Simon Cartwright, suffering from untreated serious mental illness, begged for water 19 times before dying in a prison cell due to staff negligence and indifference.
Despite being in an observation cell designed for 24/7 surveillance, Simon was found dead, with rigor mortis already set in, indicating a prolonged period of neglect.
A gastroenterologist testified that Simon's chronic peptic ulcer disease was highly treatable, and timely administration of pantoprazole could have saved him before his death.
Prison staff failed to observe all signs of Simon's serious illness, even as he exhibited extreme thinness and signs of distress in the weeks leading to his death.
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