Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0452, written 17 Oct 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 Oct 2014 |
|---|---|
| Reference | 2014-0452 |
| Deceased | William Anderson |
| Coroner | Melanie Williamson |
| Coroner area | West Yorkshire (East) |
| Category | State Custody related deaths |
| Organisation named | Yorkshire Ambulance Service NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
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ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT |S BEING SENT TO: 1. HR ariner with Lester Morrill, Solicitors for and on behalf of the Deceased’s family and next of kin 2. Michael Spurr , National Offender Management Service for and on behalf rvice 3. Partner with Hempsons, Solicitors for and on behalf of Leeds Community Healthcare NHS Trust 4. Chief Coroner 1 | CORONER | am Melanie J Williamson, Assistant Coroner, for the Coroner area of West Yorkshire (Eastern) 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. [HYPERLINKS] 3 | INVESTIGATION and INQUEST On the 22” September 2010 an investigation was commenced into the death of William Thomas Anderson, aged 35 years. The investigation concluded at the end of the Inquest on the 1* October 2014. The conclusion of the Inquest was a Narrative Conclusion, a copy of which is annexed hereto. 4 | CIRCUMSTANCES OF THE DEATH in September 2003 the Deceased was remanded into prison custody. On the 27" July 2010 the Deceased was transferred to HMP Wealstun in Thorp Arch, Near Wetherby, West Yorkshire, where he resided until his death in September 2010. On Saturday the 18" September 2010 the Deceased associated with a number of inmates, during which association he took prescriptive medication belonging to others and drank hooch. Prior to final lock up at around 4.30pm/4.45pm, the Deceased appeared, inter alia, to be inebriated and/or under the influence of alcohol/drugs. Some inmates raised concerns as to the Deceased’s welfare with Prison staff. At approximately 7.45pm the Deceased was observed to be laid on his bed with his head and neck resting on his wall at relative right angles to his torso and was breathing rapidly. At around 5.45am the following day, namely Sunday the 19" September 2010, the Deceased was observed to be in the same or a very similar position and the Deceased was not detected to be breathing. Prison officers gained access to the Deceased’s cell and discovered him to be ina lifeless condition. Paramedic assistance was summoned at 6.31am and arrived at the scene shortly thereafter. The Deceased’s death was confirmed by attending paramedics at 6.58am on the 19" September 2010 in Cell C3-G45 at HMP Weaistun, Thorp Arch, Near Wetherby. CORONER’S CONCERNS During the course of the inquest the evidence revealed maiters 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) Evidence was adduced in the course of this Inquest to the effect that in 2010, 2011 and 2012 inmates were having social get togethers on C Wing at HMP Wealstun, in particular at a weekend, during which time drugs were taken and hooch was drunk. Evidence was also heard that this is occurring at the present time at this said prison establishment. In the circumstances, there should be much greater and effective vigilance by Wing staff and Prison Service employees at HMP Weaistun in relation to such get togethers on the Wings during periods of association; (2) The Deceased was not subjected to a breathalyser test at any time during the 18" September 2010. A proportion of, but not all, Wing staff are trained in the use of such breathalyser equipment. Had the Deceased been so breathalysed, more likely than not, it would have been apparent he was not suffering from the effects of alcohol. In the circumstances all Wing staff should be trained in the use of such breathalyser equipment; (3) The Deceased’s behaviour and presentation on the 18" September 2010 was not recorded by any member of Wing staff in the C Wing Observation Book. Evidence was adduced in the course of the Inquest as to the importance of recording all relevant information in the said Observation Book, thereby apprising all members of Wing staff on ail shifts of all material facts and matters. In the circumstances, all relevant information in relation to, for example, an inmate’s behaviour and general presentation should be brought to the attention of all Wing staff and should be done so via an appropriate entry/entries in the Wing Observation Book. All Wing staff (Wing Managers, Prison Officers and Operational Support Grades) should be made aware of the importance of such, and should ensure information is recorded accordingly; (4) The members of staff who observed the Deceased at around 5.45am on the 19"° September 2010 did not “put out’ a Code Blue. It was explained in the course of the inquest that Codes Blue and Red are basic emergency codes which have been in existence for very many years. Despite the fact that, in this instance, the failure to call a Code Blue would not have affected the outcome, it is not inconceivable that to omit to use such emergency codes could, in certain circumstances, jeopardise an inmate's chances of survival. In the circumstances, all Prison staff should be fully acquainted with the use of such Codes and should use them accordingly; (5) Paramedic assistance was not called within a reasonable time and no explanation for the delay was provided in the course of the Inquest. Whilst the failure to summons outside medical assistance sooner would not have affected the outcome in this instance, it is not inconceivable that to omit to call for such assistance as soon as possible could, in certain circumstances, jeopardise an inmate's chances of survival. Consequently, emergency services should be summoned at the very first available opportunity, and all Prison staff should be instructed as to the importance of so doing. 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 12" December 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 s my report to the Chief Coroner and to the following Interested Persons Messrs Lester Morrill igitors, Michael Spurr, National Offender Management Service and oie Solicitors | 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. 17” October 2014 WEST YORKSHIRE (EASTERN) AWE MELANIE J WILLIAMSON a ASSISTANT CORONER
