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Prison staff “inappropriately” carried out CPR on a “clearly dead” inmate found face down in his cell, an investigation has found.
Officers at HMP Bullingdon tried to revive Dominic Burges, 30, who was found lifeless on his cell floor, before they were stopped by a prison nurse, who realised rigor mortis had set in.
In a newly published report, the Prisons and Probation Ombudsman said it understood the “commendable wish to attempt and continue resuscitation until death” had been formally recognised.
Trying to resuscitate someone who is clearly dead is distressing for staff and undignified for the deceased
Prisons and Probation Ombudsman
But it said: “However, staff should understand that they are not required to carry out resuscitation in these circumstances.”
The ombudsman told Bullingdon bosses to make staff aware of guidance introduced seven years ago in line with European guidelines, which say CPR should not be tried when “there is clear evidence that it will be futile”.
Rigor mortis – the stiffening of a corpse – usually appears about two hours after death, while those who found Burges described him as “cold, stiff and with no pulse”.
“Trying to resuscitate someone who is clearly dead is distressing for staff and undignified for the deceased,” the ombudsman said, though it accepted workers were not sure Burges was dead when they started CPR.
It concluded: “The officers who responded to the medical emergency inappropriately administered CPR when rigor mortis was established.”
A Prison Service spokesperson said: “We have since rolled out new CPR training to all staff at HMP Bullingdon to ensure the safety of staff and prisoners.”
Homeless and schizophrenic Burges arrived at the category B prison, which holds around 1,100 men near Bicester in Oxfordshire, in October 2021 while awaiting trial for attempted robbery and failure to surrender.
His “unusual” behaviour – including screaming from his cell – discomfited other inmates and he was moved to his own cell about five weeks before he died.
His collapse was noticed by a night patrol officer carrying out the morning prisoner count shortly before 5am on 10 February 2022.
After seeing Burges lying flat on his stomach on the floor, the officer kicked the door to try and rouse him before radioing for help.
A post-mortem examination and toxicology failed to conclude how he died, though a pathologist said it is possible Burges took a drug that failed to show up in lab tests.
Sudden adult death syndrome was another suggested cause.
The ombudsman said bosses at Bullingdon have had “some success” in tackling a known problem with drug supply at the prison, but more still needs to be done.
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