Colin Lovett
30 May 2025 · Coroner Rachael Griffin · Dorset
The coroner's concerns
1. lack of diabetes training among prison staff
“Evidence was provided by the Prison Service staff during the Inquest that they have never received training about diabetes and there is a lack of understanding, and national guidance for Prison Service staff relating to the symptoms of a hypo glycaemic or hyper glycaemic attack, which can be fatal.”
2. limited healthcare availability outside operating hours
“The healthcare department at HMP The Verne is only operated between 7.30am and 6pm daily and is not therefore available 24 hours a day. Outside of these operational times, access to healthcare would be via 111 or 999 which could cause delay in action being taken to resolve a hypo glycaemic or hyper glycaemic attack.”
3. insufficient staff awareness of chronic conditions
“It is acknowledged that there is a balance to be stuck with training non-medical individuals in diagnosing medical symptoms, which could lead to miss diagnosis, and ensuring care is provided without delay, however the Head of Healthcare at HMP the Verne stated that there would be benefit in providing an awareness to Prison Service staff of the impact on prisoners of long term conditions such as diabetes.”
4. limited staff understanding of diabetes
“Several members of Prison Service staff gave evidence at the Inquest and only one, who had personal experience through a family member, had an understanding of diabetes and the impact it can have upon an individual, including the symptoms of a hypo glycaemic or hyper glycaemic attack.”
5. insufficient staff awareness of insulin-dependent diabetes needs
“Prisoners are dependent upon support provided by Prison Staff. I am concerned that the lack of awareness of the needs of prisoners with insulin dependent diabetes amongst Prison Service staff who provide care to prisoners at times when healthcare staff are not on site, could lead to future deaths.”
6. potential systemic lack of diabetes training across prisons
“Although the evidence was based on the position at HMP The Verne, I am concerned this could be apply to other prisons nationally.”