Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0129, written 31 Mar 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 31 Mar 2015 |
|---|---|
| Reference | 2015-0129 |
| Deceased | Sharon Butcher |
| Coroner | Andrew Tweddle |
| Coroner area | County Durham & Darlington |
| 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. Governor HMP Frankland 2. National Offender Management Service CORONER !am Andrew Tweddle Senior Coroner, for the coroner area of County Durham and Darlington. 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. (see attached sheet) INVESTIGATION and INQUEST On 26" August 2014 | commenced an investigation into the death of Sharon Louise Suki Butcher. The investigation concluded at the end of the inquest on 31% March 2015. The conclusion of the inquest was Natural Causes with a cause of death given as 1a) Ischaemic Heart Disease, 1b) Coronary artery Atheroma, 2) Diabetes Mellitus and Cirrhosis of the Liver. CIRCUMSTANCES OF THE DEATH The deceased died of natural causes. 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. — The PPO report highlights an issue relating to the delay in calling for an ambulance as soon as an emergency medical code was broadcast. There was a 10 minute delay and the prisons local protocol for summoning an ambulance was not followed. There have been a series of similar failings in dealing with medical emergencies at HMP Frankland and HMP Durham with either staff using wrong or inappropriate codes, or there being delays in the control room and this recurring issue of lack of clarity in response to a medical emergency could well lead to a fatality in the future. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you 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 26" May 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. | COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons HMP Frankland and the National Offender Management Service. | have also sent it to Care UK i! who may find it useful or of interest. | 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. f[\ [DATE] > ie
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.
: a eB Equality, Rights and Decency National Offender Group ; 70 Petty France, London, SW1H SHD Riiesaee iia a H.M. Coroner Second Floor Royal Comer Crook Co Durham DLi5 SUA 22 May 2015 Dear Coroner, RE: the death of Sharon Butcher on 25 August 2014 whilst in HMP Frankland. Thank you for your letter dated 31 March addressed to the Governor of HMP Frankland and the Offender Management Service conceming the Inquest into the death of Ms. Sharon Butcher. Y has been passed to Equality Rights and Decency (ERD) Group in the National Offender Manag Service (NOMS) to respond, as we have policy responsibility for sulcide prevention and se’ Management and for sharing leaming from deaths In custody. |! am also responding on be’ Frankland. In your report, you expressed your concem about the delay in calling for an ambulance emergency medical code was broadcast. You may be aware of PSI 03/2013 Medical Emergency Response Codes which sets out the national instructions for calling a medical emergency over the establishment radio network in all prisons and NOMS operated Immigration Removal Centers. HMP Frankland revised their local contingency plans and re-issued instructions following the death of Ms. Sharon Butcher to ensure that all staff understand, that they must not delay in calling an ambulance in all cases where there are serious concems about the health of an offender. The local protocols now provide clear guidance to all staff to ensure timely, appropriate and effective response to medical emergencies and thereby maximise the likelihood of a positive outcome for the The protocol defines the nature of the medical emergency with the use of a two level code (code Red and Code Blue) system that differentiates between blood and other injuries, such as breathing difficulties, unconscious casualties as specified by PS! 03/2013. In April 2015 an additional learning bulletin was issued nationally by ERDG (please see attached). In addition HMP Frankland are also working with the North East Prisons cluster and the North East Ambulance Service to ensure joint working and consistency of approach across all establishments. hope that you find this response helpful and reassuring. Yours sincerely, NOMS Equality, Rights and Decency Group
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