22 November 2018

Before HM Assistant Coroner Ivan Cartwright
Nottinghamshire Coroner's Court
Friday 23 November – 13 December 2018  

Wayne Moore collapsed in HMP Nottingham and was pronounced dead in hospital on 16 December 2013. He was 46 years old and died following the perforation of an ulcer as a result of being denied lifesaving medication prescribed by hospital specialists, just 4 days earlier. The inquest jury found inadequacies in ensuring Wayne’s health records were transferred from the hospital to prison staff, and in the communication of potential warning signs between prison staff and healthcare when his condition was deteriorating.

On 9 December, a week before his death, Wayne had been unwell and had vomited blood whilst in the custody of Derby police. He was taken to Royal Derby Hospital, where he remained an inpatient until 12 December. The hospital diagnosed a large duodenal ulcer and prescribed and dispensed high dose medication.

The following afternoon, he was remanded to HMP Nottingham. Wayne arrived at the prison with his medication. However, information about Wayne’s recent hospital admission was not communicated. Prison healthcare policy required that a doctor review Wayne’s prescription before he was allowed his medication. The review was never undertaken and Wayne was not given his medication. The inquest heard from a consultant physician who said treating ulcers before they perforate is vital.

On 14 December, Wayne collapsed and was taken, by ambulance, to QMC hospital in Nottingham. QMC were unaware of his recent admission to hospital in Derby and discharged him the same day without a diagnosis.

Overnight on the 15-16 December, Wayne set fire to his cell and pleaded with prison staff to help him. He was moved to another cell where he repeatedly pressed his cell bell. He reported to prison staff that he had been sick and that he was dying, but this was not passed on to healthcare staff.

The jury found:

  • The reception screening process when Wayne arrived at HMP Nottingham was inadequate
  • It was unsatisfactory that Wayne’s absence at a GP appointment on the 14 December (whilst he was in hospital) was not flagged
  • It was inappropriate that emergency department at the hospital did not provide written discharge notes for prison healthcare staff
  • The communication of health warning signs from prison officers to healthcare staff was inadequate

On the morning of his death, Wayne continued to report feeling unwell to prison staff. Despite this, he was not examined by healthcare staff and was placed in an escort vehicle to go to court. Escort staff raised the alarm about Wayne’s condition, calling a nurse to examine him. He collapsed in the van and was taken by paramedics to hospital, where he was pronounced dead.

The family of Wayne Moore said: “I believe the system, the prison and everyone in who came into contact with my dad let him down but I am pleased that the inquest has brought all of the issues to light. I am pleased that my dad is able to rest now and we have finally received answers about what happened to him. It is very sad that his death could have been prevented; he had plans and looked forward to the future. He was only 46 and had his whole life in front of him still. He was let down by the state and I will never get my dad back, but I am pleased with the outcome of the inquest.”

Deborah Coles, Director of INQUEST said: “Wayne’s death was entirely preventable. He was desperately calling out for help, but his calls were consistently left unheard, ignored and disregarded by those who owed him a duty of care.

The death of Shalane Blackwood at HMP Nottingham 20 months later has alarming similarities. He also died from a burst ulcer, after being found with blood in his cell and complaining of stomach pains. This exemplifies both the systemic inertia to make changes following deaths, and the fundamental failure treat people in prison with decency, humanity and compassion.”



For further information and to note your interest, please contact Lucy McKay on 020 7263 1111 or email.

INQUEST has been working with the family of Wayne Moore since 2014. The family is represented by INQUEST Lawyers Group member Gemma Vine of Minton Morrill Solicitors & Richard Copnall of Parklane Plowden Chambers.

Shalane Blackwood, 29 years old, died 5 August 2015 from a burst duodenal ulcer. An inquest in May 2016 found neglect by the prison staff contributed to his death. Shalane was found with blood in his cell and complaining of stomach pains. His ulcer was undiagnosed, he was never taken to hospital and died in his cell.