Prevention of Future Deaths reports · 2013
Regulation 28 report to prevent future deaths, reference 2013-0329, written 6 Dec 2013. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 6 Dec 2013 |
|---|---|
| Reference | 2013-0329 |
| Deceased | Kirk Duboise |
| Coroner | Andrew Tweddle |
| Coroner area | County Durham and Darlington |
| Category | State Custody related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Prison Service, Cleland House, Page Street, London SW1P $LN 2. Care UK, c/o Clyde & Co, Chancery Place, 50 Brown Street, Manchester M2 2JT 1 CORONER I am ANDREW TWEDDLE, Senior Coroner, for the Coroner area of County Durham and Darlington 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. (see attached sheet) 3 INVESTIGATION and INQUEST On 3rd December 2013 I commenced an investigation into the death of Kirk Duboise. The investigation concluded at the end of the inquest on 5th December 2013. The conclusion of the inquest was Mr Duboise was found dead in his cell at HMP Durham on 13/2/13 and a narrative conclusion was returned “The deceased intentionally took his own life. The deceased was not correctly assessed at HMP Durham. An ACCT should have been opened at reception by prison staff.” 4 CIRCUMSTANCES OF THE DEATH The deceased arrived at HMP Durham when there was with him a prisoner escort report form highlighting self harm issues and also a suicide/self harm warning form again highlighting self harm issues. The deceased had clear self harm marks on his arms. Prison and health care staff at reception did not see both of these documents and did not open an ACCT. Mr Duboise committed suicide in his cell approximately 8 hours after arriving at HMP Durham. No other member of staff opened at ACCT in the intervening period. The Jury concluded that an ACCT ought to have been opened at reception by prison staff. Notwithstanding training which states that an ACCT can be opened by any member of staff at any time the practice of at least one senior officer at reception was that he would not open an ACCT unless at reception the incoming prisoner was subject to constant watch observations. This practice was confirmed by an experienced mental health nurse who saw the deceased as part of the reception process. Evidence was given that the reception process has, since the deceased’s death in February 2013, been changed. A prison governor confirmed that the correct code words had not been used when the deceased was found hanging in his cell which resulted in in their being a delay before an ambulance was summonsed. 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – (1) The delay in summonsing an ambulance. (2) That not all relevant forms were seen by those involved in the reception process one of whose duties at such time was to properly assess the risk of self harm of the new prisoner, particularly a prisoner who had not been in custody before. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe your organisation have the power to take such action. 1. To ensure that all staff who may become involved in an emergency situation know the appropriate protocols to be followed (both discipline and health care staff) to ensure that there is no delay in an ambulance being summonsed in an emergency situation. 2. That training be given and where necessary repeated to ensure that all staff know that an ACCT can be opened at any time by any member of staff wherever they believe the circumstances so demand. 3.That those involved in the reception process and further in induction, have access to all relevant documents so that they are best equipped to make an informed decision on the risks of the prisoner before them committing an act of self harm and/or suicide. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 31st January 2014. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner Rule 43 office and to the following Interested Persons and . I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 9 6th December 2013 HM Senior Coroner County Durham and Darlington
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
core &
PRIVATE AND CONFIDENTIAL
Name & Address
Care UK
HMP Durham Heaithcare-
HMP Durham
Old Etvet
Durham City
DH1 3HU
Durham
DH1 5JZ
Mr Andrew Tweddle
HM Coroner for Darlington & South
Durham/Narth
Durham Districts
HM Coroner's Office
PO Box 282
Bishop Auckland
County Durham
DL14 4FY
Our ref Your ref Bate
27 January 2013
Dear Sir
RE: The Inquest touching the death of Kirk Floyd Dubolse Deceased
Response to Regulation 28 Prevent Future Death (PFD") Report
Thank you for your Regulation 28 Prevent Future Death (PFD") Report dated 6" December
2013.
As you are aware Care UK has entered into an overarching contract with the County
Durham Primary Care Trust ("the PCT") and associate commissioners to provide the fuli
range of primary heaith and mental heaith services to the North East cluster of prisons
which Includes HMP Durham. As you are aware mental health services are provided by
Tees Esk and Wear Valleys NHS Foundation Trust ("TEWV"). This response is on behalf
of Care UK Clinicai Services Limited ("Care UK") who are the contracting party providing
healthcare services within HMP Durham and the North East cluster of prisons.
Box 5 lists the Coroner's concerns:
Core UK Clinical Services Limited — Primary Care Division. RegIstered In England No 3482881
Registered Office: Hawker House, 5-6 Napier Court, Napier Road, Reading, Serkshire RG BBW"
-233 FUERTE?
by
i
E
5
EN
Matters of concern
ib The delay in summoning an ambuiance.
2. That not ali relevant forms were seen by those invoived in the reception process
one of those duties at such time was to properly assess the risk of self harm of
the new prisoner, particuiarly a prisoner who had not been in custody before.
At box 6 the report states that ‘in the coroner's opinion action shouid be taken’ and that the
coroner believes the person/organisation has ‘power to take such action’ as follows:
1. To ensure that all staff who may become Invoived in an emergency situation
know the appropriate protocols to be followed (both discipline and healthcare
staff) to ensure there is no delay in an ambulance being summoned in an
emergency situation.
2. That training be given and where necessary repeated to ensure that ali staff know
that an ACCT can be opened at any time by any member of staff wherever the
circumstances so demand
KE); That those invoived in the reception process and further in induction, have
access to ail reievant documents so that they are best equipped to make an
informed decision on the risks of the prisoner before then committing an act of
seif harm or suicide.
Response to the PFD Report
1. The delay in summoning an ambulance
Prison Service instruction (PS! 03/2013/Medical Emergency Response Codes) came into
effect after Mr Duboise's death. As a resuit a coiour code system for the summoning of an
ambulance has been Introduced, This has been disseminated to all staff. A Governor's
notice to staff entitled ‘Summoning medical assistance Hotel 1/Ambuiance’. was issued and
is dated 22 April 2013. This was aiso brought to the attention of staff by the head of
healthcare at a full staff briefing, the minutes of which are sent to aii staff.
2. That training be glven and where necessary repeated to ensure that all staff
know that an ACCT can be opened at any time by any member of staff
wherever the circumstances so demand
Training bas been Implanted by NOMS. On the 7th January 2014 healthcare were
contacted in relation to further ACCT training for nurses and the Generai Practitioners.
Care UK Clinical Services Limited - Primary Care Division. Registered in England No 3462681
Ragistered Office: Hawker House, 5-6 Napier Court. Napier Road, Reading, Berkshire RGt BW
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Training sessions wili commence on 24th January 2014. Training wili be mandatory for all
healthcare staff
3. That not all relevant forms were seen by those invoived in the reception
process one of those duties at such time was to properly assess the risk of
self harm of the new prisoner, particularly a prisoner who had not been in
custody before
in addition to the steps taken by the prison service and following the re-location of the First
Night Centre, a trolley which has also been located in reception to ensure that aii of the
relevant documentation is passed onto heaithcare.
In addition further refresher training Is regularly undertaken and particular focus is given
regarding the Self Harm Warning Forms which is considered as part of the induction
training for all new staff.
{trust that you are reassured by the response and shouid you require any further
clarification on these points, please do not hesitate to contact me.
Yours sincerely
Care UK Clinical Services Limited ~ Primary Cate Division. Registered in England No 3462881
Registered Office; Hawker House, 5-6 Napier Court, Napler Rosd, Reading, Berkshire RG1 BBW"
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