'Missed opportunities' in prisoner's TB death

Prison and healthcare staff missed chances to spot an inmate at a prison in Nottinghamshire had tuberculosis (TB), an inquest has found.

Alvaro Mendoza Sillerico, a 32-year-old from Bolivia, had been at HMP Lowdham Grange since January 2021, but died in hospital on 18 November 2024.

An inquest at Nottingham Coroner's Court heard a fatal sigmoid perforation - a rupture in the bowel - "caused by disseminated tuberculosis".

Returning a conclusion of death by natural causes on Wednesday, a jury said Sillerico's "significant loss of weight" should have raised the alarm "at an earlier stage", which "could possibly have contributed to his death".

The inquest heard the Category B prison had an "outbreak " of TB in 2021, but Sillerico did not participate in a screening programme at the time.

A jury found the inmate had "no issues conversing in English as a second language", and received an initial letter warning about the outbreak, but said this was not followed up.

"We find that this lack of follow-up missed an opportunity for Mr Sillerico to make an informed decision on declining screening and to possibly identify that [he] had latent [TB], and thereby possibly contributed to his death," they said.

The jury said three missed appointments between October 2023 and September 2024 were also not pursued, and said Sillerico's "access to healthcare was not appropriately managed for several appointments".

It cited "insufficient staffing levels" in the jail - which had been taken over by the Ministry of Justice (MoJ) in December 2023 - and said the institution's "processes and procedures were fractured and chaotic".

Sillerico was admitted to hospital on 7 October 2024, when he was nearly 30kg (4st 7lb) lighter than when he had originally been transferred to Lowdham Grange, and he was found to have the same strain of TB that was identified in the 2021 outbreak.

The jury said Sillerico had been moved to a new wing weeks before, but his self-isolating behaviour "wasn't flagged formally", and he "would have appeared significantly underweight for several weeks prior to the issue being raised".

"We find that there were missed opportunities to spot possible health issues across the prison staff, the healthcare staff and Mr Sillerico himself," the jury said.

"There was a lack of communication between the prison staff and healthcare staff, with a lack of formal opportunities for them to interact through combined meetings.

"We find that better structured communication between healthcare and prison staff could have picked up issues with Mr Sillerico's health or missed appointments earlier, which could have led to earlier healthcare intervention."

Adam Pearson, assistant coroner, said there had been "significant structural change" at the prison since Sillerico's death, as well as a change in healthcare provider, and confirmed he would not be issuing a prevention of future deaths report.

Listen to BBC Radio Nottingham on Sounds and follow BBC Nottingham on Facebook, on X, or on Instagram. Send your story ideas to eastmidsnews@bbc.co.uk or via WhatsApp on 0808 100 2210.