Jake Swords

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Jake Swords, a
prisoner at HMP Peterborough,
on 2 June 2021
A report by the Prisons and Probation Ombudsman
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
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© Crown copyright, 2024
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The Prisons and Probation Ombudsman aims to make a significant contribution to safer,
fairer custody and community supervision. One of the most important ways in which we
work towards that aim is by carrying out independent investigations into deaths, due to any
cause, of prisoners, young people in detention, residents of approved premises and
detainees in immigration centres.
This office carries out investigations to understand what happened and identify how the
organisations whose actions we oversee can improve their work in the future.
Mr Jake Swords died from synthetic cannabinoid toxicity on 2 June 2021 while a prisoner
at HMP Peterborough. (Synthetic cannabinoids are psychoactive substances (PS).) He
was 28 years old. I offer my condolences to Mr Swords’ family and friends.
I am satisfied that Mr Swords received appropriate physical and mental health care at
Peterborough. There is no evidence that he intended to take his life at the time of his
death. Prison and healthcare staff ensured that he was aware of the risks of using illicit
substances and reminded him of the negative impact they could have. Mr Swords’ death
appears to have been an accidental result of using drugs.
It is troubling that Mr Swords was able to access and use PS with apparent ease at
Peterborough. HM Inspectorate of Prisons and the Independent Monitoring Board have
also expressed concern about the availability of illicit drugs at Peterborough.
We are concerned about the number of deaths we have investigated in which PS has
played a part and about the availability of PS across the prison estate. Peterborough will
need to ensure that local initiatives are implemented and developed further to reduce the
availability of drugs.
I am also concerned that healthcare staff tried to resuscitate Mr Swords despite the
presence of rigor mortis.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Kimberley Bingham
Acting Prisons and Probation Ombudsman January 2023
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Contents
Summary ......................................................................................................................... 3
The Investigation Process ................................................................................................ 5
Background Information ................................................................................................... 6
Key Events ....................................................................................................................... 7
Findings ......................................................................................................................... 13
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Summary
Events
1. On 10 December 2019, Mr Jake Swords was remanded to HMP Peterborough. He
had a history of substance misuse and mental health issues, having been
diagnosed with ADHD/Asperger’s syndrome in 2016.
2. In January 2020, the mental health team confirmed that Mr Swords had a
personality disorder as well as ADHD. He was prescribed ADHD medication and
referred to the ADHD specialist nurse. Over the coming months, Mr Swords was
inconsistent with taking his medication. After his medication was increased in June,
he appeared more settled and was discharged from the prison’s ADHD caseload on
3 July.
3. In August, Mr Swords told a substance misuse worker that he had regularly used
spice, a psychoactive substance (PS). In October, prison staff thought that he was
under the influence of PS, but Mr Swords denied that he had used any illicit
substance.
4. In December, prison staff again recorded that Mr Swords had been observed under
the influence of an illicit substance. They also suspected he had supplied illicit
substances on the wing.
5. On 2 March, staff started suicide and self-harm prevention procedures (known as
ACCT) when Mr Swords made a superficial cut to his neck. He said that he was fed
up with COVID-19 isolation, his court hearing date had been delayed due to the
pandemic and he had stopped taking his medication “in retaliation”. The ACCT
procedures were stopped on 4 March. Mr Swords subsequently agreed to restart
his medication and reported that he felt less agitated. However, by mid-April, he
had again stopped taking his medication.
6. On 1 June 2021, an officer thought that Mr Swords might have taken illicit drugs.
The next morning, staff found him unconscious in his cell. An officer radioed a
medical emergency code blue and staff responded quickly. Staff tried to resuscitate
Mr Swords until paramedics arrived and took over. The paramedics confirmed that
Mr Swords had died.
7. The post-mortem examination established that Mr Sword died of synthetic
cannabinoid toxicity.
Findings
Drug strategy
8. Although Peterborough has taken some steps to address its drug supply issues, Mr
Swords’ death is a reminder that more needs to be done to reduce the availability
and detection of drugs. The availability of illicit substances remains a problem
across the whole prison estate and should remain a priority for Peterborough.
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9. We are also concerned that there is no evidence of consideration for healthcare
assessment or additional monitoring when Mr Swords was suspected of having
taken drugs the night before he died.
Resuscitation
10. While we understand that staff wanted to save Mr Swords’ life, rigor mortis was
present. Trying to resuscitate someone who is clearly dead is distressing for staff
and undignified for the deceased.
