Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0020, written 17 Jan 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 17 Jan 2014 |
|---|---|
| Reference | 2014-0020 |
| Deceased | Wayne Broad |
| Coroner | Andrew Walker |
| Coroner area | London (North) |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
a, North London C Court, Her Majesty's Coroner for the 29 Wood Stee, Northern District of Greater London Barnet EN5 4BE (Harrow, Brent, Barnet, Haringey and Enfield) Telephone 0208 447 7680 Fax 0208 447 7689 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Department of Health Department of Health Richmond House 79 Whitehall London SW1A 2NS i (Regional Manager) G4S Forensic & Medical Service (UK) Ltd Units 6-9 The Bardfield Centre Great Bardfield Braintree, Essex CM7 4SL Deputy Director Head of Court Services Serco Wincanton Bloxham Mill Barford Road Bloxham, Oxfordshire OX15 4FF 3. ACPO lst Floor, 10 Victoria Street London SWI1H ONN 1 CORONER 1am Andrew Walker, senior coroner, for the coroner area of Northern District of Greater London 2 | CORONER’S LEGAL POWERS | 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. 3 | INVESTIGATION and INQUEST On the 6" December 2011 | opened an investigation into the death of Wayne Spencer Malcolm Broad, aged 51 years old. The investigation concluded at the end of the inquest on the 11" November 2013. The conclusion of the inquest was “Narrative verdict”, the medical case of death was ;1a hypoxic brain injury, 1b cardiorespiratory arrest, 1c seizure activity associated with alcohol withdrawal_and under paragraph 2 chronic Her Majesty’s Coroner for the Northern District of Greater London (Harrow, Brent, Barnet, Haringey and Enfield) alcoholism. CIRCUMSTANCES OF THE DEATH Mr Broad was arrested on the 15"" November 2011 at his home address, for failing to appear at St Albans Magistrates Court the day before. Mr Broad was under the influence of alcohol when arrested and taken to Hatfield Police Station to appear the next day at Hatfield Remand Court. Mr Broad was under the influence of alcohol at the time of his arrest and the custody sergeant, when he was taken to Hatfield Police Station, recognised the need for Mr Broad to have medical attention, and taken into custody. Mr Broad was seen by a nurse and gave a history of heavy consumption of alcohol. The nurse took telephone advice from a doctor and medication was prescribed for Mr Broard to take. The following morning Mr Broad was collected by SERCO officers but before being taken to court became unwell complaining of palpitations and chest pain and was taken by ambulance with SERCO to hospital. Having been seen in hospital Mr Broad was returned to Hatfield Police Station but became unwell again. The magistrates bailed Mr Broad and he was taken by ambulance to Barnet Hospital where he was admitted. Mr Ward was taken to a ward where later on in the evening he began to suffer from delirium tremens and having assaulted a member of staff and taken refuge behind a nursing station where he defended himself against all staff with a fire extinguisher until police arrived. Mr Broad was arrested and remained under police guard. Mr Broad became more unwell and collapsed, Despite resuscitation Mr Broad suffered a hypoxic injury and sadly died on the 30" November 2011. 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) That was no dedicated substance misuse team available to look after Mr Broad when he was in the custody suite at Hatfield Police Station, as there would have been had Mr Broad been detained in prison. (2 — Police are required to make risk assessments and have requirements when dealing with the handcuffing of seriously ill detainees. | here should be alignment with particular regard to those who are seriously ill and in general SERCO policy should come into alignment with ACPO guidance on the use of handcuffs. (3) ir Specially trained nursing staff should be available at hospitals for dealing with patients with substance misuse. Northern District of Greater London (Harrow, Brent, Barnet, Haringey and Enfield) 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you [AND/OR your organisation] have the power to take such action. 7 | YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by Friday 14" March 2014. |, 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 | have sent a copy of my report to the Chief Coroner and to the following Interested Persons Representative of members of the family of Mr Broad lam 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 je release or the publication of your response by the Chief Coroner.
