A prisoner who died from tuberculosis was let down by medical staff who were not trained to deal with his long-term health conditions, an ombudsman report said.

Nurses of HMP Thameside, Greenwich, did not have Semsettin Zihni’s medical records, which affected the continuity of his care.

The 55-year-old had a series of previous conditions, including diabetes, a heart condition, and kidney disease.

His mobility was also affected due to arthritis in his right knee, which he was awaiting replacement surgery for at the time.

The prisoner complained to a nurse about a cough on November 6, 2019, which he was prescribed an antibiotic for.

On November 10, Mr Zihni lost his appetite and was monitored by nurses.

He was given paracetamol and told to eat.

The next day, Mr Zihni’s condition worsened but he was unable to go to the prison healthcare clinic as the house block lift was broken.

A nurse suspected a lower urinary tract infection and suggested he should be transferred to the inpatients unit.

However, the prisoner was not transferred to the unit, as the only vacant cell had no working water or electricity.

Healthcare night staff did however visit Mr Zihni’s cell to monitor him during the night.

On November 12, the prisoner felt too ill to attend his dialysis appointment, after presenting with high blood pressure and a temperature.

The nurse called an ambulance and Mr Zihni was restrained and carried down the stairs due to the broken lift.

When he arrived at the hospital, the prisoner was put on emergency dialysis. Mr Zihni’s mother was contacted and escorted to the hospital to visit her son.

The next day, he was transferred to the intensive therapy unit and was unable to communicate, eat or drink.

A plastic tube was inserted into his arm to administer antibiotics but the patient already had ongoing problems in this part of his body in the form of a fistula.

A consultant later suspected an infection due to this additional line.

On November 19, Mr Zihni was reportedly in a coma and the cause of his infection had still not been found.

Two days later a prison coordinator visited the patient and was told he was on life support and awaiting a brain assessment.

The prisoner’s mother and son were then brought to the hospital.

When no brain activity was found, Mr Zihni’s life support machine was turned off on November 21.

He died at 4.02pm with his family present.

A Coroner concluded that Mr Zihni’s cause of death was miliary tuberculosis – a rare form of TB where tuberculosis bacilli spread around the body.

The failings of medical staff at the prison were revealed in a Prison and Probation Ombudsman report into Mr Zihni’s death.

The clinical reviewer determined that healthcare staff needed further training to handle prisoners with complex, long-term medical conditions, and that Mr Zihni’s care did not align with national guidelines

The report, published on August 31, reads: “We are concerned that, despite his poor health and limited mobility, prison managers decided that Mr Zihni should be restrained when he was admitted to hospital on 12 November until 14 November.

"We are not satisfied that this was justified by fully considered risk assessments.”

Also criticised in the report was the lack of care plans made by the nursing staff, possibly leading to infection: “The clinical reviewer noted that Mr Zihni’s poorly controlled diabetes and his dialysis put him at increased risk of infection.

"She found that there were no care plans to guide nurses and healthcare assistants in the day-to-day management of Mr Zihni’s conditions.

"The care plans should have included management of the central line and the fistula.”

Mr Zihni was recalled into HMP Thameside on September 21, after being released from HMP Ford on May 4 2018.

He was charged with intent to kidnap and possession of an offensive weapon.

Two health screens were carried out on his arrival, and the nurses did not make any care plans after not noting any significant physical concerns.

A spokesperson from the Oxleas NHS Foundation Trust, the healthcare providers for HMP Thameside, said: “Oxleas NHS Foundation Trust has received the Prisons and Probation Ombudsman report and we are fully aware of the recommendations made.

“We have taken immediate action to implement the recommendations highlighted, including additional training for clinicians and management of patients’ long-term conditions on arrival, and are looking at how we can continue to learn from these.”

Serco, who runs the privately-owned prison, was also approached for comment.

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