Recommendations
• The Director should ensure that prison staff contact healthcare staff and monitor
prisoners appropriately when they suspect that they have used illicit drugs.
• The Director and Head of Healthcare should ensure that staff are given clear
guidance about and understand the circumstances in which resuscitation is
inappropriate in line with European Resuscitation Council guidelines.
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The Investigation Process
11. The investigator issued notices to staff and prisoners at HMP Peterborough
informing them of the investigation and asking anyone with relevant information to
contact him. No one responded.
12. The investigator obtained copies of relevant extracts from Mr Swords’ prison and
medical records.
13. NHS England commissioned a clinical reviewer to review Mr Swords’ clinical care at
the prison.
14. The clinical reviewer interviewed seven members of staff at Peterborough, jointly
with the clinical reviewer. The interviews were completed by video and telephone
because of the restrictions imposed due to the COVID-19 pandemic.
15. We informed HM Coroner for Cambridgeshire & Peterborough. He gave us the
results of the post-mortem examination. We have sent the Coroner a copy of this
report.
16. We contacted Mr Swords’ family to explain the investigation. Mr Swords’ mother
asked several questions about the full circumstances leading to Mr Swords’ death.
We have addressed these questions in this report.
17. Mr Swords’ family legal representative received a copy of the initial report. The
solicitor representing the family wrote to us raising a number of questions that do
not impact on the factual accuracy of this report.
18. The initial report was shared with HM Prison and Probation Service (HMPPS).
They identified one inaccuracy which has been amended in the report. All
recommendations were accepted.
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Background Information
HMP/YOI Peterborough
19. HMP/YOI Peterborough is operated by Sodexo Justice Services. It holds men and
women in separate sides of the prison. There is 24-hour healthcare provision. All
healthcare is provided by Sodexo under the provisions of their contract with the
Ministry of Justice.
HM Inspectorate of Prisons
20. The most recent full inspection of HMP/YOI Peterborough men’s prison was a
scrutiny visit in November 2020. Inspectors concluded that, despite some staffing
difficulties, the integrated substance misuse service was providing good clinical and
psychosocial support, with regular face-to-face assessments and joint reviews.
There had been some success in reducing the entry of drugs to the prison, a good
flow of local intelligence was being analysed effectively, and the prison was
addressing emerging risks, such as the entry of drugs.
Independent Monitoring Board
21. Each prison has an Independent Monitoring Board (IMB) of unpaid volunteers from
the local community who help to ensure that prisoners are treated fairly and
decently. In its latest annual report for the year to March 2021, the IMB reported
that it was encouraged by the impact that security measures had had in reducing
the flow of illicit substances into the prison. Lockdown had made drugs and
contraband harder to access and putting residents into bubbles had reduced
distribution. The IMB also reported that the need to safeguard residents who were
in debt remained an issue.
Previous deaths at HMP/YOI Peterborough
22. Mr Swords was the fourth prisoner to die at Peterborough since June 2019. Of the
previous deaths, one was self-inflicted and two were from natural causes. There
are no similarities between our findings in the investigation into Mr Swords’ death
and our investigation findings about the previous deaths.
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Key Events
23. Mr Jake Swords had a history of illicit drug use, including a history of synthetic
cannabinoid use (also known as spice or PS) in prison. He also had a history of
binge drinking alcohol. In 2016, Mr Swords was diagnosed with ADHD/Asperger’s
syndrome. He chose not to take medication for this.
24. On 10 December 2019, Mr Swords was remanded to HMP Peterborough, charged
with attempted murder. It was not his first time in prison. A nurse noted that Mr
Swords had arrived with a suicide and self-harm warning form that had been
opened at court. It identified that Mr Swords had issues of anger and aggression
due to recent events in his life. He had also had fleeting thoughts of suicide and
self-harm, was hearing voices and had a history of mental health problems.
25. The nurse noted that Mr Swords presented as calm and had no current thoughts to
harm himself but had said that he had punched a wall in police custody. Mr Swords
said that he had had a previous admission to a mental health hospital, had anxiety
and depression and was not taking any prescribed medication. He said that he had
a history of using cocaine, cannabis, and alcohol. Urine tests showed traces of
cannabis and benzodiazepines. The nurse referred Mr Swords to the substance
misuse service and mental health team. A prison GP subsequently prescribed
amitriptyline (used to treat low mood and depression) for Mr Swords.
