Suffolk prisoner death 'could have been prevented' report finds
PUBLISHED: 13:36 13 September 2019 | UPDATED: 13:36 13 September 2019
The death of a prisoner at a Suffolk prison 'could have been prevented', an ombudsman report has concluded.
Daniel Tudor, 28, died in hospital of pneumonia after refusing food, drink and medical help at Highpoint Prison in Stradishall, Suffolk, in 2015.
A report by the Prisons and Probation Ombudsman concluded that earlier action to address his high blood sugar levels may have prevented his death.
The report listed a "number of concerns" regarding Mr Tudor's management and care at Highpoint including two missed opportunities by staff when blood test results were not followed up.
In response, Care UK who provide clinical staff to the prison said that it had reviewed its policy.
The report found that Mr Tudor, who was sentenced to three years in jail in July 2015 for robbery, had deteriorated significantly and rapidly following a move to the segregation unit at Highpoint.
More: Inquest held into death of prisoner Daniel Tudor
While at the unit, he had refused all treatment, food and fluids except a small amount of fruit and water, and had not engaged with health professionals.
Author of the report Nigel Newcomen said that the prison "did not assess and manage Mr Tudor's risk of suicide and self-harm appropriately".
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He added that he was "very concerned" that Mr Tudor was moved to the segregation unit without staff considering his condition.
On November 18 a psychiatrist tried to move Mr Tudor to a prison with 24-hour healthcare but no suitable beds were available.
Mr Tudor was then found to have high blood sugar on tests taken two days apart.
The tests "should have prompted further investigation" but "no-one took any action" said Mr Newcomen.
"The clinical reviewer felt that earlier action may have prevented Mr Tudor's death."
An ambulance was called on November 24 and Mr Tudor died at West Suffolk Hospital four days later.
The report also showed concern that staff only contacted Mr Tudor's family following his death and not when he was seriously ill in hospital.
A Prison Service spokeman said: "Our thoughts remain with Mr Tudor's family and friends.
"Since his death HMP Highpoint has improved mental health training for staff, gives one-to-one support to every prisoner and ensures those held in segregation are reviewed more regularly."