Lewes Prison death: inquest highlights ‘failures in communication’ after man died five years ago

Finlay Stuart lan Finlayson, 54, died following cardiac arrest on January 25, 2019, at HMP Lewes, while on remand. Finlay, known to family and friends as Vinney, was pronounced dead at 9.16am.

The inquest was heard by a jury before assistant coroner Laura Bradford and was scheduled for March 12-19 at Hastings Coroner’s Court.

The Record of Inquest listed Vinney’s medical causes of death as pulmonary thromboemboli, deep vein thrombosis and metastatic carcinoma of the base of the tongue.

The jury submitted a narrative conclusion, which said: “There was confusion and uncertainty about his medical conditions caused by information sharing and permissions issues with SystmOne, leading to an over reliance on Vinney’s own statements.”

The conclusion said there was ‘some poor record keeping’ and ‘confusion over when to reference the system’.

It said there were ‘failures in communication between agencies and shifts, not helped by the numbers of different staff and agencies involved, high demand and challenging workloads and associated delays in accessing healthcare’. The conclusion said this was ‘particularly relevant’ from January 21 to 24, 2019. It said ‘a lack of quantifiable evidence’ between these dates, like notes of proportionate follow-ups, ‘may have allowed any deterioration in Vinney’s condition to be missed’.

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The conclusion said there was ‘a grave and unacceptable failure in communications’ on January 25 with ‘two or three emergency radios switched off in contravention of prison rules and protocols’. It said ‘this was then compounded by a delay in timely response, i.e. the proposal of a phone call rather than an in-person response’. It added: “This was followed by unacceptable indecision on calling an ambulance, in which perceptions of Vinney’s mental health were a factor, and should have been automatic on account of his head injury.”

Inquest.org.uk released a statement from Vinney’s family, which said: “Vinney was a much loved and charismatic person. His death has left a hole in our family that can never be filled. He struggled most of his life with a lack of social care funding in the community and feeling like he was often ignored due to his Mental Health.”

Inquest.org.uk said HMP Lewes healthcare is now being run by Practice Plus Group, adding that if Vinney were in prison now, he would be ‘flagged as a prisoner with long-term health conditions and treated accordingly’.

A Practice Plus Group spokesperson said: “We sympathise with the family of Mr Finlayson. At the time of his death at HMP Lewes, Practice Plus Group were not in post as medical provider, however did later assist the Coroner with the inquest. We are committed to the ongoing care of prisoners and strive to provide the same level of care as they would receive within the community.”

Vinney had originally been arrested in 2018. On December 24, 2018, Sussex Police said a man had suffered serious injuries after a ‘machete attack’ in Lawrence Avenue, Rustington. Police later said Vinney had been arrested and charged with attempted murder and two counts of possession of a knife.

After Vinney’s death a pre-inquest review was held at Eastbourne Coroner’s Court in December 2019. Coroner Alan Craze said a post-mortem by Home Office pathologist Charlotte Randall ‘pointed to natural causes of death’. The report read out in court said Vinney, who had cancer, had died of a blood clot as a result of deep vein thrombosis.