26. Staff started suicide and self-harm procedures, known as ACCT. Mr Swords said
that he heard a voice in his head which commanded him to hurt people. Staff
assessed that Mr Swords posed a high-risk of violence if he were to share a cell
due to his offence. He was allocated a single cell.
27. Over the following months, Mr Swords had a key work session with a prison officer
every week or two to check on his welfare and to address any problems.
28. On 28 December, staff stopped monitoring Mr Swords under ACCT procedures.
2020 onwards
29. On 15 January, a consultant psychiatrist documented a detailed psychiatric history
in Mr Swords medical record, confirming his impression that Mr Swords had a
dangerous and severe personality disorder (which poses a high risk of harm to
themselves and others). He also recorded substance misuse (cocaine and
cannabis use) and some elements of ADHD. He prescribed atomoxetine (a drug to
manage the symptoms of ADHD) and referred Mr Sword to a substance misuse
practitioner, who had a special interest in ADHD.
30. The substance misuse practitioner told us that Mr Swords was periodically
inconsistent with taking his medication. She said that during periods of compliance,
Mr Swords complained of still having periods of agitation. In June, the psychiatrist
agreed to increase his medication (to 100mg daily). Mr Swords was discharged
from the ADHD caseload on 3 July as he appeared more settled.
31. Mr Swords had limited involvement with the substance misuse service at
Peterborough. A nurse from the substance misuse team recorded that, on 14
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August, Mr Swords said that he had used Spice on a regular basis. Mr Swords
asked the nurse if she was interested in bringing drugs into the prison for him. She
reported this to prison staff and Mr Swords was moved to the segregation unit for a
short period. He was moved to X Wing shortly before the end of August.
32. On 22 October, prison staff found Mr Swords seemingly under the influence of PS.
He refused substance misuse support and denied that he had used any illicit
substance. Mr Swords became irate at the allegation made against him and staff
had to ask him to calm down. A nurse reminded Mr Swords of the effect that
smoking PS could have on his mental health and general health. Mr Swords said
that he was aware of where and how to seek help and advice if he needed it.
33. On 29 October, an officer referred Mr Swords to the mental health team because he
had stopped taking his ADHD medication. The substance misuse practitioner saw
Mr Swords on 30 October. She recorded that Mr Swords had stated that his
medication was not administered when he had had moved to another wing. Mr
Swords subsequently restarted his medication, which a prison doctor increased in
dosage over the next two weeks.
34. On 11 December, staff reported that Mr Swords had been extremely abusive and
threatened healthcare staff at the medication hatch. He was subsequently given a
disciplinary warning.
35. On 17 December, staff recorded that Mr Swords had a job on the wing and was
doing well. He was considered polite and had a good relationship with staff and his
peers. Key work sessions on 23 and 29 December reiterated Mr Swords’ good
behaviour
36. On 30 December, staff recorded that Mr Swords appeared under the under the
influence of an illicit substance and did not attend the medication hatch to collect his
medication. Security intelligence investigations subsequently found that another
prisoner (through his family) had paid a substantial amount of money into a bank
account linked to Mr Swords. The intelligence report noted that it was suspected
that Mr Swords had been supplying illicit substances on X Wing. Shortly
afterwards, Mr Swords was moved to Z-1 Wing.
2021 onwards
37. At a key work session on 14 January, an officer noted that Mr Swords’ mood was
good and that he was polite and engaged well.
38. On 15 January, the substance misuse practitioner tried to call Mr Swords on his in-
cell phone, but he did not answer. She noted that she had sent him a self-report
form to describe any symptoms or side effects he experienced from his medication
to complete (on 9 January) but he had not returned it. She sent him another self-
report form and asked him to complete it. She noted that if his response showed
improved symptoms (as previously when prescribed a high dosage of his
medication), he would be discharged from their caseload.
39. On 2 March, staff started ACCT procedures after Mr Swords made superficial cuts
his neck with razor blade. During his ACCT case review, Mr Swords said that he
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was fed up with isolating. (Mr Swords’ wing was locked down at the time because
of a high number of positive COVID-19 cases.)
40. The substance misuse practitioner had remained in regular telephone contact with
Mr Swords during the COVID-19 pandemic when there were restrictions in place.
Mr Swords told her that he had stopped taking his medication “in retaliation” for
being informed that his court hearing date had been put back to September 2021.
