Inmate died after trying to swallow plastic cutlery
HMP STAFF TOOK ‘FAR TOO LONG’ TO INVESTIGATE PRISONER’S BEHAVIOUR
A HULL prisoner rushed to hospital with “laboured breathing” was found to have plastic cutlery lodged in his gullet and windpipe.
Joshua Esberger, 28, who was on remand at HMP Hull, was also found to have a ballpoint pen in his ear, which had penetrated his neck. At the hospital, Mr Esberger had a cardiac arrest and was put on life support until he died on January 11, 2021.
An independent investigation into the death has been carried out by the Prisons and Probation Ombudsman. Summarising, Kimberley Bingham, Acting Prisons and Probation Ombudsman, said Mr Esberger died in hospital from pneumonia and hypoxic brain injury following a cardiac arrest.
Offering her condolences to Mr Esberger’s family and friends, Ms Bingham said: “Mr Esberger had been remanded to Hull on November 9 [2020] and from November 12 he began to behave in an unusual manner. I am concerned that staff took far too long to investigate the possible causes of his behaviour, including whether he might have taken an illicit substance or was having a psychotic episode.
“When Mr Esberger was rushed into hospital on the afternoon of November 14, hospital clinicians found that he had plastic cutlery [a spoon and a fork] lodged in his aero-digestive tract and had inserted a ballpoint pen through his ear, which had passed into his neck.
“I have seen no evidence to suggest that staff could have anticipated Mr Esberger’s actions, but had they investigated his other behaviours more promptly and thoroughly, the seriousness of his condition might have been recognised earlier along with the need to send him to hospital urgently.”
Concerns for mental health
Mr Esberger had been remanded to HMP Hull charged with assault, threatening behaviour, possession of offensive weapon, possession of a class B drug and failing to comply with the requirements of a community order. A nurse completing an initial health assessment noted that Mr Esberger had attempted suicide and had selfharmed in the last 12 months, and he had a diagnosis of bipolar disorder and a history of substance misuse.
In the early hours of November 12, Mr Esberger began ringing his cell bell and making odd statements. A nurse called to see him noted concerns about his mental health and referred him to the prison’s mental health team.
“At least one officer speculated that Mr Esberger’s earlier behaviour might have been due to him using an illicit substance,” the report said.
Mr Esberger was due in court for a remand hearing on the morning of November 13, but when officers went to collect him, he would not get out of bed or respond to them and they noticed blood smeared in the cell.
‘Missed opportunity’
“Mr Esberger walked unaided to the Wellbeing Unit, although the officers who accompanied him noticed that his breathing was laboured. After being called to check Mr Esberger, a nurse immediately recognised that he was very unwell and she called for an emergency ambulance.”
The report said it was unclear how many times Mr Esberger might have been offered meals, which he either declined or refused, on November 13.
The report said: “Had staff explored with him his reason for refusing or declining meals that day, in line with the prison’s safety briefing document, this might have prompted them to ask a clinician to come to see him. We consider that this was a missed opportunity for a clinician to review Mr Esberger.”
Care delivery ‘lacked urgency
A clinical reviewer concluded that the healthcare Mr Esberger received at Hull was of a “mixed standard”. The report said: “The delivery of care for Mr Esberger lacked urgency and co-ordination. Had Mr Esberger been thoroughly reviewed earlier he might have been sent to hospital earlier.”
Ombudsman recommendations
The Ombudsman’s recommendations included that the Governor should ensure that all staff understand their responsibility to immediately open an ACCT (Assessment, Care in Custody and Teamwork, the Prison Service’s care planning system) if they hear or observe anything to suggest a person might be at risk of self-harm or suicide.
The Governor and the Head of Healthcare should ensure that prompt and thorough investigations are made when a prisoner is thought to have taken an illicit substance, committed an act of self-harm or commenced a dirty protest.