Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0475, written 5 Nov 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 5 Nov 2014 |
|---|---|
| Reference | 2014-0475 |
| Deceased | William Davies |
| Coroner | Mary Hassell |
| Coroner area | Inner North London |
| 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: Prevention of Future Deaths report
William DAVIES (died 16.06.14)
THIS REPORT IS BEING SENT TO:
1. Mr Kevin Reilly
Governor
HMP Pentonville
Caledonian Road
London N7 8TT
1
CORONER
I am: Coroner ME Hassell
Senior Coroner
Inner North London
St Pancras Coroner’s Court
Camley Street
London N1C 4PP
2
CORONER’S LEGAL POWERS
I make this report under the Coroners and Justice Act 2009,
paragraph 7, Schedule 5, and
The Coroners (Investigations) Regulations 2013,
regulations 28 and 29.
3
INVESTIGATION and INQUEST
On 23 June 2014, I commenced an investigation into the death of William
Davies, aged 67. The investigation concluded at the end of the inquest on
3 November 2014. I made a determination that death came about from
natural causes, being: 1a) coronary artery atherosclerosis.
4
CIRCUMSTANCES OF THE DEATH
Mr Davies was found unresponsive in his cell at HMP Pentonville.
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
1
report to you.
The MATTERS OF CONCERN are as follows.
There seems to be confusion in the prison regarding the requesting of an
ambulance after a level one (i.e. regarding a potentially life threatening
situation) call has been made by a prison officer.
1. I have been told in other inquests (and delay in HMP Pentonville
ensuring ambulance attendance has been a feature since the first
prison death inquest I heard in Inner North London, on 30
September 2013) that prison comms should call an ambulance as
soon as they have been notified of a level one.
However, the prison duty governor on the day of Mr Davies’ death,
said that when he arrived two or three minutes
after the prison officer who found Mr Davies had contacted
comms, no ambulance had been called.
told me that
he did not know why this was, though he was duty governor that
day and the most senior person from the prison in court.
2. The whole process of attending a prisoner with a life threatening
condition seemed unclear to the prison general practitioner (now
GP lead) giving evidence. She assumed that a prison officer had
responsibility for calling an ambulance, but she was not sure.
The GP also did not know that she was allowed to verify the fact of
death, and told me that, as a consequence, she carried on with
CPR after she knew that Mr Davies had died.
And if the GP lead has not got a good understanding of the
procedures in place, then other GPs in the prison may not have
either.
6
ACTION SHOULD BE TAKEN
In my opinion, action should be taken to prevent future deaths and I
believe that you 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 12 January 2015. 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.
2
8
COPIES and PUBLICATION
I have sent a copy of my report to the following.
HHJ Peter Thornton QC, the Chief Coroner of England & Wales
HM Inspectorate of Prisons
National Offender Management Service
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
interest. You may make
he believes may
representations to me, the Senior Coroner, at the time of your response,
about the release or the publication of your response by the Chief
Coroner.
it useful or of
find
9
DATE SIGNED BY SENIOR CORONER
05.11.14
3
Regulation 28: Prevention of Future Deaths report
William DAVIES (died 16.06.14)
THIS REPORT IS BEING SENT TO:
1. Mr Mike Parish
Chief Executive
Care UK Limited
29 Great Guildford Street
London SE1 0ES
1
CORONER
I am: Coroner ME Hassell
Senior Coroner
Inner North London
St Pancras Coroner’s Court
Camley Street
London N1C 4PP
2
CORONER’S LEGAL POWERS
I make this report under the Coroners and Justice Act 2009,
paragraph 7, Schedule 5, and
The Coroners (Investigations) Regulations 2013,
regulations 28 and 29.
3
INVESTIGATION and INQUEST
On 23 June 2014, I commenced an investigation into the death of William
Davies, aged 67. The investigation concluded at the end of the inquest on
3 November 2014. I made a determination that death came about from
natural causes, being: 1a) coronary artery atherosclerosis.
4
CIRCUMSTANCES OF THE DEATH
Mr Davies was found unresponsive in his cell at HMP Pentonville.
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
1
unless action is taken. In the circumstances, it is my statutory duty to
report to you.
The MATTERS OF CONCERN are as follows.
There seems to be confusion in the prison regarding the requesting of an
ambulance after a level one (i.e. regarding a potentially life threatening
situation) call has been made by a prison officer.
