Earlier motion to deal with a prisoner’s excessive blood sugar ranges would possibly have prevented his death, a report stated.
Daniel Tudor, 28, died in hospital of pneumonia after refusing meals, drink and medical assist at Highpoint Prison in Stradishall, Suffolk, in 2015.
The Prisons and Probation Ombudsman stated it had many considerations, together with “two missed opportunities” when blood take a look at outcomes weren’t adopted up.
Care UK, which supplied scientific workers, stated it had revised its technique.
Tudor, who was sentenced to a few years in jail in July 2015 for theft, had a historical past of self-harm and was segregated on 5 November 2015 after attacking a member of workers.
While on the unit he deteriorated quickly and refused food and drinks aside from a small quantity of fruit, water and milk.
No beds out there
Report writer Nigel Newcomen stated healthcare workers targeting Tudor’s psychological well being however “did not adequately assess his deteriorating physical health”.
On 18 November a psychiatrist known as for a transfer to a jail with 24-hour healthcare however no appropriate beds had been out there.
Tudor was then discovered to have excessive blood sugar on assessments taken two days aside.
“This should have prompted further investigation which may have resulted in him being admitted to hospital earlier yet no-one took any action,” stated Mr Newcomen.
“The clinical reviewer felt that earlier action may have prevented Mr Tudor’s death.”
An ambulance was known as on 24 November and Tudor died 4 days later.
The report stated the Immigration Service deliberate to deport Mr Tudor again to Romania after his sentence.
Care UK stated its crew met with Tudor regularly however “were unable to prevent his deterioration”.
Its revised technique consists of conferences for advanced instances and care plans for prisoners refusing food and drinks, together with key indicators for dehydration.
A Prison Service spokeswoman stated: “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.”