By james art Andrew Hadwin was found unresponsive on the toilet in his cell at HMP Durham on February 2 last year.
The 39-year-old, from Bowburn, County Durham, was due to be jailed for offenses including child neglect and rape on April 28, 2023, after pleading guilty to a string of offenses alongside partner Cheryl Pickles.
An inquest into his death, held at Crook Coroners’ Court this week, heard on Monday (October 28) that he died of diabetic ketoacidosis, a condition which occurs due to a lack of insulin. He was said to have previously expressed thoughts of self-harm and refused vital diabetes medication.
On Tuesday (October 29), expert Professor Partha Carr, a diabetes consultant and NHS England specialist, told the jury Hadwin might have survived if checks on his diabetes levels on the day before his death had been carried out to the same standards , as before.
The jury was told that according to medical notes, a check on ketone levels, described as “quite crucial” by Prof Carr, did not take place on February 1, the day before he died.
The nurse who saw him on Feb. 1 and 2 told jurors she did full blood sugar tests but no ketone tests.
She added that she “didn’t think it was diabetes” when she met Mr Hadwin, who came to the pharmacy complaining of feeling unwell with symptoms including stomach pains on the morning of his death. She told jurors she asked a GP to see him later that day.
Asked by Senior Assistant Coroner Crispin Oliver if he believed “lapses” in Mr Hadwin’s treatment led to his death, Prof Carr said: “Yes. I believe so.”
He added: “I think on the balance of probabilities, if his ketones were elevated, given the fact that he was recently admitted with almost the same problem that put him in hospital, then if that was elevated, he was had high blood sugar and high ketones that would have caused admission to hospital, which is a treatable condition and on the balance of probabilities he would have survived.
The inquest was told that checks on his blood sugar and ketone levels had previously been carried out since he arrived at the prison on January 17, including leading to his hospitalization for two spells.
Prof. Carr added: “I would say that if we held to the same standards of what was done in the same field and followed the same protocols, it would have picked up the elevated ketones.
“It’s just maintaining the same standards that would take him.”
Jurors watched a body camera video from a prison officer of Hadwin refusing his insulin at around 5.25pm on the day before his death, in which he was asked “Do you understand the consequences of not having it?”, and the 39-year-old responded by saying he would die.
Professor Carr said “any reduction in insulin” could “absolutely” affect his diabetes control.
Hadwin had been held in the vulnerable prisoner unit at HMP Durham since being detained on January 17 and was under round-the-clock surveillance, the jury was told.
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He suffered from type 1 diabetes, used a cane and a wheelchair for long distances and was generally not a “healthy person”, the court was told, and spent two stays at University Hospital North Durham between January 18 and 23 and again on 25 January 2023 while in custody.
His partner Cheryl Pickles watched the proceedings at the Coroner’s Court via video link from prison along with a priest.
The investigation, which is expected to last a week, is ongoing.