Exeter prisoner thought to have Covid dies of rare infection

His sister said she was 'haunted' by the way he was treated

An independent investigation has found that healthcare staff at HMP Exeter gave inadequate care to an inmate who was believed to be presenting with coronavirus symptoms but later died from a rare infection. A daming report published by the Prisons and Probation Ombudsman (PPO) is highly critical of most aspects of the clinical care Marcus Drury received in the prison.

The 46-year-old passed away on June 23, 2020, at the Royal Devon and Exeter Hospital. He died of infective endocarditis - a rare and potentially fatal infection of the inner lining of the heart, the cause of which could not be determined.

The PPO report, shared publicly this week, follows a two-week jury inquest held into his death in March at Exeter Coroner's Court. During the inquest, his family said they were deeply concerned Mr Drury did not receive any physical observations during the five days he was at HMP Exeter and observations taken of him were based on subjective questions taken at the cell door or through a small hatch.

The PPO report concluded the clinical care Mr Drury received at HMP Exeter was 'not equivalent to that which he could have expected to receive in the community and healthcare staff took 'too long' to respond to Mr Drury’s 'clear clinical deterioration'. On June 1, 2020, Mr Drury was recalled to prison at HMP Exeter for eight weeks after breaking a domestic violence restraining order in Dawlish.

At the time, he was said to be of no fixed abode and was sentenced to eight weeks in custody. On his arrival at Exeter, the report states he was taken to an isolation cell because he had been displaying Covid-19 symptoms and a full initial health screen was not carried out and no secondary health screen was completed.

Mr Drury was required to remain there until June 8 but within that time his health deteriorated. At 5.25am on June 5, a healthcare assistant (HCA) saw Mr Drury lying on the floor of his cell, moaning in pain. There were faeces on the floor and the HCA called Mr Drury’s name, but he did not answer.

The HCA raised concerns with a nurse who did not check on him until three hours later at 7.30am. At that time he was said to be lying in his bed, alert and orientated, but he was only seen and spoken to through the observation hatch in his cell door.

As there were deemed to be no immediate clinical concerns, the plan was for a nurse to review him again later that morning. However, two hours later he was found lying on the floor again having soiled himself and shivering and not responding to his name.

Healthcare staff attended and as it was believed he might have sepsis and appeared extremely unwell, an emergency ambulance took him to hospital at around 11.30am. He was diagnosed with streptococcus A - an infection caused by bacteria also known as strep A.

He was said to have suffered a number of small seizures, treated with antibiotics and taken to the Intensive Care Unit (ICU). He was later diagnosed with rheumatic heart disease but his condition continued to deteriorate.

On June 16, Mr Drury was diagnosed with endocarditis and tested positive for MSRA and was put on palliative care.

At the time of Mr Drury’s death, GP and primary care health services were delivered by Practice Plus Group (PPG), formerly known as Care UK. Devon Partnership NHS Trust provide mental health services and substance misuse services are provided by PPG and EDP Drug and Alcohol Services.

In December 2022, provision of GP and primary health services changed to Oxleas NHS Foundation Trust. At the time of Mr Drury's death, the prison was said to be experiencing staffing problems in healthcare that coincided with the need to manage the pandemic.

Its long-standing issues with healthcare provision at the prison has been highlighted by His Majesty’s Inspectorate of Prisons. Mr Drury was the 20th HMP Exeter prisoner to die since July 2017.

Of the previous deaths, 10 were from natural causes, eight were self-inflicted and one was drug-related. When the report was written, there had been nine deaths since Mr Drury’s death.

Two were from natural causes and seven were self-inflicted. There were said to be 'no particular similarities between' the findings in Mr Drury's investigation and previous investigations.

The inquest into Mr Drury's death recorded a narrative conclusion. The jury said: "During a short period of detention in HMP Exeter, the deceased’s health deteriorated. Consequently, the deceased was admitted to the Royal Devon Exeter hospital on June 5, 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 June 23, 2020.

Following the conclusion of his inquest, his sister Tracy said: “After waiting nearly four 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’s death by the organisations involved in his detention and medical care."

Although the coroner did not issue a prevention of future deaths report, the PPO report made a number of recommendations, including that the head of healthcare should ensure staff use the best available evidence when assessing prisoners’ physical health.

Oxleas NHS Foundation Trust has been approached by DevonLive for a comment.