Prisons and hospital criticised after rapist death
A rapist who died in hospital was denied the chance of an early release from prison on compassionate grounds as his cancer was not diagnosed in time.
Shortcomings at Aberdeen Royal Infirmary, HMP Peterhead and HMP Glenochil were highlighted after an inquiry into Giovanni Cocozza's death.
The criticism is made by Sheriff Derek O'Carroll in a written judgement after a fatal accident inquiry in Alloa.
Cocozza, 78. had been serving a 10-year sentence at Glenochil jail.
He had been taken to hospital from his cell in March 2011, after becoming unwell.
The prisoner died in Stirling Royal Infirmary the next morning from a brain haemorrhage secondary to longstanding high blood pressure.
Cocozza also had lung cancer, first diagnosed less than 24 hours before his death, which had spread to his liver.
Sheriff O'Carroll said that had it not been for "a series of shortcomings, both personal and institutional", it was likely that Cocozza's cancer would have been diagnosed several months earlier.
The sheriff said he wanted to flag up shortcomings in the medical treatment of prisoners, who were entitled to care just as good as anyone at large.
"The absence of timeous diagnosis resulted in Mr Cocozza losing two opportunities," he concluded.
"The first was access to treatment for his cancer, though any such treatment could only have been palliative and would not have extended his life, though it might have improved his quality of life.
"The second was the chance of being considered for compassionate release."
However, Sheriff O'Carroll stressed that the failure to timeously diagnose and therefore treat the cancer did not materially contribute to the cause of death.
He said that, at Aberdeen Royal Infirmary, there had been a failure to see that a CT scan ordered by a consultant was carried out.
When Cocozza was transferred to Glenochil from the HMP Peterhead, formerly Scotland's main sex offenders' prison but which was then closing down, nobody appeared to notice that medical investigations had not been completed.
The medical team at Glenochil did not realise either.
Sheriff O'Carroll found that, at HMP Glenochil, there was no system for summarising current medical issues for incoming prisoners, something he contrasted with the General Services Contract for General Practitioners, which requires such a summary to be done within eight weeks.
"This is against a background where it is universally accepted that early and swift diagnosis of suspected cancer is extremely important," he said.
"It appears to me that many of the failures leading to the lack of timely and accurate diagnosis were institutional failures.
"The concern must be that, if this happened in Mr Cocozza, it could happen to others.
"The consequences for others of a similar series of institutional failures could be more catastrophic for them than it was for Mr Cocozza, killed as he was by an intervening event."
Sheriff O'Carroll pointed out that Sir Harry Burns, chief medical officer for Scotland, had said that prisoners were the most deprived class of persons, medically, in the country.
"I hope that the contents of this determination will assist those who wish to improve the shortcomings in the systems that I have attempted to describe, so that the treatment of prisoners may approach the quality of care that is generally expected among those cared for in the community," the sheriff added.
He said it was "a fundamental principle" that a prisoner was entitled to the same quality of care as anyone who was at liberty.
Cocozza, once a well-known Lanarkshire chip shop and ice cream van owner, was jailed after admitting raping two young women and sexually abusing five young girls between 1964 and 1976.