Darren Wright

0 1 APR 2015 TL Annex 16.5

Ministry of
JUSTICE | HM PRISON

SERVICE
National Offender . .
Management Service

HM Prison Norwich

Knox Road

Norwich .

Norfolk ,
NR1 4LU

Tel:
Fax:

Jacqueline Lane Your Ref:

HM Senior Coroner

Norfolk Coroners Services Our Ref:

69-75 Thorpe Road :

Norwich Date: 27 March 2015
Norfolk

NR11UA

Ks
+

Dear Madam,

RE — Mr Darren Wright
Regulation 28 report to prevent future deaths

| refer to the above regulation 28 report which was sent to me regarding the matter of concern
surrounding CPR training.

The Health and Safety (First- Aid) Regulations’ 1981, require employers to: ,

« Ensure there is adequate and appropriate equipment and facilities to provide first-aid to
employees who become injured or ill at work;

e Ensure that there are a sufficient number of “suitable persons” able to administer first-aid
if employees become injured or ill at work. :

This is the current legislation in which NOMS and the wider Prison Service operate in, and at
the time of Mr. Wright’s unfortunate death.

Those in charge of NOMS premises are required to carry out a risk assessment of the first aid
needs for their prison. HMP/YOI Norwich has such an assessment in place which takes into
account:

e The number of staff;

e The number of prisoners;

e Workplace hazards and risks;

e The size and distribution of the workforce;

e Risks posed by additional activities carried out on site such as workshops etc;

TL Annex 16.5
¢ The shift patterns operating in the establishment including night state and weekends;
¢ The risk of suicide or self-harm by prisoners.

Such an assessment was in place in 2013.

The regulations give general guidance on the number of first aiders that may be required in
workplaces. HMP/YOI Norwich operates within the existing advice which is one first aid at work
trained per 50 staff.

In addition to this, all our permanent night staff are trained to ensure adequate cover on nights
and weekends. .

At this present time there is no requirement in the First Aid Regulations or Guidance to provide
AEDS in the workplace, therefore we do not provide defibrillator training to staff.

It simply isn’t reasonably practicable to train all of our Prison Service staff and keep them in
date.

| would also like to point out that Norwich Prison has a very significant Healthcare team, |
providing 24 hour healthcare cover within the Prison. This puts us in a position that
professional nursing staff are able to attend any serious incident very quickly at any time of the
day or night. ;

1 would be very grateful if you would consider our current position and advise me further.

| fully appreciate how busy you are and the huge challenges of your role and the very difficult
situations you are asked to make decisions on.

| am therefore very grateful that you have been able to find the time to visit the prison in the
near future. You will be a very welcome guest and we will be very interested to hear your
thoughts and observations following a look around.

| hope that this assures you of HMP/YOI Norwich's commitment to ensure the health, safety
and welfare of prisoners in our care and to prevent future deaths.

On this and any other matter please do not hesitate to contact me,

Respectfully yours

Governor

Bringing service to life S e rco

Serco UK & Europe

jacqueline Lak
Jacq ake Enterprise House

HM Senior Coroner 11 Bartley Wood Business Park
Norfolk Coroner's Service ] 2 FE Bartley Way

69-75 Thorpe Road B 20% Hoek axe

Norwich United Kingdom

Nevexnes m7
FE
Our reference:

11 February 2015

WWW.S8ICO.COM

Dear Madam,

RE: REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
MR DARREN WRIGHT (DECEASED)

We refer to the above regulation 28 report which was sent to the Chief Executive of Serco Pic, Mr Rupert
Soames. Mr Soames has requested me to respond to the letter on his behalf.

Whilst at the time of Mr Wright's unfortunate death Serco was the healthcare provider at HMP Norwich, as
from 1* April 2014 all responsibility for delivery of healthcare services passed to Virgin Care. Accordingly,
Serco no longer have any involvement in service delivery at HMP Norwich.

We note the MATTERS OF CONCERN:-

(1) On receiving Code Blue notification the Staff Nurse did not know where to go and had to call on her
radio to be found and then taken to the cell.

(2) The Prison Officers attending Mr Wright had not had recent CPR training. It is understood that due to
a lack of resources, CPR training has had to be allocated to certain members of staff only. This will
result in gaps in CPR-trained Officers available and able to attend emergencies.

As stated above, Serco does not provide any services to HMP Norwich (either custodial or healthcare).
Therefore, the company has no power to implement these recommendations at HMP Norwich. However, we
note that the Regulation 28 report has been sent to HMP Norwich and Virgin Care Limited and these parties
do have power to implement the recommendations.

As Serco was an Interested Party, the recommendations made will be taken forward and used to aid learning
and to effect continuous improvement as part of Serco's Safer Custody commitment.

We hope that this assures you of Serco’s commitment to ensure the health, safety and welfare of prisoners,
and to prevent future deaths.

Yours faithfully
For Serco Limited

Associate General Counsel

Cc. HMP Norwich
Virgin Care Limited

Serco Limiled. A company registered in England and Wales No. 242246.

Reglstered Office: Serco House, 16 Bartley Wood Business Park, Barlley Way, Hook, Hampshire RG27 SUY, United Kingdom.