G:S Mr. Andrew Walker, Her Majesty’s Coroner for the Northern District of Greater London, H.M. Coroner’s Court, G4S Forensic and Medical Services Limited Unit 6-10 The Bardfield Centre Great Bardfield Essex CM7 4SL United Kingdom Telephone: +44 (0) 1371 812600 Facsimile: +44 (0) 1371 812601 medical.info@uk.g4s.com 29 Wood Street, High Barnet ENS 4BE 27" February 2014 Dear Sir Re: G4S Forensic and Medical Services response to Regulation 28 Report following the Inquest into the death of Wayne Spencer Malcolm Broad. | respond to the matter of concern that you raised following the above inquest in respect of the fact that there was no substance misuse team available to look after Mr Broad when he was in the custody suite at Hatfield Police Station as there would have been had Mr Broad been detained in Prison. G4S Forensic and Medical Service are responsible for the provision of medical services to Hertfordshire Police as defined in a specific contract written by Hertfordshire Police (“the Contract”), which does not at this time, provide for putting a dedicated substance misuse team into each of the police stations served by the Contract. Rather, the Contract requires us to provide medical staff to deal with a wide range of issues from the confirmation of death, intimate examinations of victims of sexual assault, advice on medical issues across a wide spectrum of circumstances and the provision of face to face clinical treatment of those detained in custody. The role that our clinicians undertake in custody is to provide the Police with a clinically based assessment as to whether it is medically safe to continue the detention and, where medical issues are identified, to supply a short term care plan covering the anticipated term of detention. The amount of medical assistance that can be provided in the custody environment is limited to assessment, advice and a low level of clinical intervention. Should the outcome of the assessment identify a clinical reason for additional medical support, be that short or long term, the advice would be that detention is not safe and that the detainee should be taken to a hospital where appropriate specialised services can be provided. G4S Forensic and Medical Services (UK) Limited is a trading company of G4S Integrated Services (UK) Limited. Registered Office: Southside, 105 Victoria Street, London, SW1E 6QT, UK. Registered in England No. 3333860 Whilst i fully accept that any service provision could be enhanced, G4S provide an efficient and effective service within the confines of a contract provided by a public body that, in turn, is suffering from the general reduction of funding experienced over the last few years. By ensuring that timely and appropriate advice is given | am satisfied that we meet the needs of Hertfordshire Police as they currently stand and in accordance with the Contract. Yours Sincerely Regional Manager G4S Forensic & Medical Services Ltd Unit 6 ~ 9 The Bardfield Centre Great Bardfield Braintree Essex CM7 4SL 01371 812600 1102053 3364843.1 2
GREATER MANCHESTER Assistant Chief Constable i O L | C [2 National Policing Lead for Custody Mr A Walker HM Coroner for the Northern District of Greater London North London Coroners Court 29 Wood Street Barnet EN5 4BE Your Ref: Our Ref: 12" March 2014 Dear Mr Walker REGULATION 28 LETTER — WAYNE SPENCER MALCOLM BROAD | write in response to the above as the National Policing Lead for Custody to address recommendation (1), which falls within my remit. | note your recommendation that Hertfordshire ought to have a substance misuse team available at the police station, similar to that which would be provided within the Prison Service. Unfortunately this is not a facility that police forces have available; the cost and relatively short timescales of police detention mean this is not a viable or cost effective option for Forces. We do however take our duty of care for the welfare of detainees very seriously and provide medical care in custody which effectively triages our detainees to assess that they are fit to be detained and are kept safe. However, in this arena things are changing rapidly. You will be aware Lord Bradley undertook a review of mental health and the justice system in 2009 and one of his recommendations was to transfer the commissioning responsibility for police custodial healthcare to the NHS. The national police Custody business portfolio support the current work in English forces to undertake this transfer and sit at the national Police Healthcare Oversight Board, jointly chaired by Home Office and Department of Health to oversee the transition. The legislative change for this is set for April 2015. All English forces are now engaged with specialist NHS commissioners who already commission services in prisons, to ensure the appropriate specification of police custodial healthcare, improve clinical governance of healthcare services and improve the care pathways to and from Accident and Emergency services. It is noted that Hertfordshire is part of a 4 force consortium who are going through a tender process at this time. Furthermore, NHS England are also rolling out Liaison and Diversion services in police custody and courts to ensure that those people with mental health issues and associated substance misuse are appropriately signposted and diverted to manage their longer term health needs and thus reduce reoffending. Force Headquarters, Central Park, Northampton Road, Manchester M40 5BP. Tel: 0161 856 2018, Fax: 0161 855 2148, Minicom: 0161 872 6633 | | Thus we believe that healthcare services in police custody are going through a step change in service provision, with the introduction of NHS expertise to ensure appropriate timely service with clinicians with the right skill sets. This is supported by clinical IT infrastructure and care pathways to acute and community care. Whilst these provisions in the future may still not include bespoke substance misuse teams in police custody centres they will seek to provide a more bespoke and joined up health care package within and outside the custodial setting. | hope this addresses your concerns. If you have any further queries please do not hesitate to contact me. Yours sincerely he Assistant Chief Constable
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.
