9 July 2019

Before HM Coroner Neil Cameron
Doncaster Coroner’s Court
24 June – 9 July 2019 

Jordan Hullock, a 19 year old from Leeds, died in June 2015 whilst a prisoner at HMP Doncaster. An inquest has today concluded, with the jury finding his death was by ‘natural causes’ and that there were serious failures and shortcomings in his care in the days leading up to his death.

Jordan’s family describe him as funny and daft, a typical 19 year old with a caring and loving nature. He had never been in prison before. HMP Doncaster is run by the private company Serco, with healthcare provided at the time by Nottinghamshire Healthcare NHS Trust. Jordan was remanded to HMP Doncaster on 1 June 2015.

Jordan soon began complaining of feeling unwell at the prison. From 12 June, he developed headaches and was soon unable to get out of bed, eat, or drink without assistance. His cellmate helped him drink and carried him to the toilet. Prison officers alerted healthcare staff on several occasions, as Jordan was experiencing dizziness, headaches and chest pains. Healthcare staff attended numerous times but often failed to take observations. Where observations were noted, a high temperature and low blood pressure were recorded but not acted on.

On the 18 of June, Jordan’s cellmate was released, leaving him alone for hours on end and unable to care for himself. Jordan had a GP appointment booked the following day but did not attend. No GP was asked to visit the cell. Despite concerns from other prisoners and prison staff, Jordan’s condition declined to the point of verbal unresponsiveness. On various occasions after this, healthcare staff attended and noted issues with his health, including again recording low blood pressure and a high temperature, and that Jordan looked severely unwell, but still no action was taken.

On the morning unlock of 23 June, staff found Jordan's body and cell were covered in faeces, due to the fact he had become incontinent. Healthcare staff were called but did not arrive until the afternoon and then would not enter the cell until Jordan and the cell were properly cleaned. Delays in sourcing the equipment for this (until around 6.30pm) meant Jordan was left in the contaminated cell, unchecked by healthcare and in his own faeces, for at least ten hours.

At this point, Jordan had to be physically carried to the shower block but was unable to wash himself. Another prisoner and prison officer attempted to assist, but Jordan collapsed in the shower blocks. Healthcare staff were urgently called, but on arrival failed to take his blood pressure or temperature and completed the assessment after only eight minutes. The senior nurse, leaving Jordan on the floor of the shower block, then advised officers to return Jordan to his cell.

The nursing assistant present was not content with this, and took it upon herself to return and try to assist further. Jordan gulped down the water she gave him, having not had fluid since 21 June, and urgently ate the breakfast bars she offered. She and the prison officer who assisted then left Jordan alone, where he collapsed again and was left on the floor for a further ten minutes before an officer arrived to carry him back to his cell, unable to walk unsupported.

The following morning (24 June) Jordan was found on his cell floor having collapsed again. Healthcare staff attended and again found incontinence. A nurse escalated concerns, and arrangements were made for Jordan to finally see a GP by 2.45pm. After seeing the GP, Jordan was urgently transferred from prison to hospital. Although his mother had contacted the prison on numerous occasions prior to and when Jordan had been hospitalised, she was not told where he was until the following day when he had already been placed in an induced coma. Jordan died six days later on 30 June.

The inquest jury concluded that Jordan’s death was by ‘natural causes’, with the medical cause of death relating to Bacterial Meningitis, pneumonia and his existing heart condition (Aortic Stenosis). The jury narrative said that further steps ought to have been taken by prison healthcare staff and prison officers to try to ensure that Jordan was seen earlier by a GP. They also commented that, “The facts show serious failures in the medical attention given to the deceased following his collapse on 23 June and prior to being seen by the doctor on 24 June 2015.”

The jury recorded that, during the course of the inquest, Nottingham Healthcare NHS Foundation admitted there were “shortcomings in the standard of physical healthcare provided” to Jordan between 17 and 23 June 2015, as a full set of physical observations and a full clinical assessment was not completed or recorded, and the indicators of physical illness were not acted upon. The jury further commented that, though the evidence did not sufficiently allow them to determine whether this contributed to his death, there were both shortcomings in care over the period described by the NHS Trust, and “serious failures” from 12 to 24 June 2015.

