22 March 2024

Before HM Area Coroner Laura Bradford
East Sussex Coroner’s Court
Heard 12 – 19 March 2024

An inquest has concluded on the death of a prisoner who faced “appalling” healthcare conditions and “grave” and “unacceptable” failings. 

Finlay Finlayson, known to his family and friends as Vinney, was only 54 years old when he died at HMP Lewes in East Sussex on 25 January 2019. The inquest this week found failings by healthcare staff and systems contributed to his death. 

When Vinney was remanded to Lewes Prison on 27 December 2018. He was suffering from multiple long term health conditions, both physical and mental. He had survived cancer a few years earlier but, unknown to him, it had returned. He died on 25 January 2019 due to serious blood clots in his lungs (pulmonary thromboemboli due to deep vein thrombosis). 

The inquest heard from prison staff that Vinney’s health had dramatically deteriorated in the days before. Despite requests by both Vinney and prison officers, he was not seen by healthcare staff until the evening before his death, when the response by a nurse was not appropriate. 

The inquest jury conclusions made particular reference to the lack of quantifiable evidence of notes, follow ups or recorded observations, and use of tools to respond to early warnings of health deterioration (known as NEWS).

Evidence was heard of Vinney struggling to get a healthcare appointment. His family described that he had filled in many applications to see a doctor, but these went unanswered. 

Many witnesses described long waits for prisoners to see healthcare. During a HM Inspectorate of Prisons inspection at the time of Vinney’s death in 2019 there were 143 non-actioned applications from prisoners to see healthcare, dating back more than a year.

At the inquest, a nurse described the healthcare system at the time as “appalling”. The jury found that the system for prisoners to be seen by healthcare was not effective. 

On 25 January, Vinney collapsed in his cell. It took 27 minutes for healthcare to attend. The inquest found that healthcare staff had switched off their emergency radios in contravention of prison guidelines. The jury described this as a “grave and unacceptable failing in communication”. 

Prison staff expressed their frustration about the delay in healthcare arriving, remaining evident five years later. 

Finally, the jury found it took too long to call an ambulance, in part because of an incorrect perception that Vinney’s presentation may be because of his mental health. The jury described this as “unacceptable indecision over whether to call an ambulance that should have been called automatically”. 

Vinney struggled with his mental health and often reported to his family that, because of this, he wasn’t listened to when he complained about his physical health. 

HMP Lewes healthcare is now being run by Practice Plus Group. The family were reassured to hear that if Vinney would have been in prison now, he would be flagged as a prisoner with long term health conditions and treated accordingly. 

Whilst the coroner accepted that improvement has been made, there were still ongoing concerns relating to information sharing within the electronic record sharing software, System One. The coroner will be issuing a Prevention of Future Deaths report in due course.

Vinney’s family said: “Vinney was a much loved and charismatic person. His death has left a hole in our family that can never be filled. He struggled most of his life with a lack of social care funding in the community and feeling like he was often ignored due to his Mental Health. 

Vinney told us he felt like he was going to die in prison, he said he had begged to see doctors and told many people that he didn’t feel well but did not receive help.

The inquest result has proved what we always knew – Vinney was let down by healthcare staff who thought his mental health issues were more important than him saying he was in pain. I promised Vinney that I would get his story heard, I finally know that I have fulfilled my promise.”

Selen Cavcav, Senior Caseworker at INQUEST, said: 

“In this country everyone has the right to access healthcare when they need it. Yet too many people in prison are denied this.

The jury in this inquest highlighted a very disturbing reality of healthcare in our prisons. We know the problems identified do not only apply to HMP Lewes. They are indicative of years of neglect and systemic failures in healthcare across our prisons. 

This is an urgent public health issue and should be viewed as such. There can be no justification for prisoners who are put behind bars to be further punished by these harmful systems.”



For further information, please contact Lucy McKay on [email protected] 

A photo of Finlay is available here.

The family are represented by INQUEST Lawyers Group members Jo Eggleton and Rachel Tribble of Deighton Pierce Glynn and Nick Armstrong KC of Matrix Chambers. They are supported by INQUEST Senior Caseworker Selen Cavcav.

Other Interested Persons represented at the inquest are HMP Lewes, Sussex Partnership NHS Foundation Trust and MedCo Secure Healthcare Services Ltd.