Inquest for Marcus James Drury

Marcus James Drury was imprisoned at His Majesties Prison (HMP) Exeter when he became very unwell. He died on the 23^rd June 2020 following his hospitalisation at the Royal Devon and Exeter Hospital. The cause of death was infective endocarditis with cerebral, renal, splenic and hepatic abscesses.

The inquest touching into Marcus’ death took place between 11-18 March 2024. The expert evidence heard at inquest did not find a causal link between the standard of care Marcus received and his death from this rare infection. The jury concluded the following:

“During a short period of detention in HMP Exeter the deceased’ health deteriorated. Consequently, the deceased was admitted to the Royal Devon Exeter hospital on 5th June 2020 where he was diagnosed with infected endocarditis. Where, when and how he contracted infective endocarditis cannot be determined. He died as a result of infection on 23rd June 2020.

Marcus died from infective endocarditis cause of which cannot be determined.”

Marcus’ inquest heard evidence from a number of prison service and healthcare professionals who were involved in his care during his five days at HMP Exeter. His family remain concerned about the standard of care he received.

When Marcus entered prison on 1 June 2020, it was noted on his Prison Escort Record (PER) that he had a raised temperature. As a result, he was placed into Covid isolation in a cell. The inquest heard that no physical observations were taken on reception to prison and that he did not receive a full reception screening.

The inquest heard that by 3 June, prison staff were concerned Marcus had not eaten since his entry into prison. Marcus was complaining of pain and expressed he found it hard to walk to collect medicines. On 4 June he complained of chest pain. Marcus was offered an ECG but refused. The family are concerned that Marcus was not questioned sufficiently about the reasons for his refusal given the symptoms he was experiencing.

On 5 June just after 5am, Marcus was observed as having soiled himself and was lying on the floor. He was mumbling and incoherent. Marcus was not attended to in-cell by healthcare professionals until around 10am.

The family are deeply concerned that Marcus did not receive any physical observations between his entry into prison on 1 June and shortly before he was taken to hospital on 5 June. He did not receive a reception health screening or a secondary health screening, and observations taken of him were based on subjective questions taken at the cell door or through a small hatch.

Marcus was treated in intensive care upon his reception into hospital on 5 June. Marcus tested negative for Covid, but doctors very quickly identified he was suffering from infective endocarditis. On 17 June, the decision was taken to place him into palliative care. He died on 23 June 2020. His mother and sister spent every day with him during his hospital admission, playing music and chatting to him.

Care UK (now Practice Plus Group) undertook a Comprehensive Internal Learning Review into Marcus’ death. It identified the following care and service delivery problems:

• There was no reception screening, and Marcus was not seen by a GP as part of the reception process. The relevant policy by HMP Exeter on reception screenings was not followed, nor was the Health in Justice pathway for isolated patients.
• There was insufficient record keeping and poor communication between staff. Records were back timed without an explanation.
• Staff were blinkered in their thinking, and perceived Marcus as demonstrating challenging behaviour. It was assumed Marcus’ refusal to, for example, walk to collect medicine or undertake an ECG was due to behavioural issues.
• Marcus was not clinically examined by a member of the healthcare team until 5 June.

The Prison and Probation Ombudsman have also completed an investigation, including a clinical review, which concluded that the care Marcus received at HMP Exeter was not equivalent to that which he could have expected to receive in the community.

Healthcare services at HMP Exeter are now provided by Oxleas NHS Foundation Trust.

Marcus’ family are determined to ensure that prisons’ responses to the pandemic, including their approach to clinical monitoring in isolation, are considered as part of investigations into the Government’s response to the pandemic. They feel it is vital that people like Marcus, who died in prison or following imprisonment during the pandemic, are remembered, and that we learn from their experiences in prison during lockdown.

Following the conclusion of the inquest into Marcus’ death, his sister Tracy said:  “After waiting nearly 4 years for the inquest to be heard into my brother’s death, we have now learned the details of his short imprisonment at HMP Exeter in June 2020. I am haunted by the evidence I heard and read, and particularly by the fact that Marcus was held in isolation without in-cell treatment or observations for several days. As a family, we feel he was viewed as just another drug user, not as a person who was unwell and needed support. We hope lessons will be learned from Marcus’ death by the organisations involved in his detention and medical care. 

Marcus’ family are supported by INQUEST, who have emphasised the “serious consequences of highly restrictive regimes [in prisons] on people’s mental and physical health”.

Marcus's family  was represented by Jade Brown of Taylor Rose MW and Isabel Bertschinger of One Pump Court.

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