Staff have been criticised in a report for not attempting to resuscitate a paedophile maths teacher who died in prison after choking on his breakfast.
John McKno, was serving a 14-year sentence in Norwich Prison when he died on September 29, 2019, aged 74.
A post-mortem report concluded that McKno died from breathing in the contents of his stomach due to choking on food in his oesophagus.
The Prison and Probation Ombudsman (PPO) report said McKno had a Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) order.
It said: "The clinical reviewer’s most significant concern was the decision not to attempt to resuscitate McKno. She found that there was a failure to follow the Resuscitation Council’s guidelines which make it clear that choking is not a reason for not attempting resuscitation.
"She considered that the lead nurse’s decision not to attempt resuscitation was based on the DNACPR that was in place, and she did not seek enough information from the other staff who had arrived on the scene before her. The clinical reviewer’s opinion was that resuscitation should have been attempted."
McKno, who had several health conditions, started choking at around 10am on September 29 and was attended to by a healthcare assistant who was working on his own, according to the ombudsman.
He had reported feeling faint 30 minutes before and the assistant did some observations but did not use the National Early Warning Score, which "would have prompted an early assessment".
After doing some back slaps and looking at the airway, the healthcare worker asked for help on his radio from the lead nurse and another healthcare assistant but they did not appear quickly because the assistant "failed to call a medical emergency code".
The report added: "A nurse and healthcare assistant from a different wing attended. They placed McKno in the recovery position, gave back slaps and removed some food from McKno’s mouth. The lead nurse and healthcare assistant attended shortly afterwards. The lead nurse found no signs of life and said that McKno had a DNACPR order in place so resuscitation should not be attempted."
The PPO made several recommendations including further investigations into the lead nurse’s actions.
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