Hayden Norton

13 Apr 2015 · Coroner Elizabeth Earland · Exeter & Greater Devon

The coroner's concerns

1. lack of blood pressure monitoring
“there was no record that his blood pressure was monitored”
2. delay in calling emergency ambulance
“There was a delay in calling an emergency ambulance because HMP Dartmoor did not have an emergency code (unlike HMP Exeter) protocol”
3. history of cardiovascular disease
“known to have extensive and well documented history of high cholesterol, ischaemic heart disease with episodic angina, two previous myocardial infarctions, blood pressure 220/100”
4. ruptured aortic aneurysm
“ruptured aortic aneurysm at HMP Dartmoor”