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The investigation revealed that prison personnel performed CPR on an inmate who was clearly deceased and found facedown in his cell in an “inappropriate” manner.
Staff members at HMP Bullingdon attempted to resuscitate 30-year-old Dominic Burges, who was discovered unconscious on his cell floor. However, their efforts were halted by a prison nurse who observed that rigor mortis had already taken place.
According to a recently released report, the Prisons and Probation Ombudsman acknowledged that the desire to persist with resuscitation efforts until death is commendable and has been officially recognized.
However, it was stated that staff are not obligated to perform resuscitation in these situations.
The ombudsman instructed the leaders of Bullingdon to ensure that their employees are informed of the guidelines implemented seven years ago, in accordance with European standards. These guidelines state that CPR should not be attempted when there is evidence that it would ultimately be ineffective.
After death, a corpse typically experiences rigor mortis, which is the stiffening of the body. Those who discovered Burges noted that he was cold, stiff, and had no pulse.
The ombudsman acknowledged that attempting to revive someone who is obviously deceased is upsetting for staff and lacks respect for the deceased. However, it was noted that the workers were uncertain of Burges’ death when they began performing CPR.
The report stated that the CPR given by the responding officers during the medical emergency was not appropriate as rigor mortis had already set in.
A representative from the Prison Service stated that they have now implemented updated CPR training for all employees at HMP Bullingdon in order to prioritize the well-being of both staff and inmates.
In October 2021, Burges, who is both homeless and schizophrenic, was brought to a category B prison located near Bicester in Oxfordshire. This prison houses approximately 1,100 male inmates and Burges was awaiting trial for charges of attempted robbery and failure to surrender.
His “unusual” behaviour – including screaming from his cell – discomfited other inmates and he was moved to his own cell about five weeks before he died.
A night patrol officer conducting the morning prisoner count on February 10, 2022, noticed his collapse around 5am.
Upon witnessing Burges lying face down on the ground, the officer proceeded to kick the door in an attempt to awaken him, and then called for assistance via radio.
An autopsy and analysis of substances in the body were unable to determine the cause of death, although a medical expert suggested that Burges may have ingested a substance that did not appear in laboratory tests.
Another possible explanation was sudden adult death syndrome.
According to the ombudsman, the leaders at Bullingdon have achieved some progress in addressing a recognized issue with drug distribution in the facility, but further action is necessary.