An independent investigation into the death of convicted child sex offender David Fuge has identified significant missed opportunities by prison healthcare staff to recognise and escalate symptoms of a fatal cardiac event.
Fuge, aged 76, originally from Wallasey, died while detained at HMP Wymott, near Leyland, Lancashire.
He was serving a lengthy custodial sentence after being convicted in 2017 of multiple sexual offences, including rape, indecent assault, and indecency with a child.
The investigation, conducted by the Prisons and Probation Ombudsman (PPO), evaluated the standard of medical treatment provided to Fuge prior to his death.
The ombudsman concluded that the clinical care delivered by the prison healthcare team was only “partially equivalent” to the care a patient could reasonably expect to receive in the NHS community.
According to the published findings, Fuge first reported feeling unwell several days before his death.
Prison staff initiated a code blue medical emergency and conducted an electrocardiogram (ECG), which produced results within normal parameters.
However, investigators identified a crucial missed opportunity when a responding emergency ambulance was stood down before paramedics could evaluate Fuge.
Furthermore, staff failed to review his medical charts, which clearly documented pre-existing clinical risk factors including high blood pressure and high cholesterol.
The following day, Fuge informed a healthcare assistant that his condition was worsening, explicitly reporting a burning sensation in his chest.
The PPO report found that staff committed a further missed opportunity by failing to escalate his deteriorating condition to the senior medical team or initiate a secondary emergency response, alongside critical failures in clinical handover communications between staff shifts.
At an inquest conducted between 17 and 19 August, the coroner returned a narrative conclusion, certifying that Fuge died from hypertensive and ischaemic heart disease.
A clinical reviewer appointed by NHS England concluded that healthcare personnel failed to conduct an adequate physical assessment or escalate treatment when Fuge presented with chest pain.
The ombudsman has issued formal recommendations requiring healthcare leaders at HMP Wymott to implement robust escalation protocols for patients reporting chest pain and ensure mandatory training for all staff.
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