Coroner’s Office 71 Northgate Wakefield WF1 3BS Telephone: 01924 302180 Fax: 01924 302184 Email: hmcoroner@wakefield.gov.uk HER MAJESTY’S CORONER for the County of West Yorkshire (Eastern District) David Hinchliff LLB LLM DipFMSA Our Ref: MJW/CS/2597L/10 Please quote our reference on all correspondence 16 December 2014 By email only to: rule43reports@justice.gsi.gov.uk Chief Coroners Office 11" Floor Thomas More Royal Courts of Justice Strand London WC2A 2LL Dear Judge Thornton Inquest touching the death of William Thomas ANDERSON (deceased) | refer to the Inquest touching the death of William Thomas Anderson which was concluded by Ms M J Williamson, Assistant Coroner, in our Wakefield Court on 1° October 2014. A copy of the Regulation 28 Report to Prevent Future Deaths in respect of this case was sent to you on 17" October 2014. | am now in possession of the response and | enclose it for your information. Yours sincerely Melanie J Williamson Assistant Coroner West Yorkshire (eastern) Encls ZV] (© / Mi 5 f Amy Harbin Se National Offender Management Service inistry O Equality, Rights & Decency Group. J U STIC FE 4" Floor (post point 4.12), Clive House 70 Petty France National Offender London SW1H SHD Management Service _Ms Melanie Williamson HM Assistant Coroner for West Yorkshire 11 December 2014 Dear Ms Williamson, Thank you for your letter addressed to the Chief Executive of the National Offender Management Service (NOMS), Michael Spurr, concerning the recent inquest into the death of William Anderson who died on 19 September 2010 at HMP Wealstun. Your letter has been passed to Equality, Rights and Decency Group in NOMS, as we have responsibility for the policy on suicide prevention and self-harm management and for sharing learning from deaths in custody. ! have liaised with colleagues at Wealstun in formulating this response which addresses in turn each of the matters that you have raised. Vigilance of wing staff Your first concern relates to reports of the use of ‘hooch’ and drugs by prisoners at Weaistun, and the action taken by staff in response to this. This behaviour is clearly unacceptable and staff have been made aware of the findings of this inquest and instructed to ensure that greater vigilance is exercised over prisoners on association. They have also been instructed to report any evidence ef the use of ‘hooch’ or drugs immediately to the Duty Manager and to follow this up on the Intelligence Reporting System, and are able to share any intelligence with the Security department. Any prisoner found making or in possession of hooch, or found in possession of or taking / trading drugs will face prisoner discipline procedures. Training in the use of breathalyser equipment lysed on 18 September, and you Your second concern is that Mr Anderson was not breathal suggest that all wing staff should be trained in the use of breathalyser equipment. Since Mr Anderson's death additional staff have been trained in the use of breathalyser equipment. It is not considered necessary to train all wing staff, and managers at Wealstun are satisfied that there are sufficient trained staff to undertake testing when it is required. Staff entries in wing observation books Your third concern is that information about Mr Anderson's behaviour was not recorded. Wing staff been reminded of the importance of ensuring that all relevant information is recorded in the wing observation book, and in particular to ensure that concerns raised by prisoners about changes in another prisoner’s behaviour is recorded and shared with other wing staff. The importance of making appropriate referrals to the Duty Governor, Orderly Officer and/or healtheére professionals following ‘the recording of such information has also been stressed. . Emergency response Your fourth and fifth concerns are about the use of emergency codes and the time taken to call a paramedic. A Notice to Staff was re-issued to staff in July 2014 (please find enclosed) to remind all staff of the emergency code system and of the need to call for paramedic assistance immediately. | hope you found this letter helpful. Yours sincerely Amy Harbin. we HM PRISON National Offender SERVICE Management Service GOVERNOR'S NOTICE TO STAFF — 133/14 (b) Title: Medical Emergency Response Codes Reference No: cone 14 May 2014 Date: Expiry Date: Continuing _| Originator: Elaine Goodwin Head of Health Care oe-icuieimenm™ ALL STAFF This order sets out the procedures for Emergency Response Codes as weil as to ensure that an ambulance is called in all cases where there are serious concerns about the health of a prisoner. It is essential that any member of staff who discovers a prisoner who is showing any of the symptoms listed below clearly and concisely convey the nature of the medical emergency simultaneously and contact the communication/control room. There must not be a delay calling for an ambulance, if a red or blue code is called then the Communication room must automatically call an ambulance they must not wait for the Duty Governor or Healthcare to attend, The relevant codes must be used when the medical emergency is being called these are detailed below: Prisoner's . Mandatory Contingency Responses S' tom _| Symptoms __| = | e Communication/Control Room [ex System * Chest Pain automatically calls an ambulance and e Difficulty in awaits updates from the scene Code Blue (or Breathing * Where available, Duty Nurse attends Code One) e Unconscious with necessary equipment and * Choking assesses the patient + Fitting or concussed * Where no nurse cover is available, e Severe allergic other staff attend with necessary reaction equipment e Suspected stroke e Gate prepare to receive ambulance Code Red (or | + Severe loss of Blood | ° Ambulance escort staff arranged Code Two) e Severe burns or e Escort staff and equipment arranged scalds e Any further action required by the local e Suspected fracture healthcare commissioner to assist in the preservation of life PROTECT we HM PRISON National Offender SERVICE Management Service EX - If a healthcare professional determines that an ambulance is not required they will inform the orderly officer who will arrange for the ambulance to be cancelled through the control room. Further information on emergency access to the establishment for ambulance services can been found on the HMP Wealstun and Yorkshire Ambulance Service NHS Trust document and the PSI 03/2013 Medical Emergency Response Codes. Approved By: f Dian 7 | 24" July 2014 | PROTECT
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