Stephen Charters, imprisoned for sex crimes, died from heart disease after collapsing while cleaning.
The inquiry was required by law; it’s mandatory for deaths in custody. Charters was in prison for sex crimes, including rapes of four women from 1984 to 2015.
He used to be a worship leader. A court found him guilty and gave him a five-year sentence along with a lifelong restriction order. He died only a few days later.
The inquiry found he died of natural causes. Heart disease, specifically coronary artery atheroma leading to ischaemic heart disease, caused his death. He had also experienced chest pains.
He was cleaning before he collapsed. Another prisoner helped him right away, placing him in a recovery position within 13 seconds.
Prison officers helped quickly, too. A nurse arrived soon after that, in under two minutes. A “Do Not Resuscitate” order was in place, reflecting Charters’s wishes about his care.
He requested this order earlier, writing it down during COVID-19 restrictions. He didn’t want resuscitation under any circumstances. He only wanted morphine for pain.
An autopsy occurred after his death. The pathologist said his condition could cause sudden death, finding no signs of injury and no intoxication.
The inquiry included a written statement confirming he died from heart disease. He had complained of chest pain for a long time, and the prison had treated his medical issues previously.
Staff helped immediately after he collapsed, but treatment stopped due to his order. The “Do Not Resuscitate” order was his express wish and a doctor discussed it with him.
These orders aren’t typical there, and the order lacked a review date, which seems contrary to policy rules. But it didn’t affect this case.