Health care provided to jailed Wisbech paedophile had ‘serious deficiencies’

The health care provided to a convicted paedophile who raped an underage girl has been criticised by a prison watchdog.

John Burnley, from Wisbech was jailed in November 2016 after being found guilty of three charges of raping a girl under the age of 13 and four charges of assaulting a girl under 13 by touching, following a seven-day re-trial at Cambridge Crown Court.

Burnley, who was living in Alexandra Road at the time of his conviction, died of a heart attack in Stafford Prison in November 2021.

The Prisons and Probation Ombudsman, which carries out independent investigations into deaths due to any cause, to understand what happened and identify any changes needed, looked into Burnley’s death and the report of their findings was published earlier this month.

The report, by Kimberley Bingham, Acting Prisons and Probation Ombudsman, said Burnley had a complex medical history and was prescribed 23 medications for various conditions.

It continued: “The clinical reviewer concluded that only some of Mr Burnley’s clinical care was equivalent to what he could have expected to receive in the community. While he had appropriate care plans for some of his conditions, these were absent for the management of his heart condition, diabetes, and obesity.

“The clinical reviewer was also concerned about the management of Mr Burnley’s medication. There is no record that healthcare staff changed Mr Burnley’s diabetic medication at the request of a specialist. I am also concerned that there was not a follow-up medication review when the pharmacist highlighted a potential adverse drug interaction.”

Burnley was found unresponsive in his cell at 8.55am on November 7 2021 by a fellow inmate.

Staff administered CPR but an air ambulance crew confirmed he had died an hour later at 9.55am.

Ms Bingham said: “The pathologist concluded that Mr Burnley’s cause of death was a heart attack caused by angina (chest pain caused by reduced blood flow to the heart).”

Her report said Burnley had undergone a medical review when he was first imprisoned and “he had several serious long-term conditions that required monitoring by specialist consultants.

“These conditions included diabetes, hypertension (high or raised blood pressure), cardiac concerns, asthma, sleep apnoea (a sleeping disorder that disrupts breathing), prolapsed discs, and deep vein thrombosis (a blood clot in a vein, usually the leg).”

He was subject to several medication changes but the report said some of these were not followed up and were significant in managing his diabetes.

On October 17 and 27 2021 the prison pharmacist and prison GP both separately recorded concerns about the combination of his prescription medications potentially being harmful.

The clinical reviewer concluded after Burnley’s death “there were serious deficiencies in his medication management. Significant changes in medication to manage Mr Burnley’s diabetes were delayed or not actioned following the request of a specialist. Healthcare staff also failed to appropriately assess and review the possible negative effects of Mr Burnley’s complex combination of prescribed medication”.

Following the ombudsman’s investigation, which involved interviewing healthcare staff, a number of recommendations were made including:

• The Head of Healthcare should review current practice and ensure that appropriate, consistent processes are in place for assessing, managing, and prescribing for long-term conditions.

• The Head of Healthcare should complete an immediate medication management review, focusing on patients who take multiple medications in line with the Royal Pharmaceutical Society’s (RPS) Professional Standards for Optimising Medicines for people in Secure Environments.

• The Head of Healthcare should ensure that there is a robust system in place for safe prescribing, a patient-focused approach to medicines use and that any discrepancies are followed up.

• The NHS England and NHS Improvement Commissioner for the West Midlands region should write to the Ombudsman setting out what she is doing to satisfy herself that HMP Stafford has a robust system for managing medication safely and that prisoners with long-term conditions have appropriate care plans in place.