) said in her police statement that she and the prison officer heard a cell bell, but attempted to finish a task they were involved in before the officer said that he needed to leave to respond to the cell bell. She said this was approximately two minutes.

But from the records, it seems that the officer arrived at the cell and answered the cell bell within three minutes of it being pressed.

The officer said in an interview that he did not know either prisoner and made a dynamic risk assessment that it was not safe for him to enter the cell at that stage.

The OSG joined him and used her radio to call a code blue emergency.

This was at 8.24pm. This prompted the control room to call an ambulance. The control room log does not record what time an ambulance was requested; Ambulance Service records showed that the call was received at 8.26pm.

The officer, who is first aid Prisons and Probation Ombudsman 7 trained, used his radio to reiterate that medical staff were needed.

Another officer arrived at the cell approximately two minutes after the OSG. She thought that the protocol was that three prison officers (not including OSGs) should be present to unlock a cell with two prisoners, but decided that in the circumstances they should enter the cell. As she was radioing for permission to open the door, she saw another prison officer arriving on the landing so she unlocked the door.

They started to perform cardiopulmonary resuscitation (CPR). The radio recordings indicate that the officer said that they were entering the cell two minutes from the OSG making the code blue call.

A nurse had responded to the emergency call, and the prison log showed that he arrived at the cell two minutes after the prison officers went into the cell. He could not detect a pulse nor any sign that Mr Flanagan was breathing.

They applied a defibrillator (a machine that monitors and, in some circumstances, can restart the heart).

He and the officers continued to attempt to revive Mr Flanagan until the ambulance crew arrived and took over. Having detected a pulse, they transferred him to the ambulance and on to Broomfield Hospital.

Mr Flanagan was put into an induced coma in the High Dependency Unit.

At approximately 10pm, a prisoner telephoned Mr Flanagan’s parents, telling them what had happened. They contacted the prison and, having been told where Mr Flanagan was, subsequently travelled to the hospital.

Mr Flanagan remained in a coma. His condition did not improve, and following a discussion between doctors and his family, the decision was taken to switch off life support. Mr Flanagan died at 12.45am on March 23. His family were with him.

A statement from the Prisons and Probation Ombudsman added: “We have commented several times in previous reports of investigations in Chelmsford on staff failing to follow the correct emergency procedures in calling emergency codes. In response to our recommendations, Chelmsford undertook a programme of training that involved an emergency scenario exercise to reinforce staff knowledge of what to do when faced with such a situation, including correct use of radios. This began in October 2019 and was scheduled to be an annual event.

“We acknowledge that the officer was a new member of staff, only completing his training and starting his role less than a month before the emergency with Mr Flanagan. It is, though, disappointing that once again we are commenting on the same issue.”

It added: “The recorded timings for cell bells are not accurate. The CCTV footage was of poor quality and while we know in which order staff arrived, we were unable to accurately determine the time lapse between the cellmate raising the alarm and staff going into Mr Flanagan’s cell. While we do not know if the delay made any difference to the outcome for Mr Flanagan, it may do in other emergency situations.”

A Prison Service spokesperson said in response to the report: “Our thoughts remain with Mr Flanagan’s friends and family.

“We have accepted all of the Ombudsman’s recommendations and since this incident, HMP Chelmsford has upgraded its CCTV and improved the way staff respond to medical emergencies.”

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Piers Meyler

Local Democracy Reporter

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