Lawyer who died in prison had various medical issues: Coroner findings

(PHOTO: Singapore Prison Service)
(PHOTO: Singapore Prison Service)

SINGAPORE — A former lawyer who died in prison while serving a sentence for misappropriating legal fees had been discharged from the hospital three days before his death for a heart condition.

Zaminder Singh Gill, 57, had been found unresponsive in his single-man cell by prison officers on the morning of 5 October last year.

Delivering the findings into Gill’s death on Wednesday (4 August), Coroner Kamala Ponnampalam ruled that the former lawyer’s cause of death was hypertensive heart disease, which is a natural disease process, with no basis to suspect foul play.

Zaminder had been a lawyer with Hilborne Law before he was sentenced to two years and three months’ jail on 28 September. He pleaded guilty to five charges of criminal breach of trust as an attorney, involving $31,550 from 16 clients.

He had a medical history of hypertension, asthma, and glaucoma, and a past left ankle fracture, with his latest admission to Changi General Hospital for chest pain.

He was diagnosed with congestive cardiac failure with poor heart function during his admission on 30 September, and was discharged on 2 October.

Upon his discharge, he was monitored for two days at the Cluster Medical Centre before he returned to his single-man cell at Cluster B on 4 October.

A doctor attached to Singapore Prison Service found Gill to be fine with no medical complaints. He was comfortable, his vitals normal, was eating well and ambulatory.

He was given five days of medical leave excusing him from strenuous physical activity. The doctor was not aware that Gill was housed in a single man cell and said that it would have been safer to have him with a fellow inmate. This was so someone else could call for assistance if Gill fell ill. There was no evidence however, to suggest that Gill might not have been able to press the call bell.

On 4 October 2020, Gill sent an e-letter to his family stating that he was well and did not raise any concerns. His brother gave evidence that his brother had a known history of high blood pressure. The family wanted to know why Gill was placed in a single-man cell despite his medical problems and if anyone was monitoring him via the CCTV or conducting checks on him.

On the same day, when Gill returned to his cell, he knocked on the viewing panel of his neighbouring inmate to ask after him. The neighbour also asked after Gill, who replied he was feeling fine after having his electrocardiogram test.

That night, Gill spoke to his neighbour at the toilet area of his cell. Gill said he was fine and had his dinner, with his neighbour asking him to walk around his cell before going to bed.

Gill then asked his neighbour if he needed a wake up call the next day by banging the wall separating their cells, and his neighbour agreed. Gill had done so on several occasions previously by calling his neighbour’s name and banging the wall.

However, Gill did not give the wake-up call. At around 6.45am on 5 October, the neighbour woke up on his own and realised that Gill had not kept to their arrangement. The neighbour called out to Gill and banged on the wall, but Gill did not respond. He only learned about Gill’s death later on.

At around 7.30am, a prison officer conducting a routine check on Gill’s cell saw that he was lying on a mattress on the ground. He assumed Gill was sleeping.

Two inmates who were tasked to collect dirty laundry took turns to knock on Gill’s cell door to call out for laundry, but he did not respond. They saw through Gill’s viewing panel that he was lying face up with a face mask covering his eyes.

After they failed to rouse Gill, the inmates alerted prison officers who rushed and requested the control room to open Gill’s cell door at 7.40am.

One tapped him on his shoulder and the other check his pulse, but was unable to detect any. They began cardiopulmonary resuscitation (CPR) on him and activated the “code blue” a few minutes later. A nurse took over the CPR process and applied an automated external defibrillator on him.

A medical team used a bag valve mask to pump oxygen into Gill’s lungs, stopping only when paramedics arrived. Gill was conveyed to Changi General Hospital but did not respond and was declared dead at 8.54am.

CCTV footage of Gill in his cell showed that he was still moving around normal at about 6.18am on 5 October. He lay down in a supine position on his mat at 6.20am and wore an eye mask. He was seen positioning his left hand to his chest for a few seconds before becoming still.

Extending her condolences to Gill’s family members, Coroner Ponnampalam said that she was satisfied that increased vigilance would not have prevented Gill’s death.

“However I note with satisfaction that the Singapore Prison Service has endeavoured to improve its electronic medical records system to include a visual prompt to alert prison medical officers to any special cell arrangements for the inmates.”

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