Jury finds that neglect and multiple failings by prison staff led to death of Floyd Carruthers
Floyd Everton Carruthers died on 14th June 2021 after not leaving his cell in HMP Birmingham for four days, and not eating multiple evening meals. He was found by prison staff collapsed in his chair on 29th May 2021. After being conveyed by ambulance to Birmingham City Hospital, he was discovered to have bacterial endocarditis which had led to septic shock and multi-organ failure. The bacterial endocarditis likely developed while he was in prison, in the weeks or months before he collapsed.
The jury found that the prison staff failed to take sufficient steps to safeguard Floyd, including insufficient record keeping, handovers and escalation. In particular, there was a serious failure to make a referral to healthcare based on Floyd’s overall pattern of behaviour and presentation. This amounted to neglect. There was evidence from an expert cardiologist that Floyd likely went into septic shock and multi-organ failure during the night of 28th May 2021. Had he been conveyed to hospital before this time, he probably would have survived.
In particular, the jury found that prison staff had insufficient training in, and understanding of, the National Offender Management Service (NOMS), Adults Safeguarding in Prison policy, PSI 16/2015, to allow them to undertake their role in compliance with that policy.
The Ministry of Justice and HMP Birmingham accepted that there was no system in place for staff to identify such patterns of behaviour over multiple shifts, and that staff were not recording single incidents of prisoners not leaving their cells or refusing meals. Consequently, at the end of the first week of evidence, on 16th December 2022, the Governor Paul Newton issued a Governor’s Order mandating that prison staff must record every time that a prisoner fails to access the regime e.g., by refusing to leave their cell or have an evening meal.
Floyd had suffered with mental health problems for over 20 years and had a diagnosis of paranoid schizophrenia. He had been living in Midlands Heart Housing for 30 years where he had a designated housing officer who was aware of his mental health history and that he was receiving treatment from the community mental health team.
In March 2021, Floyd was reported by the housing association to police for breaching an anti-social behaviour injunction. He was arrested and held in police custody for three days before being transferred to Birmingham prison on 12th April 2021. Unfortunately, during his medical screening, staff did not identify Floyd’s mental health condition or treatment in the community, and so he was not seen by the prison mental health team within 48 hours of arrival, as he should have been.
Healthcare staff did note that Floyd had a pacemaker fitted, and that more information was needed, but this was never followed up.
Following his arrest, Floyd’s family raised their concerns about his mental health directly with the prison. They were assured that he was ok. Floyd’s family also contacted the community mental health team, but were told that they could not give any further information due to confidentiality.
The Coroner will be issuing a Prevention of Future Deaths (PFD) report in respect of the failure of prison staff to comply with PSI 16/2015.
The family was represented by Matthew Turner instructed by Lucie Boase and Nicola Miller of Broudie Jackson Canter.
The Coroner was HM Assistant Coroner for Birmingham and Solihull, Ian Dreelan.
The other Interested Persons were the Ministry of Justice, Birmingham Community Healthcare NHS Foundation Trust (BCHC), and Birmingham and Solihull Mental Health Foundation Trust (BSMHT).
