Wayne Bayley

I am: Coroner ME Hassell Senior Coroner Inner North London St Pancras Coroner’s Court Camley Street London  N1C 4PP

On  25  May  2022,  one  of  my  assistant  coroners, [REDACTED], commenced an investigation into the death of Wayne Bayley, aged 43 years. The investigation concluded at the end of the inquest earlier today. The jury made a narrative determination at inquest, which I attach.  You will see that this includes a finding that death was contributed to by neglect.

Mr Bayley died in HMP Pentonville, some ten hours after a restraint. His medical cause of death was: 1a acute chest syndrome 1b hypoxia and chronic sickle cell lung disease 1c sickle cell disease and restraint.

During the course of the inquest, the evidence revealed matters giving rise to concern. In my opinion, there is a risk that future deaths will occur unless action is taken. In the circumstances, it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. In attempting to learn lessons from Mr Bayley’s death, a great deal of work  has  been  done  by  the  primary  healthcare  provider  in  HMP Pentonville, Practice Plus Group, in liaison with the mental healthcare provider, Barnet Enfield & Haringey NHS Trust, and the prison itself. This work has covered the assessment, treatment and medication of all prisoners, from healthcare planning on arrival in prison, through any control  &  restraint,  to  the  entering  of  a  cell  in  an  emergency,  all particularly in the context of any underlying health conditions – including, but not limited to, giving staff a proper understanding of the identification of and risks associated with an acute sickle cell crisis. However,  I  am  not  at  all  clear  that  this  work  has  been  replicated nationally.  Whilst PPG provides healthcare in 57 prisons, I understand that there are over double that number in England & Wales.  I did hear evidence of the work of University College London Hospital in setting up an innovative outreach pilot. Nevertheless, my concern remains that learning and improvements in practice may not have been shared across the country.

In my opinion, action should be taken to prevent future deaths and I believe that you have the power to take such action.