Jury find neglect in healthcare contributed to the death of Michalla Sweeting at HMP Eastwood Park

Monday 21 May 2018

Michalla’s family were represented by Fiona McGhie of Irwin Mitchell and Kirsten Heaven of the Garden Court Chambers Civil Liberties and Inquest Teams.

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Today a jury sitting at Avon Coroners Court before Her Majesty’s Senior Coroner Ms. M. Voisin found that Michalla Sweeting died (whilst incarcerated at HMP Eastwood Park) of aspiration of gastric content in association with methadone toxicity and that her death was contributed to by neglect. At the time of her death Michalla was on a methadone detoxification programme prescribed by a GP. The jury returned the following verdict:

“Michalla arrived 28 May 2016 at prison after three days in police custody and an appropriate reception process was conducted resulting in her being put on an alcohol and drug detox programme, and placement on ACCT observations. On 1 June 2016 at 14.50 she was noted by a HCA to seem over sedated which was not acted upon by nursing staff. At 22.14 she was vomiting and seen by a nurse in her cell; inadequate clinical observations were carried out during the night and on 2 June 2016 at 07.00. Michalla was found unresponsive in her bed with vomit round her mouth. Resuscitation was unsuccessful and she was pronounced dead on 2 June 2016 at 07.42, due to aspiration of gastric contents."

Michaela’s death was contributed to by inadequate carrying outing response to prison officer ACCT checks, unsatisfactory handover quality between shifts, inappropriate process of assessment at the medicine dispense hatch and inadequate communication between healthcare and prison staff. There was neglect due to a combination of the following gross failures:

  • Nurse to act on handover by HCA as noted on System One 1 June 2016 at 14:50 by physically assessing Michalla and making a plan, and by still administering Methadone at 17:56
  • Nurse failed to check and update Michalla’s records and contact a doctor and formulate a care plan after witnessing Michalla being sick at 22:14 1 June 2016
  • Nurse performed woefully inadequate clinical observations from 1 June 2016 at 22:14 onwards, including 2 June 2016 at 03:12

HM Coroner, under her powers to Prevent Future Deaths, has referred a nurse to the NMC and has made recommendation regarding handover for all prisoners undergoing detoxification and taking observations on a prisoner before medication is dispensed.

The case has been reported on by The Bristol Post.

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