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Virgin Care Services Limited
Lynton House
7-12 Tavistock Square

FAO: Jacqueline Lake London
HM Senior Coroner WC1H 9LT
HM Coroner's Office

69-75 Thorpe Road ‘
Norwich ae
Norfolk w: www. virgincare.co.uk
NR1 1UA

27 March 2015
Dear Sirs
Inquest touching the death of Darren Wright

We are providing this letter in response to the Coroner's report issued pursuant to Regulation 28 of
the Coroner's (Investigations) Regulations 2013 dated 2 February 2015.

At the conclusion of the inquest, the Coroner raised two concerns, one of which is directed to the
healthcare department, which is currently provided by Virgin Care Services Limited (“Virgin Care”).
We have set out below the steps Virgin Care has taken to address the concerns raised by the
Coroner.

At the outset which the Coroner may already be aware of, at the time of Mr Wright’s death, on 3
November 2013, Virgin Care was not the provider of healthcare services at HMP Norwich. The
provider at the time was SERCO.

The Coroner's conclusions have been of considerable assistance in informing our review of the
training and guidelines which are currently in place.

We now address the specific concern directed at healthcare which the Coroner has required Virgin
Care's response to in his Rule 28 report.

(1) On receiving Code Biue Notification the Staff Nurse did not know where to go and had to calf
on her radio to be found and then taken to the cell

Mr Wright was transferred to HMP Norwich on 4 September 2013. Mr Wright was found dead in his
cell on 3 November 2013. This was Mr Wright's first time in prison at HMP Norwich and no active
tisks were identified, allhough he was described as ‘nervous and anxious’. The cause of death was
hanging and the coroner heard that the contributory factor was due to inconsistencies with sharing
and access to information across different departments within the prison system.

As stated previously, this incident occurred before 1 April 2014, and therefore pre-dates Virgin Care's
management of the healthcare service at HMP Norwich. The provider at the time of the incident was
SERCO.

We have instigated two specific measures as a result of our review but it is worth setting out a short
summary of the background on these matters.

Virgin Care
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The specific issue in this matter was that the staff nurse did not know how to get to the cell. To
address this, it is important to understand the building issues within HMP Norwich. HMP Norwich is
split into two sites and the layout is not similar in a number of locations due to the differing ages of the
building. As a result, the cell numbering is not straightforward and it can be confusing to know which
cell numbers can be found where, and the sequence being followed in a specific part of the building.
This is of particular note as healthcare services are provided in the F/G wing and does not usually
require our nurses to attend to prisoners in their cells and hence their knowledge of the numbering of
cells is limited.

In terms of training, all new nurses working in HMP Norwich are required to undergo a two week
‘shadow’ period where they are fully inducted to all areas of the prison. During this time, emergency
response kits are highlighted to staff. This amended process for shadowing of new staff was already
in place on 1 April 2014 when Virgin Care’s contract to provide the service came into force.
Unfortunately, whilst we did consider introducing maps of the prison to assist our staff in locating cell
numbers, this is not permitted by the prison governor for security reasons in prisons.

During normal operational hours, prison officers would direct nurses to the medical emergency but
this can be more challenging during ‘patro! state’ (when prisoners are locked in their cells) as the
number of prison staff on duty is reduced.

In response to the concerns raised, we have undertaken the following:

* The induction process has been reviewed and revised to include ‘shadowing’ time for all new
starters and agency staff. To further evidence this, a local induction process and checklist
template is being developed and introduced to record an individual's completion of this process.
This will therefore increase the knowledge of our staff in terms of the layout of cells when they are
required to attend an emergency. This will be followed up with refresher training on an annual
basis.

e A review of the response procedure — the Head of Healthcare at HMP Norwich has met with the
Operations Governor within the prison and agreed where a medical emergency arises when the
prison is in patrol state, a prison officer will wait for the nurse in the entrance corridor and direct
the nurse to the medical emergency. This has already been put into place and a joint protocol will
be ratified by both ourselves and HMP Norwich by 31 March 2015. This will ensure that our
nurses can be directed to the correct cell to attend to medical emergencies.

As a result of these measures, Virgin Care is confident that it has in place a robust process for
ensuring that staff members have completed the appropriate training when they commence work at
HMP Norwich and that they complete the induction process. Virgin Care is also confident that the
agreed process with the Prison Operations Governor will ensure that nurses are appropriately
directed in a medical emergency.

For completeness, we enclose the following documents:
« Local Induction Process and Checklist template (to be in place by 31°! March 2015);

e Guidance for Resuscitation - joint protocol with HM Prison Service (to be in place by 31* March
2015).

Virgin Care
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We also note the second concern raised by the Coroner as follows:

(2) The Prison Officers attending Mr Wright had not had recent CPR training. it is understood that
due to lack of resource, CPR training has to be allocated to certain members of staff only. This
will result in gaps in CPR-trained Officers available and able to attend emergencies

Unfortunately, this is a concern that Virgin Care is unabie to respond to as it is not within our remit.

In conclusion, Virgin Care has welcomed the constructive comments which have been made by the
Coroner in his Rule 28 report. The contents of the report have been considered carefully, and Virgin
Care has instituted changes to its procedures fo ensure robust processes are now in place to address
the concerns raised by the Coroner.

Should the Coroner have any queries once she has had an opportunity to consider this letter and the
attached documentatian, she should not hesitate to contact us.

Yours faithfully

Karen Millen
General Counsel and Company Secretary
For and on behalf of Virgin Care Services Limited

Enc.

Virgin Care

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sid, Dyrton flows, 7-12 Cavislock Sqnare, Condon WC TE OET.

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