Entrance to healthcare, Verne immigration removal centre (HMIP)

Staff at the Verne Immigration Removal Centre in Dorset told an inquest jury yesterday that medicine monitoring practice could have been better back in 2014, when a young man died in their care.

A nurse told the jury at Dorchester Coroner’s Court that there were “better systems in place now” and that things had changed after “what happened to Bruno”.

Bruno Dos Santos was 25 when he was found dead in his cell on the morning of 4 June 2014. The court heard that he died of natural causes, which involved swelling in parts of his brain, causing pressure on his spinal cord, affecting his ability to breath. Coroner Sheriff Payne told the jury they must consider how he died. “Were there gaps in his care? Was there something that could have been done that might have predicted his death?”

Dos Santos moved to the UK from Angola at the age of six. When he was 10 in 1998 he was knocked down by a car and suffered serious head injuries. He recovered but later developed epilepsy. Sometimes his fits were so bad that he would convulse and dislocate his shoulder, which had to be put back into place.

However, the court heard that Dos Santos was a “generally fit young man” in the months leading up to his death, though he had a reported having a seizure just two days before being transferred to the Verne early in May 2014. Prior to his detention at the Verne Dos Santo served a prison sentence at HMP Thameside. His foreign nationality meant that once his sentence was up, deportation proceedings automatically kicked in.

Dos Santos had been prescribed carbamazepine, an anti-epileptic drug designed to prevent seizures, which he was supposed to take twice a day. But during the few weeks he was detained at the Verne, Dos Santos would frequently miss appointments with healthcare staff to collect his medication. On his death a stack of unused medication was found in his room.

Nick Brown, the barrister from Doughty Street Chambers representing the family, repeatedly questioned healthcare staff about procedure for detainees who failed to take medication or turn up to appointments. Julie Leighton, a nurse working at the Verne, answered: “We have got better systems in place now. We have got better compliance checks.” She later added: “We have got more checks in place now in light of what happened to Bruno, to make sure people are more compliant.”

Brown asked again about the systems in place at the time of Dos Santos’s death, “Was there any system in place for anybody to go back and check?” he said. Leighton said: “The onus is on themselves. Like the onus is on me if my own doctor prescribes me something.” She later told the court that she had 300 people to keep track of and was unable to remember every single one. Though there were several messages about Dos Santos on the nurses’ ‘task’ system (the programme used to manage workload at the time) no one person was allocated responsibility for following up on concerns raised about Dos Santos frequently missing appointments.

However, David Hill, the solicitor from Hill Dickinson solicitors, representing Dorset Healthcare, the private contractor for the Verne, challenged this. Addressing Leighton, he said that while “things have improved now”, was there an expectation at the time that nurses would check on patients? “Yes,” Leighton replied. “It was down as part of our weekend duties to check medications.”

The court heard that Dos Santos had several serious fits witnessed by prison staff as well as the one he reported two days before arriving at the Verne. He was also waiting for an appointment to have his shoulder operated on at the time of his death.

Dr Jane Fowler, a GP working at the Verne, assessed Dos Santos when he first arrived. “I don’t recall any specific concerns. I was not concerned about his mental state. I didn’t need an interpreter,” she said. Dos Santos told her about his shoulder, the fit, and that he was waiting an MRI and EEG appointment. A neurologist had made the referral the previous February. He was taking anti-depressants. A letter written in 2013, the year before, by the neurologist had also expressed concern that his carbamazepine prescription was low and should be increased slowly and checked again in 14 days. Dr Fowler noticed that this hadn’t been actioned; Dos Santos was still on a low dose and so she prescribed an increase. After that she had no further dealings with him.

Brown: “Why didn’t you book in a further appointment in about 14 days time to see how he was coping?”

Dr Fowler: “I can’t recall. In terms of availability of appointments that can be difficult. Better practice … in retrospect would have been to see him 14 days time.”

Brown: “How can an individual taking that medication not be checked up on?”

Dr Fowler: “It is not infrequent that people would miss appointments and not collect medications. The system has improved and it is easier for nurses to see who’s taking their medications and who isn’t.”

The court heard accounts and statements from 11 witnesses including several prison officers, who could not remember Bruno Dos Santos because of the chaos and confusion at the centre. At the time, the Verne was transitioning from a prison to immigration removal centre. Mr Sheriff Payne, senior coroner presiding over the inquest, asked Robert Dorey, a prison officer working at the Verne, what Dos Santos was like. He couldn’t answer, instead he said: “It was a very chaotic time. It was very stressful.” Dorey discovered Dos Santos’s body and was still visibly shaken by the memory. “His eyes were closed. He was wrapped in his duvet. He looked like he was just asleep.”

The inquest continues.