St George's Hospital launches review of custody deaths after two prisoners die

Documents from the Tooting hospital revealed failures by the trust "contributed to harm".

One incident related to a patient who had a reaction during surgery at the hospital, but it was not followed up properly.

The patient died after having a repeat reaction when the surgery was rescheduled.

Following this incident a number of changes are being implemented by the trust and a spokeswoman added: "An investigation into the incident identified some learning objectives which focused on communication and a review of existing clinical pathways."

Another man died in custody at Wandsworth Prison, where the trust supplies staff, and is understood to have hanged himself. A number of issues have been identified including the need for further staff training for resuscitation.

A spokeswoman said staff received annual training in resuscitation and were given refresher training tailored to a prison environment following this death.

The second man died in Wandsworth Prison 

A spokesman for the Ministry of Justice said they were unable to comment before inquests were concluded but said: "Every death in custody is a tragedy. Each death is the subject of investigations by the police and the Prisons and Probation Ombudsman, as well as a coroner's inquest.

"We always look closely at the findings of these investigations and make strenuous efforts to learn lessons from them."

The hospital would not reveal any more details about the patients or when the deaths occurred.

A review of custody deaths is expected to start in January 2015.

A spokeswoman added: "When there are multiple similar events it is usual to review the incidents and themes arising to see if there are any systemic contributory factors which need attention."