RES From the Rt Hon Jeremy Hunt MP eee Secretary of State for Health Department of Health Richmond House 79 Whitehall London POC1_836541 SIVIA 2NS Tel: 020 7210 3000 Mr A Walker Mb-sofs@dh.gsi.gov.uk Senior Coroner North London Coroner’s Court 29 Wood Street Barnet ENS 4BE 11 FER Den Me. Wether Thank you for your letter following the inquest into the death of Wayne Broad. In your report you conclude that the medical cause of death was hypoxic brain injury, cardiorespiratory arrest, seizure associated with alcohol withdrawal and chronic alcoholism. Mr Broad had a history of heavy alcohol abuse. While under the influence of alcohol, he had been arrested and taken to Hatfield police station to appear the next day at Hatfield Remand Court. At the police station, the custody sergeant recognised the need for him to have medical attention. A nurse took telephone advice from a doctor and medication was prescribed. Next morning, when due to appear in court, he became unwell and was escorted by SERCO officers in an ambulance to hospital. He was seen at hospital and then returned to the police station but became unwell again and was then taken by ambulance to Barnet hospital where he was admitted. Later that evening on the ward, he suffered delirium tremens and assaulted a member of staff. He was arrested and remained in hospital under police guard. He became more unwell and collapsed. Despite resuscitation he suffered hypoxic injury and died on the 30 November 2011. You raise the following matters of concern: e There was no dedicated substance misuse team to look after Mr Broad when in police custody which there would have been had he been detained in prison e Police are required to make risk assessments and have protocols for dealing with the handcuffing of seriously ill detainees. SERCO policy should align with ACPO guidance on the use of handcuffs e Specially trained nursing staff should be available at hospitals for dealing with patients with substance misuse. Your second point concerning police risk assessments and the use of handcuffs is not a matter for the Department of Health. I note that you have sent a copy of your report to both SERCO and ACPO. Your first point concerns the lack of a dedicated substance misuse team for persons in police custody. At present, forensic physicians (sometimes known as forensic medical examiners) are contracted by police authorities on an individual basis or through appointed agencies to provide medical care in police custody suites. The responsibility for healthcare in police custody suites will however soon transfer from individual police authorities to NHS England. Healthcare for persons in police custody will therefore be commissioned to NHS standards of care. This should lead to more consistent and improved healthcare standards, by ensuring that the same range and quality of substance misuse services are available to persons in police custody as would be available in prison or community settings. An individual requiring a clinical intervention for substance misuse will receive one. You suggest in your third point that specially trained nursing staff should be available in hospitals for dealing with patients with substance misuse. I do not however consider that such specialist nurses should routinely be available in all hospitals. All registered nurses (RNs) should have skills to deal with patients presenting with symptoms of alcohol abuse. In addition, the care and management of people with alcoholic withdrawal symptoms requires a multi-disciplinary team which includes both medical and nursing staff. However, the provision of specialist substance misuse nurses is a matter for local commissioners to determine based on an assessment of local needs. There may be some hospitals where the resources required to make this facility available would be justified but, where there are very few presentations from patients with substance misuse problems, providing such a service might not be the most effective use of available resources. ae Department of Health In this case the patient was admitted with a life threatening condition needing emergency intervention. The effect of long term alcohol abuse and associated complications led to the need for emergency resuscitation. The role of a specialist substance misuse nurse would in contrast involve making an assessment of the patient and determining the best options in terms of referral or appropriate care pathway. In this case I do not feel that the presence of a specialist substance misuse nurse would have led to a different outcome for Mr Broad. There should be well established arrangements locally for ensuring that patients with substance misuse problems are referred to the right specialist services whether they present at a GP surgery, hospital or police custody suite. There currently exists a care pathway for treating such patients within a hospital setting which has been produced by the National Institute of Care Excellence (NICE). The care pathway is for alcohol use disorders and can be seen on the NICE website at the following address: http://pathways.nice.org.uk/pathways/alcohol-use-disorders Within this pathway is guidance for dealing with patients admitted to hospital with acute alcohol withdrawal. Essentially, any patient suffering from acute alcohol withdrawal will require emergency clinical intervention and I would expect that this is made routinely available in hospital settings. Where this treatment has not been provided in individual cases it would be a matter for the local hospital and commissioner to investigate jointly. I hope that this response is helpful and I am grateful to you for bringing the circumstances of Mr Broad’s death to my attention. GA slew a JEREMY HUNT
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