Marie Hullock, Jordan’s mother, said: “Not being informed of our child’s admission to hospital denied us of the chance to say goodbye. We cannot believe the inhuman and degrading treatment he received while in Doncaster prison. Four years on we are still devastated and angry that we have lost our loving son. We have persisted with this battle to try to get some answers and justice, not only for Jordan losing his life, but for the days and days of suffering he endured whilst he was ridiculously poorly in HMP Doncaster.

Even after this long inquest we do not feel satisfied with the outcome, though we are truly grateful for the jury’s carefully considered conclusions. We feel people need to be punished for their behaviour and actions towards Jordan. Many failings have been admitted by Nottinghamshire NHS Trust and the individual nurses. What we really wanted was admission as to why certain people did not comply with the requirements of their job, including prison management.

We understand the staff may have had high workloads, but we truly feel many had an uncaring nature towards Jordan, as I assume they do towards all prisoners. We hope that the individuals involved have considered their actions and inactions towards Jordan for the past four years, and are faced with guilt and regret. Those who failed him so terribly should not be allowed to nurse again.

On the other hand, we would like to thank the very few people that did try to help Jordan. Even if it cannot be proven, we 100% believe that Jordan would still be with us now if he had received the care he needed sooner.”

Deborah Coles, Director of INQUEST, said: “Jordan was in need of urgent physical healthcare but instead was dehumanised and ignored. The serious failures in care resulted in him being left to deteriorate in his cell, dependent on another prisoner for his basic needs. Like too many deaths in prison, Jordan’s death was far from natural and should have been prevented.”

In their investigation following his death, Elizabeth Moody the Deputy Ombudsman at Prisons and Probation Ombudsman commented: “This is a sad and disturbing case in which no one took responsibility for ensuring that Mr Hullock received urgent medical attention as he became seriously unwell. It is unacceptable that any prisoner, and particularly a vulnerable young man, should have been treated in such an uncaring manner, allowed to deteriorate in full view of staff and to spend his final days in appalling conditions before he was finally, belatedly, sent to hospital.”

Ruth Bundey, of Harrison Bundey solicitors who represent the family, said: “The image of Jordan, left motionless over days in his cell behind a locked door, unable to reach his bell or water tap, and gradually losing the power of speech, is like something out of the dark ages. There can be no excuses for the lack of care afforded to him and the neglect of his needs. His family has sat through horrendous evidence with huge dignity.”

ENDS

NOTES TO EDITORS
For further information, interview requests please contact INQUEST Communications on 020 7263 1111 or [email protected] or [email protected]  

INQUEST has been working with the family of Jordan Hullock since July 2018. The family is represented by INQUEST Lawyers Group member Ruth Bundey from Harrison Bundey.

Other Interested persons represented are Serco Ltd, Nottinghamshire Healthcare NHS Trust, the Nursing and Midwifery Council and individual healthcare staff.

‘Prisoners are dying because of poor healthcare’, Media Release, 1 November 2018

Parliament’s Health and Social Care committee echoed INQUEST’s concerns on failing healthcare in prisons, in their report into prison healthcare. INQUEST submitted written evidence to the inquiry, which details numerous so called ‘natural cause’ deaths in prisons, which often relate to serious failings by prison and healthcare staff. 

HMP & YOI Doncaster:

• HMP & YOI Doncaster was inspected by HM Inspectorate of Prisons shortly after Jordan’s death (from 5–16 October 2015). The critical report found outcomes for prisoners in terms of both safety and respect were poor. It also noted that the prison had not rigorously implemented recommendations following formal Prison and Probation Ombudsman investigations into recent deaths.
• The most recent inspection, published in on 12 October 2017 found outcomes for safety were still not sufficiently good, though there had been improvements more broadly.
• Since January 2015 there have been 20 deaths in HMP Doncaster, five of which were self-inflicted, one a homicide, and 14 non-self-inflicted. The majority of non-self-inflicted deaths were of men over 60 years old, except Jordan and a man in his 30s.
• In October 2017, the inquest into the self-inflicted death of Gerard Scahill in HMP Doncaster found multiple failings by the prison caused his death on 22 April 2016. See the Media Release.