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Inquest jury finds failures in detainee healthcare

An MRI brain scan that was wrongly cancelled might have led to life-saving treatment for Bruno Dos Santos, who died aged 25 in the care of UK immigration authorities.

Bruno Dos Santos, a 25 year old Angolan man, died from unexpected natural causes at the Verne immigration removal centre in Dorset on 4 June 2014, an inquest jury found today.

His healthcare in the months leading up to his death was criticised today in a narrative verdict by the jury sitting at Dorchester County Court.

Dos Santos died from neurosarcoidosis, a rare brain disease. Although this condition showed no symptoms, he also suffered from epilepsy and was receiving treatment for that.

The jury found that during his time in custody, “Planned MRI scans did not take place due to a succession of failures within organisations involved.”

The ten jurors said in their verdict that neurosarcoidosis could have been detected before he died: “An MRI scan may have led to diagnosis and possible medical treatment, which may have prevented his death.”

Dos Santos was booked in for an MRI appointment as far back as January 2013 after he suffered a seizure at Belmarsh prison.

That scan “never happened” and the senior coroner said in his summing up that this was “not a very good state of affairs”.

Another opportunity was missed in February 2014, when a consultant neurologist Dr Cocco arranged a second MRI scan.

By this time, Dos Santos was being held at HMP Thameside, a private prison run by Serco.

It was there that healthcare staff, working for private provider Care UK, refused to let Dos Santos attend the appointment for “security reasons”.

The jury heard evidence that it was routine at Thameside to cancel all pre-booked external medical appointments that a prisoner was aware of, in case it provided a chance for them to plan an escape.

However, Dos Santos was being held under immigration powers at Thameside and was not a normal prisoner.

RECORD OF INQUEST 27 May 2016As such, he was entitled to a more flexible regime. Home Office policy stipulated: “Every effort should be made to meet medical appointments for detainees.”

The coroner said that not following this policy was a “very unsatisfactory state of affairs”.

Dr Cocco said that the brain scan appointment could have led to life-saving treatment.

“It was probable that I would have seen abnormalities and definite that I would have made further investigations,” the neurologist said. 

Although this takes time, Dr Cocco said tests could have been completed before Dos Santos died.

He would then have given Dos Santos potentially life-saving steroids at least ten days before he died. 

Shortly before his death, Dos Santos was moved to the Verne immigration removal centre in Portland, Dorset.

Officers found him dead, face down in his bed, at 7.44am on 4 June 2014.

Nick Brown, the family's barrister, said after the five day inquest: “This has been a very difficult experience for the family.”


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