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Nurse missed dying prisoner's pneumonia

PUBLISHED: 16:47 23 October 2009 | UPDATED: 10:46 12 August 2010

A NURSE who gave methadone to a prisoner dying from pneumonia revealed that her check ups at the prison usually relied on questions like how do you feel ?

A NURSE who gave methadone to a prisoner dying from pneumonia revealed that her 'check ups' at the prison usually relied on questions like "how do you feel"?

Rory Kinloch, 38, from Beckenham, died in Brixton prison on June 15, 2006 after being remanded for failing to answer a warrant.

A pathologist told the Southwark Coroners Court that his pneumonia was so bad that he had abscesses on his lungs.

Yesterday the inquest heard how the doctors and nurses who treated him at the prison were unaware that he had asthma or recently contracted pneumonia.

His niece Sydney Kinloch, 23, burst into tears yesterday (22) when she told coroner Andrew Walker that the last time she saw her uncle, three days before his death, his skin was yellow and he was wheezing.

She said: "His skin was yellow and he was very unwell looking.

"He just didn't seem at all like his usual self.

"He seemed small, hunched. It was a bit of a shock how small he seemed.

"His skin colour was a big concern.

"I don't think he felt comfortable talking about his health. I don't think he liked to worry people.

"I think he would be embarrassed to talk about his health with his niece.

"He did assure me that he would make an appointment to see a doctor."

Before he was arrested by Bromley police the former heroin user was on Subutex to help stay off heroin but once he was remanded at Brixton prison, he was subscribed methadone.

GP Dr Desmond Coffey who prescribed the new medication said: "I did not recollect any outstanding physical problems."

When asked by the coroner what he would have done if he found out the patient had asthma he said: "I would have to find out to what degree, if he was clinically unwell.

"I would have seen pneumonia, if pneumonia was recently - we are trying our best to pick them up and ordering an x-ray is easy to arrange.

"If I had reports from the nurses that he was unwell, we would have seen him."

It was only after the death that Dr Coffey found out in an interview that the patient had pneumonia and asthma. He told the court: "I was shocked. I was surprised.

"I wasn't aware of it."

When asked if the asthma guidelines were followed, he told the court: "One was trying to do it. But it is an impossible task. There isn't the resources."

"I would have actively intervened.

"He would have been seen that day."

Nurse Norma Ngema told the court yesterday (22) at the time of Mr Kinloch's death, nurses at Brixton prison did not have patient medical records in the treatment room.

Therefore she did not know he has asthma or that he had a recent bout of pneumonia when she watched him drink a large dose of methadone.

She also failed to check his blood pressure.

When asked how she would check for chest infection, she said: "By asking questions such as how are you today, are there any problems?

"I wouldn't administer methadone to someone with respiratory problems.

"I would get the doctor to assess the patient.

"I would have liked to have known more about the asthma.

"I would have talked to doctor."

The coroner asked if she knew he had pneumonia previously or if he still had it and she said: "No. He didn't mention it to me."

A juror asked her if she is aware of prisoners pretending to be in good form, in order to get methadone. She said: "No. Because we don't inform them why we are asking the questions."

Friend and fellow prisoner Mark Ismael was brought from Brixton prison by security guards yesterday to tell the coroner to give evidence.

Wearing a v-neck lilac jumper and beige trousers he told the coroner: "He told me he was getting over pneumonia. He didn't look too well. He was in a queue waiting for treatment.

"He didn't look right. You know your friend and you know when they look unwell. He said I am okay but I am getting over pneumonia.

"The weight had come off him.

"I just thought he was having an off day."

The inquest continues.

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