It is known whether the nurse is still practising
A man died after receiving unsafe healthcare at HMP Bristol, a report has found(Image: BristolLive)
Nearly three years on from the death of Lockleaze man Marc Uzzell in prison, mystery surrounds the fate of a nurse who provided him with “poor and unsafe care” in the days before he died. Uzzell, 42, started coughing up blood on Christmas Eve 2022 while he was on remand in HMP Bristol for ‘violent offences’ – he died in hospital four days later.
Uzzell had previously been jailed for two years for slashing security guards at a Sainsbury’s in Stoke Gifford in 2019.
The ombudsman’s investigation found that poor and unsafe clinical handling when Mr Uzzell initially reported feeling unwell led to delay in assessing and treating him.
The first nurse, an agency worker referred to only as Nurse A in an ombudsman’s report into the death, to attend to Uzzell shortly after midnight on Christmas Eve did not record his clinical observations, or mention Uzzell’s condition during a morning handover. This led to “clear delays” in Uzzell’s condition being properly assessed.
A second nurse to examine Uzzell, Nurse B, subsequently reported the actions of Nurse A to the prison’s head of healthcare.
“The clinical reviewer considered that the clinical assessment and actions of Nurse A were unsafe and that recording of Mr Uzzell’s clinical observations would have presented a better understanding of his condition and stability,” the Prisons and Probation Ombudsman report said. “The failings meant that there were clear delays in Mr Uzzell being appropriately assessed and treated when he first reported his symptoms. However, it is not possible to say if this contributed to the outcome.”
The nurse’s conduct, and his subsequent refusal to cooperate with the investigation into Uzzell’s death, meant he was referred to the Nursing and Midwifery Council for further investigation.
The NMC refused to comment about the status of the investigation, citing confidentiality concerns. They also did not disclose whether Nurse A had been suspended to allow for the full investigation to take place.
A spokesperson from Oxleas NHS Foundation Trust, who manage healthcare in the prison, said the matter had been referred to as a matter of urgency to the employing agency, Sanctuary, following Uzzell’s death. They added the Trust had no visibility as to the outcome of the NMC inquiry.
Despite repeated requests from Bristol Live, Sanctuary refused to say what the outcome of the investigation into Nurse A’s conduct had been, or whether it was still ongoing.
“We have fully cooperated with the Nursing and Midwifery Council as required,” a Sanctuary spokesperson said.
“However, Sanctuary Personnel is not a party to their inquiry and is not privy to it’s (sic) progress or outcome.”
Nurse A is no longer on Sanctuary’s books.
The spokesperson for Sanctuary said the Trust was ultimately responsible for the day-to-day management of healthcare in the prison.
“In regulated settings such as prisons, agency workers operate under the day-to-day direction and control of the end client,” the spokesperson said. “The client is responsible for ensuring the working environment, operational controls, and duties assigned are appropriate to the worker’s qualifications, skills, and experience and it is the client who reviews their competence and performance.
“All required recruitment, safeguarding, and professional registration checks were completed in full before Nurse A was supplied to the NHS Trust and our contracts with our clients mean that we are regularly audited to ensure that we are meeting all relevant standards.”
The Trust confirmed that in the three years since the incident, a ‘competency framework’ had been developed and implemented in the prison when it came to agency staff.
At the time of his death, Uzzell was the seventh prisoner to have died while incarcerated at HMP Bristol. At least seven more have died there since he passed away.
A 2023 report into the prison described it as one of the most unsafe in the country.