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Young man died in prison after suffering three alcohol withdrawal seizures in space of three hours, inquest hears


Cork Prison

Cork Prison

Cork Prison

A HOMELESS young Polish national died after suffering three alcohol withdrawal seizures in the space of three hours in custody as it emerged an Irish prison has no doctor on call after 8pm.

A Cork coroner's inquest heard that Mariusz Serbin (31) died less than a day after being committed to Cork Prison for stealing beer kegs from a city centre pub.

Coroner Philip Comyn and an inquest jury were told Cork Prison does not have a GP on call after 8pm - and that an ambulance was not called to the jail despite the Pole suffering three severe alcohol withdrawal seizures between 2am and 5am on July 19 2018.

One seizure was so severe he rolled over a metre out of his bed onto the floor where he banged his head off a pipe.

The inquest heard that the system in place at the prison exerts enormous pressure on nurses who have no access to consultative supports.

Mr Serbin was given the special alcohol withdrawal drug Librium at 5.40pm in Cork Prison on his admission to custody on July 18 2018.

However, when he had a seizure at 2am and a further two by 5am no further Librium was administered to him.

A nurse on late night call felt that that an ambulance was not warranted. Mr Comyn heard that Cork Prison is without the assistance of a GP from 8pm each night because of changes to the system in 2013.

Nurses have no option but to call an ambulance or contact South Doc in the event of a medical emergency.

Assistant Governor at the Prison, Liam Spacey, says the lack of a GP on call at the prison after 8pm places enormous responsibility on nurses as they have "nobody to speak to or (access) to a second opinion."

Mariusz Serbin, who was originally from Poland, was an alcoholic who had had many periods of sobriety before reverting to drinking when he suffered the loss of his father, mother and grandmother in a short period of time.

His father died in particularly tragic circumstances.

Dr Anne Marie Naughton who attends to the homeless in the Simon Community in Cork said the deceased had become homeless after losing his job. The court heard he had made valiant attempts to give up alcohol which included a stay at Tabor Lodge treatment centre in Cork in 2017.

Dr Naughton said when Mr Serbin returned to drinking he consumed in the region of one and a half litres of vodka a day. He was never formally diagnosed with epilepsy but instead suffered from violent alcohol withdrawal seizures.

He was taken in to custody on July 18 2018 after his appearance in court for minor theft.

Senior Probation Officer Deirdre Coakley said Mr Serbin had worked as a hotel maintenance officer. However, he lost his job and his life became progressively worse.

Ms Coakley said that Mr Serbin was desperate to give up alcohol. He had appeared in court charged with stealing beer kegs from outside the Rob Roy pub in Cork in May of last year. At the time of his court appearance on July 18 last year he was sleeping rough and was remanded in custody for up to ten days to help him come off drink.

Mr Coakley said said that she sent an email to the prison detailing his need for medical attention. She also spoke to a nurse onsite.

Mr Serbin was given two 10mg Librium tablets at 5.41pm on the day of his admission in keeping with the information received.

The nurse who treated him left work at 7.40pm having completed the late night handover with another nurse.

When the first nurse returned to work the following morning at 8am the cell was opened and the prisoner was experiencing medical difficulties.

His cellmate explained that Mr Serbin had experienced seizures during the night.

Mr Serbin was transferred to hospital where he died a short time later.

The second nurse said he had attended Mr Serbin in his cell three times during the night.

The pulse of the patient was normal as were his oxygen saturation checks.

However, no blood pressure check was conducted. The second nurse didn't feel the patient was at risk.

However, the second nurse said there was no facility to consult anyone for a second opinion.

Assistant State Pathologist Dr Margaret Bolster carried out a postmortem on the deceased at Cork University Hospital.

She found he died of severe seizure disorder with a background of alcoholic problems with the liver.

She said that Mr Serbin had an old traumatic brain injury and that his death was "multi factorial."

Dr Eugene Morgan, a former prison psychiatrist, said that Librium was normally administered as part of a regime over a number of days. He stated that the withdrawal of the doctor on call at night was not a "desirable" situation at any prison.

After a lengthy deliberation the jury recorded a verdict of misadventure in the case.

The jury recommended the full reinstatement of on call GP cover at Cork Prison.

They also recommended that nurses coming on duty should have all relevant data about prisoner needs, that they ought have iPads or palm pilots to allow them make notes of prisoner observations immediately, and that if there is any doubt about the duration of a prisoner's seizure the emergency services should be called.

No members of Mr Serbin's family were present at the inquest.

At the funeral of the deceased mourners were asked to donate to Cork Simon Community in lieu of flowers.

Online Editors