Jonathan McCarthy

I am Mr Hassan Shah, Assistant Coroner for the coroner area of Northampton.

On 08/11/2018 I commenced an investigation into the death of Mr Jonathan Michael McCarthy (“Mr McCarthy”). The investigation concluded at the end of an inquest on 12/10/2023. I recorded the conclusion as natural causes. The medical cause of death was: 1a – Bronchopneumonia and multi organ failure 1b – Acute cardiac arrhythmia (with initial resuscitation) 1c – Myocardial fibrosis (related to drug and alcohol abuse)

Mr McCarthy died on 12th August 2018 at University Hospital Coventry  and Warwickshire as a result of a cardiac arrhythmia whilst at HMP Onley. The arrhythmia occurred as result of scarring of the heart.

Upon Mr McCarthy’s arrival at HMP Altcourse on 5 June 2017, it is recorded that he had an outstanding hospital appointment. There was no evidence that HMP Altcourse took any steps to verify this appointment. Mr McCarthy was transferred to HMP Thameside on 7 May 2018. It is recorded that he had an appointment to see the cardiologist at Whittington Hospital on 13 June 2018. There was no evidence that HMP Thameside took any steps to verify this appointment. He was transferred from the prison on the next day, 14th June 2018. It was suggested in evidence that HMP Thameside automatically re-arrange all community medical appointments for security reasons. It was clarified that the prison would only try to get a new appointment if there was a specific security concern. There was also no evidence that Mr McCarthy had a fitness to transfer assessment at either HMP Altcourse or HMP Thameside. In light of these matters, I consider that a Regulation 28 report is required in relation to the policies and procedures for:

1. verifying a prisoner’s pre-existing community hospital appointments.
2. determining the clinical importance/urgency of pre-existing community hospital appointments and the impact of security issues upon this assessment.
3. assessing fitness to transfer and determining medical hold.

In my opinion action should be taken to prevent future deaths and I believe you AND/OR your organisation, have the power to take such action.