He was angry that he had been on remand for over 12 months. She told us that
she tried to persuade Mr Swords to comply with treatment and made him aware of
the risks and impact that stopping medication would have on his mood and
behaviour.
41. On 4 March, a Prisoner Custody Officer (PCO) completed a key work session with
Mr Swords. Mr Swords raised no concerns. He said that he felt safe on the wing,
did not have any health issues and, although he felt a little low in mood, had made a
mistake by harming himself. That day, staff stopped ACCT monitoring.
42. On 10 March, a PCO completed a key work session with Mr Swords. He noted that
Mr Swords’ mood had been “up and down” and that he struggled with being locked
in his cell. Staff has noticed that Mr Swords was always trying to manipulate them
to let him out at times when he was not supposed to be, either to use the shower or
kiosk. When his request was refused, Mr Swords became rude and abusive.
43. That day, the substance misuse practitioner had a follow up session by telephone
with Mr Swords who said that he was still not willing to take his atomoxetine
because of his delayed court hearing date. She again encouraged him to consider
the impact that this could have on his daily functioning. She noted that she would
discuss Mr Swords with the psychiatrist to review discharging him from the ADHD
pathway.
44. Staff also conducted an ACCT post-closure interview that day. Mr Swords said that
he had no concerns. He said that he had a big support network, including his
brother who lived on the same wing.
45. On 17 March, the substance misuse practitioner reviewed Mr Swords, who agreed
to restart his medication.
46. On 25 March, Mr Swords told a member of the Trauma Team that his mental health
was deteriorating due to the current regime and because he no longer had a wing
job. His court hearing had also been postponed until September 2021. They
discussed coping mechanisms.
47. On 26 March, a security intelligence report alleged that Mr Swords was facilitating
drugs on Z-1 Wing by supplying paper soaked in PS. No action points were noted.
48. On 30 March, Mr Swords had an appointment with the mental health team which he
refused to attend. The substance misuse practitioner spoke to Mr Swords on his in-
cell phone. Mr Swords said that he felt less agitated and was less reactive to things
that were going on around him. He was keen to restart the medication as it would
further reduce his agitation and impulsivity. She told Mr Swords that his ADHD
medication would be restarted the next day. The dosage would be gradually
increased, and he would be reviewed in a fortnight’s time.
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49. At a key work session on 3 April, Mr Swords said that he felt safe on the wing and
would inform staff if he had any issues. An officer noted that Mr Swords’ mood
fluctuated between being respectful and polite on some days and, on others, being
rude and obnoxious. Mr Swords blamed his mood on not having a wing job.
50. On 14 April, Mr Swords said that he felt frustrated that he still had not been offered
a job on the wing.
51. On 16 April, a PCO had a key work session with Mr Swords who said that he was
still upset that he had not been allocated a wing job. The PCO explained that Mr
Swords’ attitude and behaviour had caused a delay in wing staff offering him a job
as it required a trustworthy person.
52. On 19 April, a nurse prescriber recorded that Mr Swords had stopped taking his
medication. She discussed this with the substance misuse practitioner, and they
agreed to stop his prescription until a psychiatrist had reviewed him. The substance
misuse practitioner said that she tried to review Mr Swords on 22 April (by
telephone), however he did not answer his phone. (She was unable to review him
again before his death.)
53. On 6 May, at a key work session, Mr Swords said he that was okay and felt safe on
the wing. At his next key work session on 18 May, Mr Swords raised no concerns.
54. On 26 May, Mr Swords telephoned his mother’s number from his in-cell phone and
spoke to his father. Mr Swords told him that he had smoked “a joint” and got
“stoned” and had a “brain wave”.
Tuesday 1 June 2021
55. PCO A had a number of interactions with Mr Swords on 1 June. He saw him at
breakfast, lunch and in the afternoon/evening. He described Mr Swords as happy
and said that he had no concerns about him.
56. PCO B noted in a statement that Mr Swords collected his dinner in the evening
before being locked in his cell. She noted that Mr Swords’ eyes looked a bit watery,
and she thought that he might have taken something (an illicit substance). She
asked him if he was okay, and he said that he was. She noted that Mr Swords was
very upbeat and chatty. She noted that another unknown officer had said that he
would submit an intelligence report about Mr Swords.
