Ombudsman Annual Report 2018-2019

32 Ombudsman Sixth Annual Report 2018 - 2019 VLGH DQG EORRG LQ WKH XULQH 7KUHH GD\V ODWHU KH GLHG 7KH 2PEXGVPDQ 2IÀFH DOVR UHYLHZHG 0U &·V KRVSLWDO medical records. It was found that following his transfer WR WKH6DOPDQL\D0HGLFDO &RPSOH[ RQ )HEUXDU\ he was diagnosed with Thrombotic Thrombocytopenic Purpura and was admitted to the Intensive Care Unit WR UHFHLYH WKH DSSURSULDWH WUHDWPHQW 7KUHH GD\V ODWHU KRZHYHU 0U &·V KHDUW VXGGHQO\ VWRSSHG DQG HIIRUWV to resuscitate him were unsuccessful. Mr. C was SURQRXQFHG GHDG RQ )HEUXDU\ 7KH FDXVH RI death was recorded as blood and respiratory circulation failure resulting from Thrombotic Thrombocytopenic Purpura. 7KH 2PEXGVPDQ 2IÀFH UHYLHZHG &&79 IRRWDJH RI 0U C from the time that he was taken by staff from his cell to the Rehabilitation Centre clinic and then transferred IURP WKH FOLQLF WR WKH 6DOPDQL\D 0HGLFDO &RPSOH[ 7KH IRRWDJH VKRZHG WKDW RQFH 0U & EHFDPH YHU\ XQZHOO the transfer took place quickly without any delays. 7KH 2PEXGVPDQ 2IÀFH UHTXHVWHG DQG H[DPLQHG WKH 3XEOLF 3URVHFXWLRQ ÀOH RI WKH LQYHVWLJDWLRQ LQWR 0U &·V GHDWK DQG WKH UHODWHG IRUHQVLF UHSRUW ,W ZDV then concluded that no evidence of wrongdoing or of a criminal act was found and that the death was from natural causes. $V WKH 2PEXGVPDQ 2IÀFH LQYHVWLJDWLRQ IRXQG WKDW QR issue of concerns relating to the care of Mr. C. it was GHWHUPLQHG WKDW QR IXUWKHU DFWLRQ ZDV UHTXLUHG DQG WKH case was closed. Death in Detention Investigation 4 Name Mr. D Age 28 Cause of Death Chronic Disease Date 30 July 2018 Location Salmaniya Medical Complex 2Q -XO\ WKH -DX 5HIRUP DQG 5HKDELOLWDWLRQ &HQWUH LQIRUPHG WKH 2PEXGVPDQ 2IÀFH RI WKH GHDWK RI 0U ' DW WKH 6DOPDQL\D 0HGLFDO &RPSOH[ ,W ZDV explained that Mr. D had been transferred to the medical complex on 24 July 2018. 7KH 2PEXGVPDQ 2IÀFH FRPPHQFHG DQ LQYHVWLJDWLRQ DQG YLVLWHG 0U '·V FHOO ,QYHVWLJDWRUV UHTXHVWHG DQG obtained all medical reports relating to Mr. D from the time of his admission to hospital. They also requested Rehabilitation Centre administration and PHGLFDO UHFRUGV DQG &&79 IRRWDJH VKRZLQJ 0U '·V PRYHPHQWV EHIRUH EHLQJ WUDQVIHUUHG WR WKH 6DOPDQL\D Medical Complex. $Q H[DPLQDWLRQ RI 0U '·V PHGLFDO UHFRUGV VKRZHG WKDW DW WKH WLPH RI KLV DGPLVVLRQ WR WKH 5HKDELOLWDWLRQ &HQWUH he was medically examined and found to be suffering IURP VLFNOH FHOO DQHPLD ZKLFK UHJXODUO\ FDXVHG KLP SDLQ 0U '·V PHGLFDO UHFRUGV VKRZHG WKDW ZKHQ KH H[SHULHQFHG SDLQ KH ZRXOG DWWHQG WKH FHQWUH FOLQLF WR get painkillers. 2Q WKH PRUQLQJ RI -XO\ 0U ' ZDV VXIIHULQJ ZLWK VHYHUH SDLQ DQG ZDV WDNHQ WR WKH FHQWUH·V FOLQLF where a painkiller was administered. When Mr. D FRQWLQXHG WR EH LQ SDLQ KH ZDV WUDQVIHUUHG E\ FOLQLF VWDII GLUHFWO\ WR WKH 6DOPDQL\D 0HGLFDO &RPSOH[ $W WKH medical complex he was taken to the dedicated ward for patients with sickle cell anemia. An Ombudsman investigator interviewed the doctor in charge of the clinic at the Reform and Rehabilitation &HQWUH WR ÀQG RXW PRUH DERXW WKH HYHQWV OHDGLQJ XS WR the death of Mr. D. The doctor stated that Mr. D attended WKH FOLQLF GXH WR SDLQ FRQQHFWHG ZLWK VLFNOH FHOO DQHPLD RQ -XO\ ,Q OLQH ZLWK WKH SUHVFULEHG SURFHGXUH a pain killer was administered by injection and Mr. D was kept under observation to check that the pain relief KDG ZRUNHG 7KH GRFWRU VDLG WKDW RQ WKLV RFFDVLRQ 0U D continued to experience severe pain and a decision was taken to transfer him to the emergency department DW WKH 6DOPDQL\D 0HGLFDO &RPSOH[ 7KH 2PEXGVPDQ 2IÀFH UHYLHZHG WKH SUHOLPLQDU\ PHGLFDO UHSRUW LVVXHG E\ WKH 0LQLVWU\ RI +HDOWK·V 'HDWK Registration Department. It was recorded that the death of Mr. D was due to multiple organ failure as it was to VXVSHFWHG WKDW KH KDV DQ DEGRPLQDO LQÁDPPDWLRQ resulting from sickle cell anemia. 7KH 2PEXGVPDQ 2IÀFH UHTXHVWHG WKH UHSRUW RI WKH Public Prosecution investigation into the death of Mr. D and the related forensic report. The forensic report