An investigation into the death of a convicted sex offender in prison has found an officer did not realise the inmate was dead on his cell floor.
Stephen Maddock was sentenced to 16 years in prison in April 2015 for sexual offences, but died in December 2019 HMP Rye Hill, in Northamptonshire.
The 59-year-old had been “dead for some time” before fellow prisoners noticed his absence and alerted staff, NorthamptonshireLive reports.
An investigation carried out by the Prisons and Probation Ombudsman found an officer, who unlocked Maddock’s cell on the morning of December 7 did not carry out a welfare check, so did not notice he was dead.
It was found Maddock failed to collect his dinner the night prior to his death and told an officer he was feeling nauseous.
The following morning, no concerns were raised by officers who had carried out roll check at 6am and 7.15am before Maddock’s cell was unlocked at 8am.
Despite this, the report found Maddock had been dead for “at least two hours” before he was discovered, meaning he was “certainly dead when the 7.15am roll check was carried out.”
It said: “Although this failure did not affect the outcome for Mr Maddock, as it appears he had been dead for some time, it is essential that unlock procedures are carried out correctly so that any welfare needs are identified and addressed as soon as possible.
"Mr Maddock had rigor mortis when he was found, which indicates that he had been dead for at least two hours.
“He was almost certainly dead when the 7.15am roll check was carried out, and possibly also at the 6.00am roll check.”
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Maddock was pronounced dead by paramedics at 8.50am on December 7, 50 minutes after the cell had been opened.
Following a disciplinary investigation, the officer that failed to conduct a welfare check was dismissed from their position.
The report details Maddock had diabetes and hypertension and that a post mortem revealed the prisoner had died from acute pancreatitis.
Clinical reviewer for the Prisons and Probation Ombudsman recorded: "When unlocking a prisoner's cell, the officer is supposed to get a response from the prisoner to satisfy themselves that they are alive and well.
"This did not happen, which meant that no one realised that Mr Maddock was dead for another half an hour.
"Following Mr Maddock’s death, the Director of Rye Hill reissued a notice to staff reminding them of the unlock procedures.
The officer who unlocked Mr Maddock’s cell was dismissed following a disciplinary investigation.
"The fact that Mr Maddock had rigor mortis when he was discovered at around 8.30am, indicates that he was almost certainly dead when the 7.15am roll check was carried out, and possibly also at the 6.00am roll check.
"We are concerned that neither roll check was carried out correctly despite two notices having been issued to staff in 2019 reminding them of the correct procedures."
The Rye Hill prison director has been told to ensure all staff know what is expected of them when conducting roll checks.
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