- 53 88. In the course of the 2015 visit, the delegation examined a number of deaths in prison and found that in several cases the deaths might have been avoided if proper medical care and management processes were in place. Reference is made to two specific cases as an illustration: i) CC, a heroin user, was remanded to Korydallos Men’s Prison in October 2014 and on 4 April 2015 his medical record noted that he was transferred to Korydallos Prison Hospital in a “semi-comatose condition after reported using substances. Is on methadone. Intravenous drug user. Narcan injection and sodium chloride infusion; referred to general hospital for further treatment and monitoring.” He returned from Nikaia Hospital at 22h15 that same day after treatment. At 8h35 the next morning he was found to be not breathing and pronounced dead, supposedly from an overdose of opiates. The CPT’s delegation is concerned that the discharge letter from Nikaia Hospital does not provide any information as to how the patient was assessed or treated. Further, there is no record of the patient being assessed by medical staff upon his return to the prison hospital. Good practice would normally entail monitoring a person who had suffered an overdose of opiates to ensure the continued effects of opiate intoxication were not apparent, especially as opiate intoxication causes respiratory depression. Further, while Nalaxon (“Narcan”) is an antidote to opiates, it is short acting and often further injections are required until the effects of the opiate toxicity have worn off. Moreover, it appears from the post-mortem that the patient was suffering from bronchiopneumonia and a pulmonary oedema (fluid in the lungs), which combined with opiate intoxication could cause respiratory depression. The chest infection and pulmonary oedema would not have developed suddenly and should have been diagnosed at Nikaia Hospital. In sum, an appropriate examination at Nikaia Hospital and proper monitoring following discharge back to the prison hospital might well have prevented this patient’s death. ii) YA was admitted to Nafplio Prison on 7 December 2011 and died on 4 March 2013. The autopsy report records the cause of death as being tuberculosis of the lungs and liver. In the 12 months prior to his death he had seen the prison doctor on numerous occasions complaining of abdominal pain, fatigue and loss of weight, and the three blood tests taken (7 July, 3 and 24 October 2012) each showed that his inflammation/infection was getting worse as was his anaemia. Regrettably, the blood tests taken at Argos Hospital on 24 October, where he stayed for five days, made no reference to the previous blood tests. A simple chest x-ray, routine for anyone complaining of weight loss, would have revealed the tuberculosis. The prison doctor never weighed the person despite noting weight loss in the medical record on several occasions. The result was that this man suffered a painful and lingering death, as witnessed by fellow inmates, when such an outcome was avoidable. The CPT considers that every death of a prisoner should be the subject of an effective investigation to ascertain, inter alia, the cause of death, the facts leading up to the death, including any contributing factors, and whether the death might have been prevented, and to establish whether there has been any negligence warranting disciplinary or criminal proceedings. Such inquiries are necessary in order to identify possible means to improve the system of prevention in place as well as to provide the relatives of the deceased person(s) with relevant information concerning the circumstances of the death.