Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0324, written 14 Jul 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 14 Jul 2014 |
|---|---|
| Reference | 2014-0324 |
| Deceased | Adam Williams |
| Coroner | Andrew Haigh |
| Coroner area | Staffordshire (South) |
| Category | State Custody 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.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. The Governor, HMP Featherstone, Wolverhampton, West Midlands CORONER | am Mr Andrew Haigh senior coroner for the coroner area of Staffordshire South 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. INVESTIGATION and INQUEST On the 2™ day of April 2013 | commenced an investigation into the death of Adam Amos Williams aged 29 years. The investigation concluded at the end of the inquest on the 4"" day of July 2014. The conclusion of the inquest was natural causes. The cause of death being sub-arachnoid haemorrhage. CIRCUMSTANCES OF THE DEATH Adam Williams was certified dead at New Cross Hospital, Wolverhampton at 17:44 on 6 March 2013. He died from a bleed by the brain. He was a serving prisoner who had sustained recent blows to his head but these are unlikely to have been causative. He collapsed at HMP Featherstone at about 18:45 on 5 March 2013 and was soon attended by staff. An ambulance was called at 18:59 and he was then taken to the hospital in an escort chain. 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) Picking up on recommendation 2 from the Prisons and Probation Ombudsman’s report | wonder if there is a training need for nursing staff at the prison regarding communication between healthcare staff in the event of an emergency. Can it be improved be it face to face, over the radio or otherwise? (2) Picking up on recommendation 3 in the Prisons and Probation Ombudsman’s report | wonder if the “dynamic assessment’ referred to does specifically take into account the need for a prisoner to be restrained at all. Please note that in respect of these first two matters | have since the conclusion of the Inquest received an updated copy of the action plan and these issues may already have been covered. (3) Although | accept that resource factors must be taken into account in this, | wonder if it may be beneficial for there to be more CCTV in common areas of the prison such as the gym or CV rooms. 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. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by Monday 8 September 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. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons : The Treasury Solicitor The Prisons and Probation Ombudsman Irwin Mitchell, Solicitors Thompsons, Solicitors Corporate Governance Manager IMB at HMP Featherstone HM Inspectorate of Prisons National Offender Management Service | 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. 14” July 2014 A Hy Andrew A Haigh HM Senior Coroner Staffordshire (South) No. 1 Staffordshire Place Stafford Staffordshire ST16 2LP
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.
RR Sarah Anderson Equality, Rights and Decency National Offender | Group j National Offender Management Service Management Service | 4th Floor, Clive House, 70 Petty France, London, SW1H 9HD | | | | | me | Coroner Andrew A Haigh Senior Coroner Staffordshire (South) No.1 Staffordshire Place Stafford | Staffordshire ST16 2LP 30 September 2014 Dear Mr Haigh, RE: the death of Adam Amos Williams on 2 June 2012 in HMP Featherstone. | Thank you for your Regulation 28 Report of 14 July 2014, addressed to the Governor of HMP Featherstone, concerning the recent inquest into the death of Adam Amos Williams on 2 June 2012 at HMP Featherstone. Your letter has been passed to Equality, Rights and Decency (ERD) Group, in the National Offender Management Service (NOMS), as we have!the policy responsibility for suicide prevention and self-harm management, and for sharing learning from deaths in custody. | have noted the conclusion of the jury and am responding to your concerns in the order in which they were raised. (1) Training need for nursing staff at the prison regarding communication between healthcare staff in the event of an emergency. The sharing of medical information over the radio has been considered by the prison and healthcare provider who are conscious that a secure bandwidth would need to be available for the prison to be able to share confidential information over the airways. However, at present two members of healthcare staff are expected to attend emergency calls throughout the day, and at weekends when staffing is reduced a single staff member attends emergency calls. In the future, Healthcare staff will ensure two members of staff attend all health emergencies called over the radio. Where nurses are completing tasks alone and are called to attend a Code Red or Code Blue emergency, they should request another colleague to attend by making the request over the radio. (2) If the ‘dynamic assessment’ referred to in the PPO Report takes into account the need for a prisoner to be restrained. At HMP Featherstone a standard risk assessment proforma is in place for all external escorts, which is audit compliant. This is completed on an individual basis for each prisoner which considers various risk factors, such as criminal history, behaviour in prison, risk to the public, risk to the victim and escape potential. Where it is confirmed that a prisoner is in a life threatening condition then cuffs will not routinely be applied. Where medical professionals or our staff are in doubt about the physical condition of the prisoner, a risk assessment will be completed to ascertain whether cuffs will be applied. This can be reviewed at any point following advice from medical professionals. Since the inquest, all Duty Managers have received advice and guidance on emergency escorts, and this issue is regularly reviewed at morning operational meetings by the Senior Management Team (SMT) to discuss whether the level of restraint applied at recent hospital visits was appropriate. For your interest, | am attaching the National Concordat between NOMS and the NHS which explains the nationally agreed arrangements for prison escorts to hospitals and the bed watch function. (3) The benefits of having more CCTV in common areas of the prison such as the gym or Cardio-Vascular (CV) rooms The requirement for CCTV in common areas of the prison is risk assessed, and dependant on the need in that area. It is not possible to install CCTV in every area of the prison due to the resource |implication; however the location of unsupervised CV rooms enables staff to promptly attend when required. The effectiveness of CCTV is dependant on staff bring available to simultaneously watch the CCTV camera, which cannot be resourced. An analysis of reported incidents for the year to date shows that incidents in CV rooms are extremely rare and therefore there are no plans at present to extend the use of CCTV cameras at Featherstone. | hope this provides assurance that the specific issues identified in this case, both at the inquest and by the PPO, have now been addressed adequately at a local level. ecency Group
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