21st September 2015

Avon Coroner, Bristol
Before HM Senior Coroner for the District of Avon Ms. Maria Voisin

After 3 weeks of evidence about the multiple failures leading up to the death of Natasha Evans at HMP Eastwood Park, an inquest jury has found that neglect contributed to her death.

On 27 November 2013, Natasha Evans died of kidney and heart infections which caused her to develop sepsis, whilst she was a prisoner at HMP Eastwood Park.  The jury heard about multiple missed opportunities throughout the day to identify her dangerously deteriorating condition. 

The jury, reaching their conclusion, noted “serious” failures on the part of the nurse who attended to Natasha around lunchtime after she had become so unwell that she was incoherent.  His assessment of Natasha’s condition was inadequate. He failed to call an ambulance or alert a GP but instead asked a fellow prisoner to monitor her condition.  At a subsequent nurses handover meeting there was “inadequate” discussion about Natasha and no plan was made for her care.

Later that afternoon, Natasha was found collapsed in her cell.  She was eventually seen by a doctor who requested an ‘emergency blue light’ ambulance: despite this, Natasha waited a further 59 minutes for an ambulance, a wait which the ambulance trust accepted, in evidence, was too long. Unfortunately by that time it was too late to save Natasha, and  she died whilst being treated by paramedic and ambulance crew.

Further failings were identified in relation to lack of record keeping and, systemically, alack of clear process or systems for identifying which nurses were responsible for which patients at handover meetings. 

Suzanne Davies, Natasha’s mother, said on behalf of the family:

"Listening to 3 weeks of evidence about how my daughter was failed repeatedly on the day of her death, by the very people who were meant to look after her, has been incredibly hard.  The expert evidence was that had Natasha received the care she deserved around lunchtime, she would have survived.  All I can hope now is that lessons will be learnt so that another mother might be spared what I have had to endure"

Clare Richardson, the family’s solicitor, said:

"The evidence in this inquest raised serious concerns about healthcare practices within Eastwood Park.  The exposure of poor practice during the inquest, culminating in a critical narrative conclusion and a finding that neglect contributed to Natasha’s death, is a tribute to the tenacity and bravery of our clients since Natasha’s death nearly 2 years ago."

Deborah Coles, co-director of INQUEST said:

“Natasha was sentenced to four months imprisonment for a non-violent offence.  Evidence at this inquest showed that her death could have been prevented if she was provided with adequate healthcare.  8 years on from Baroness Corston’s report recommending a fundamental overhaul of the way women are dealt with in the criminal justice system, it is absolutely tragic to see that women are continuing to lose their lives in prisons in this way.   The family had to wait almost two years for this inquest to be heard and it was once again through representation funded by legal aid that has enabled them  to properly explore all of the  issues surrounding this tragic death.”

INQUEST has been working with the family of Natasha Evans since May 2014.  The family is represented by INQUEST lawyers Group members Clare Richardson of Bhatt Murphy Solicitors and barrister Maria Roche of Doughty Street Chambers.