A prisoner with epilepsy was found dead in his cell despite staff seeing him lying prone on the floor during earlier checks.
Failings in the duty of care towards the inmate at HMP Maidstone has been highlighted in a damning report released this week.
Igor Vujkovic, described as a “beloved son and brother”, was serving a five-and-a-half-year sentence at HMP Maidstone for drug offences at the time of his death last year.
When he was first transferred to the facility in April 2023, he told staff he had epilepsy, but said he managed it in the community by using cannabis and had not had a seizure for three months.
The reception nurse at the prison did not refer him to a GP.
At about 6.50am on May 11, 2024, an officer – known only as A – looked through the observation panel into the 25-year-old’s cell and saw him lying on the floor, with his head underneath the sink area and his feet pointing towards the door.
She thought she could see Mr Vujkovic breathing but found it difficult to see properly because of his position, so called another officer – known as B – to double check.
He also thought he could see him breathing and both then continued with the roll check.
However, at 8.49am, another officer – known in the report as C – who was unlocking prisoners’ doors, also saw him on the ground and called his name.
When he did not respond, a code blue alert was issued and 999 was called.
At 9.08am paramedics arrived and commenced CPR but, noting that the Croatian national had been dead for some time, declared him deceased.
A report into his death has been conducted by Adrian Usher from the Prisons and Probation Ombudsman.
It revealed that some staff did not know Mr Vujkovic had epilepsy and criticised the fact he had not been referred to a GP at his arrival.
Mr Usher stated in his report: “Mr Vujkovic gave consent for his medical information to be shared so there was no reason why prison staff should not have been made aware of his epilepsy.
His position on the floor of his cell and lack of response should have prompted the officers to go into the cell…
“However, prison staff gave varying accounts of whether they knew Mr Vujkovic had epilepsy and how they had been informed.
“Despite Mr Vujkovic telling the reception nurse when he arrived at Maidstone that he had epilepsy, he was not referred to a GP, was not placed on a long-term condition pathway and a care plan was not created to support the management of his epilepsy.
“We recommend the head of healthcare at HMP Maidstone should ensure that prisoners with epilepsy are referred to a GP, placed on a long-term condition pathway and have a care plan.”
Furthermore, Mr Usher uncovered inconsistencies in staff’s statements, with Officer A saying that neither she nor Officer B tried to get a response from the inmate, but B claiming they had, and he did not respond.
He said: “Even if they thought they saw him breathing, his position on the floor of his cell and lack of response should have prompted the officers to go into the cell.
“We cannot say if it would have made any difference to the outcome as there is a strong possibility that Mr Vujkovic was already dead at 6.50am.”
On December 19, Mr Vujkovic saw a GP and said that as he no longer had access to cannabis, he had had three seizures in less than 20 days.
Mr Vujkovic said they were due to stress and they usually happened at night.
As he was not keen on taking anticonvulsants, the GP prescribed mirtazapine – an antidepressant used to treat symptoms of depression and anxiety – to manage his stress.
The GP made no further plans for Mr Vujkovic’s care to be reviewed.
But from December 29, 2023 to March 29, 2024 Mr Vujkovic did not collect his medication.
There is no evidence from the medical records that staff followed this up with him.
A four-minute delay in the ambulance arriving was also noted, due to control room staff being unable to answer the question: “Is the patient breathing?”
Mr Usher added: “The clinical reviewer concluded that the care Mr Vujkovic received at HMP Maidstone was not equivalent to that which he could have expected to receive in the community.”
He advised HMP Maidstone to improve information sharing between healthcare and prison staff so that wing staff are aware of prisoners with potentially life-threatening medical conditions.
Mr Vujkovic was in a single-person cell and was classed as ‘standard risk’, meaning there was not another inmate present to raise the alarm.
Mr Usher recommended there be a regional policy on cell sharing for prisoners with epilepsy, which could help save lives.
He also urged them to establish a system for medication reviews with prisoners who fail to collect on several occasions.
Mr Vujkovic was due to be deported to Croatia on May 20, 2024.
His next of kin, his mother in Croatia, was called at 12.10pm on the day of his death to inform her he had died.
An online tribute page described the young man as “our beloved son and brother”.
The prison contributed financially to Mr Vujkovic’s funeral in line with national guidance.