57. At 5.35pm, PCO A unlocked Mr Swords so that he could collect his medication. Mr
Swords went to another prisoner’s cell. In a statement, that prisoner said that Mr
Swords was a good friend. He said that Mr Swords had come to say goodnight and
had asked for a cup and some food. He gave him these and said that as Mr
Swords was leaving his cell, he made a groaning noise while simultaneously
holding the left side of his chest. Mr Swords said that he had had regular pain for a
while. Mr Swords left to collect his medication. After interacting with some other
prisoners, he returned to his cell. There is no evidence that Mr Swords spoke to
prison or healthcare staff about having chest pain.
58. PCO A told us that he locked Mr Swords in his cell at around 6.00pm. He said that
he had no concerns about him and said that Mr Swords was in a good mood. He
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said that Mr Swords was laughing and played music in his cell. He told us that Mr
Swords did not appear to be under the influence of an illicit substance.
59. CCTV shows that PCO C, a night duty officer, completed the night roll check on Z-1
Wing between 9.15pm and 9.17pm. He checked that all cells were locked and
accounted for all prisoners. Mr Sword did not press his emergency cell bell during
this period.
Wednesday 2 June
60. At 4.30am, PCO C completed the morning roll check. He used his torch and looked
into each cell. He said that he believed that Mr Swords was in bed when he
checked.
61. At around 6.50am, PCO B started delivering breakfast packs to prisoners in their
cells. Three prisoner orderlies helped her with this task. When she arrived at Mr
Swords’ cell, she unlocked the door, looked in and immediately saw Mr Swords on
the floor. Mr Swords’ chair was upturned, and he was lying on his back, with one
knee up and the other leg straight. She called Mr Swords’ name, but he did not
respond. She went into his cell and saw that his head was under the table, his lips
were dry and bloody, and his mouth was open. His face was purple, and his neck
was blue. She thought Mr Swords looked dead and noticed that he was cold. Mr
Swords did not respond to her. She radioed a medical emergency code blue,
indicating a life-threatening situation. The control room log recorded that this
occurred at 6.57am, and an ambulance was called straightaway.
62. Ten seconds later, two PCOs arrived at Mr Swords’ cell. They saw him lying on the
floor and immediately checked him for signs of life but did not find any. One PCO
told us that Mr Swords’ body was freezing cold and rigor mortis was present. The
other PCO said that he tried to place Mr Swords flat on his back, but it was
impossible as his arms and legs were completely stiff, and it was clear that he was
dead. One of his arms was stuck underneath his body.
63. At 6.59am, a nurse arrived at Mr Swords’ cell and PCO Wooley trying to move Mr
Swords. He examined Mr Swords and found no signs of life. He instructed the
officers to start cardiopulmonary resuscitation (CPR). At 7.01am, an officer arrived
at the cell with emergency medical equipment. Another nurse followed shortly
afterwards. She told us that Mr Swords appeared unresponsive and was cold to
touch. She said that his limbs were stiff, he had no pulse, and he was not
breathing.
64. The second nurse told us that she asked the prison staff move Mr Swords onto the
wing landing to create more space. She then took over and continued to administer
chest compressions, while the first nurse used the emergency equipment. The
second nurse said that Mr Swords was blue and rigor mortis was clearly present.
Healthcare and prison staff continued CPR until paramedics arrived at 7.12am and
took over his care. At 7.15am, the paramedics confirmed that Mr Swords had died.
Contact with Mr Swords’ family
65. At 8.26am, a prison family liaison officer telephoned Mr Swords’ mother and broke
the news of his death.
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66. The Prison Service contributed towards the cost of his funeral in line with national
policy.
Support for prisoners and staff
67. After Mr Swords’ death, a prison manager debriefed the staff involved in the
emergency response to ensure they had the opportunity to discuss any issues
arising, and to offer support. The staff care team also offered support.
68. The prison posted notices informing other prisoners of Mr Swords’ death and
offering support. Staff reviewed all prisoners assessed as at risk of suicide or self-
harm in case they had been adversely affected by Mr Swords’ death.
Other information discovered after Mr Swords’ death
69. Cambridgeshire Police searched Mr Swords’ cell and found a miniature mobile
phone, a number of USB sticks and electric cables, and a number of clingfilm wraps
(some empty and some containing a slight residue of an unknown substance). They
also found a number of small glass vials, which were empty but contained a small
amount of residue believed to be Spice.
Post-mortem report
70. The post-mortem report concluded that Mr Swords died from synthetic cannabinoid
toxicity.
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Findings
Assessment of risk and substance misuse
71. Mr Swords’ post-mortem report confirmed that Mr Swords died from synthetic
cannabinoid toxicity.