The whole process of attending a prisoner with a life threatening condition
seemed unclear to the prison general practitioner (now GP lead) giving
evidence. She assumed that a prison officer had responsibility for calling
an ambulance, but she was not sure.
The GP also did not know that she was allowed to verify the fact of death,
and told me that, as a consequence, she carried on with CPR after she
knew that Mr Davies had died.
And if the GP lead has not got a good understanding of the procedures in
place, then other GPs in the prison may not have either. This could prove
fatal, depending upon the circumstances.
6
ACTION SHOULD BE TAKEN
In my opinion, action should be taken to prevent future deaths and I
believe that you 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 12 January 2015. 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 following.
HHJ Peter Thornton QC, the Chief Coroner of England & Wales
HM Inspectorate of Prisons
National Offender Management Service
I am also under a duty to send the Chief Coroner a copy of your
response.
2
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
interest. You may make
representations to me, the Senior Coroner, at the time of your response,
about the release or the publication of your response by the Chief
Coroner.
it useful or of
find
9
DATE SIGNED BY SENIOR CORONER
05.11.14
3
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.
PRIVATE AND CONFIDENTIAL Coroner ME Hassell Inner North London St Pancras Coroner's Court Carnley Street London NC1 4PP 23 December 2014 Dear Mr Hassell, Healthcare Department HMP Pentonville Caledonian Road Islington London N7 8TT RE: Prevention of Future Deaths - Mr William Davies (died 16.06.14) On 5 November 2014 Coroner ME Hassell issued a Regulation 28 :Prevention of Future Deaths Report to Care UK. This letter is in response to the aforementioned PFD report (a copy of which we have enclosed for your reference) and we will deal with each point highlighted in turn: 1. Requesting an ambulance after a level one emergency has been declared We understand from our prison colleagues that on 3rd December 2014, the Head of Safer Prisons, Head of Operations 2 (gates and the control room) and the Deputy Governor met with the local London Ambulance Service (LAS), Emergency Planning & Resilience Officer and Station Officer to discuss how make the process clearer regarding the calling of an ambulance. We are told that the following actions are being taken forward: • Control Room staff have been re-briefed about their requirement to call an ambulance when a level 1 emergency is called (See Appendix 1 - Calling of an Ambulance). • Information specifically required by the LAS has been made into a crib sheet so control room staff are aware of what questions the LAS could ask before attending to the emergency. It is anticipated that this will speed up the phone call process. The details of this can be found at Appendix 1, page 2. • A publicity campaign (based on PSI 2013/03 Emergency Response Codes) has taken place reminding staff of who can call a medical emergency, who calls the ambulance, the use of the correct medical emergency codes, and what information they should be communicating with the control room (See Appendix 3 - Emergency Healthcare Response). This document was jointly developed with prison service colleagues prior to us taking over healthcare services in HMP Pentonville and our Health in Justice team are reviewing this as part of a wider piece of work around emergency care, including training of staff and standardisation of the emergency bags. The publicity campaign has reached out to all staff working within Pentonville; operational, non-operational and healthcare. The leaflet has been published to staff via the intranet, publicised at the main gate entrance and a small copy will be attached to all operational staffs' payslips for December 2014. The leaflet and information has been added in induction for new non-operational and healthcare staff. • Better signage has been ordered to help emergency services identify Roman Way Gate (January 2015). 2. GPs understanding of their responsibilities and permission to verify the fact of death The Care UK National Medical Director for Health in Justice has spoken with the lead GP to clarify her role regarding decision to cease CPR and declare life extinct. The Head of Healthcare has additionally briefed all General Practitioners working at HMP Pentonville about their responsibility and legal right to declare life extinct following their examination in an emergency situation. All doctors are given orientation and induction prior to working at HMP Pentonville; this has been reinforced with the existing team and any locum providers. This is also included in all GP inductions. Decisions to cease CPR or to not commence CPR can be difficult in emergency situations so in addition to the above actions, our National Medical Director and National Lead Nurse a·re currently working with our networks of lead GPs and lead nurses to develop guidance and additional training to help support good decision making in cases of unexpected collapse or death. In the case of expected deaths and palliative care situations we have well established protocols for DNAR (do not actively resuscitate) forms to be used in our prisons elsewhere and are in the process of sharing this practice as part of a wider project on improving end of life care across our prisons. We trust this answers all of your concerns raised in the Prevention of Future Deaths Regulation 28 Report. Should you require any further clarification please do not hesitate to get in touch with us. Yours Sincerely, Company Secretary Care UK Limited Enc. Page 2 of 2
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