72. We found nothing to indicate that Mr Swords was at high risk of suicide or self-harm
at the time of his death. Although he had a history of substance misuse, he was not
actively involved with substance misuse services at Peterborough because he
repeatedly denied taking PS when staff suspected that he had done so. Prison
intelligence reports noted that staff had last seen Mr Swords under the influence of
an illicit substance on 30 December 2020.
73. We cannot say whether Mr Swords continued to use drugs regularly after 30
December but it is clear that he had taken PS soon before his death. There is no
evidence that he wanted to take his life or harm himself.
74. We are satisfied that staff made Mr Swords aware of the potentially fatal risks of
substance misuse and that he was offered support to stop.
75. On the evening of 1 June, PCO B suspected that Mr Swords had taken an illicit
substance. There is no evidence that she considered asking for a healthcare
assessment or additional welfare checks over the following hours or that she told
night duty staff about her concerns. We make the following recommendation:
The Director should ensure that prison staff contact healthcare staff and
monitor prisoners appropriately when they suspect that they have used illicit
drugs.
Drug strategy at HMP Peterborough
76. It is troubling that Mr Swords was able to access PS, particularly during the COVID-
19 lockdown when severe restrictions had been put in place on prisoner and visitor
movements.
77. In April 2019, HM Prison and Probation Service (HMPPS) issued a national
instruction that all prisons should review their drug strategies. HM Inspectorate of
Prisons (HMIP) expressed concern at the easy availability of drugs at Peterborough
when they completed their inspection in July 2018. Since this date, Peterborough
has made efforts to ensure support for prisoners with substance misuse issues and
to reduce the supply and demand for illicit substances. It revised its Drug Strategy
in line with HMPPS guidance. We note that in their scrutiny visit in November 2020,
HMIP found that Peterborough had had some success in trying to reduce the supply
of drugs into the prison. Nevertheless, we are concerned by the ease with which Mr
Swords was able to obtain illicit drugs and it is apparent that the prison must
continue to work hard towards reducing supply and demand.
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Clinical care
78. The clinical reviewer noted that overall, the healthcare that Mr Swords received was
of a good standard and was equivalent to that which he could have expected to
receive in the community.
79. The clinical reviewer noted that the mental health team managed Mr Swords’
mental health care and ADHD treatment appropriately and responsively, including
during periods when he did not comply with treatment.
Emergency response
80. In September 2016, the National Medical Director at NHS England wrote to Heads
of Healthcare for prisons to introduce new guidance to help staff understand when
not to perform cardiopulmonary resuscitation (CPR). This guidance was designed
to address concerns about inappropriate resuscitation following a sudden death in
prison. It was taken from the European Resuscitation Council Guidelines which
states, “Resuscitation is inappropriate and should not be provided when there is
clear evidence that it will be futile”. The European Guidelines were updated in May
2021, but the same principles apply.
81. Prison and healthcare staff responded promptly to the medical emergency code on
2 June and called an ambulance for Mr Swords. Prison staff identified quickly that
Mr Swords showed no signs of life. We are concerned that healthcare staff
instructed prison staff to initiate resuscitation on Mr Swords, and then continued
themselves, when he had clearly died. Mr Swords’ arms and limbs were completely
stiff, which indicated that rigor mortis (stiffness of the limbs after death) was
present. Rigor mortis normally sets in between two and six hours after death,
indicating that Mr Swords had been dead for some time when he was found.
82. At interview, the investigator asked the second nurse whether any consideration
was given to not starting CPR as rigor mortis was present. She said that she was
not aware of the guidance from NHS England and thought that because she was
unable to confirm death, she was obliged to start CPR even though it was clear that
Mr Swords was dead.
83. We understand the wish to continue resuscitation until death has been formally
recognised but trying to resuscitate someone who is clearly dead is distressing for
staff and undignified for the deceased. The guidance highlights that resuscitation is
inappropriate and should not be provided when there is clear evidence that it will be
futile. The guidelines give examples of futility as including the presence of rigor
mortis. We make the following recommendation:
The Director and Head of Healthcare should ensure that all staff are given
clear guidance about and understand the circumstances in which
resuscitation is inappropriate in line with European Resuscitation Council
guidelines.
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Inquest
84. The inquest into Mr Swords’ death was held in July 2024. The conclusion of the jury
was that Mr Swords’ death was by misadventure as a result of synthetic
cannabinoid toxicity.
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