Hayden Norton

Regulation 28 Report 
Regarding the death of Mr H Norton on 06.01.2014 

1. 

Introduction  

1.1. 

The  Trust  commenced  the  provision  of  services  within  the  Devon  Prisons  on  1st April 
2013. It was recognised that prior to this there were significant issues with the quality of 
the  service  being  provided  and  the  Trust  has  been  working  hard  to  improve  service 
provision  since  taking  over  the  service.  Since  the  contract  award,  the  Trust  has 
implemented  new  policies  and  procedures  which  ensure  a  quality  service  is  being 
delivered and these are closely monitored.   

1.2. 

This  report  has  been  produced  in  response  to  the  Regulation  28  report  to  prevent 
future deaths received by 
 Specialist Services Manager on behalf of Dorset 
HealthCare on 24th April 2015.  

1.3.  As at the 25th July 2013, Coroners Rule 43 reporting, which gave coroners the power to 
report  at  their  discretion,  has  been  replaced.  Under  Regulation  28  of  The  Coroners 
(Investigations) Regulation 2013, coroners now have a statutory duty to issue a report 
where, in their opinion, action should be taken to prevent future deaths. The term Rule 
43 has been replaced by ‘Report on Action To Prevent Future Deaths (PFDs).  

1.4. 

1.5. 

1.6. 

The Regulation was issued by HM Senior Coroner for the County of Devon and Exeter 
and  Greater  Devon  District  Dr  Elizabeth  A  Earland.  The  Trust  is  required  to  respond 
within 56 days of the date of the report (24th April 2015) no later than 8th June 2015. 

The Trust was not made aware of the occurrence of the inquest, or invited or requested 
to attend or provide statements.  

In response to the Regulation 28, a review of the case has been undertaken and this 
report outlines the process, findings and action arising out of this review.  

2. 

Investigation team and terms of reference  

2.1. 

2.2. 

The review was carried out by the Executive Quality and Clinical Risk Group, Chaired 
by  the  Medical  Director 
,  and  Director  of  Nursing  and 
Quality 

 who have not had previous involvement in this case.  

The Terms of reference for the review were to consider the recommendations relating 
to Mr H Norton and review the actions taken by the team, and ensure that the Trust is 
assured that a robust change in practice has occurred.  

2.3. 

This  report  constitutes  the  formal  Regulation  28  report  to  HM  Senior  Coroner  for  the 
County of Devon and Exeter and Greater Devon District Dr Elizabeth A Earland. 

3. 

Coroners Concerns  

3.1. 

The regulation 28 letter related to concerns that arose out of the inquest held into the 
death of Mr H Norton, Concluding on the 11th March 2015. These concerns were:  

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 It  is  noted  that  Mr  Norton  was  medically  assessed  whilst  an  Inmate  of  HMP  Albany 
(now part of HMP Isle of Wight) on 28th September 2006 and known to have extensive 
and well documented history of high cholesterol, ischaemic heart disease with episodic 
angina,  two  previous  myocardial  infarctions,  blood  pressure  220/100.  After  arrival  at 
HMP Dartmoor on 15th March 2013 is noted that:  

  There was no record that his blood pressure was monitored   

  There  was  no  record  that  he  had  been  informed  of  screening  test  for  aortic 

aneurysm  

  There  was  a  delay  in  calling  an  emergency  ambulance  because  HMP  Dartmoor 

did not have an emergency code (unlike HMP Exeter) protocol.  

The Coroner noted that whilst there is insufficient evidence that these are causative of 
Mr Norton’s death there would have been an awareness of possible problems to come 
had the monitoring been in place.  

The third of the concerns relates to the HMP Dartmoor service, at the time of this report 
it is not clear whether the prison have been asked to respond separately or whether the 
Trust is expected to do so on their behalf. The Trust is awaiting a response from HM 
Coroner’s  office  to  determine  this.  For  the  purposes  of  this  report  the  third 
recommendation  has  been  left  for  HMP  Dartmoor  Governing  Governor  Bridie  Oaks-
Richards to respond to as this is a prison responsibility.  

Prison  and  Probation  Ombudsman  (PPO)  Report  and  Clinical  Reviewers 
Investigation  

The Trust received the PPO report relating to Mr Norton in October 2014 (see appendix 
1) which provides a chronology of events (see PG 8 and 9) following which an action 
plan was drafted to address the recommendations. The PPO noted:  

3.2. 

3.3. 

4. 

4.1. 

‘I am concerned that there is no record that Mr Norton’s blood pressure was monitored 
during his time at Dartmoor or that he had been informed of a screening test for aortic 
aneurysm. However, we do not know whether Mr Norton would have decided to be 
screened and, if so, whether this would have altered the outcome. I am also concerned 
that, because Dartmoor did not have an emergency code protocol, as national 
instructions require, there was a delay in calling an emergency ambulance. In future 
emergencies such a delay could be crucial’ 

PPO Nigel Newcome CBE 

4.2. 

The following recommendations were made by the PPO:  

  The  Head  of  Healthcare  should  ensure  that  staff  appropriately  monitor  and  record 
blood  pressure  readings  for  prisoners  with  hypertension  in  line  with  national 
guidelines. 

  The  Head  of  Healthcare  should  ensure  that  information  on  national  screening 
programmes  is  available  for  eligible  prisoners  as  part  of  good  health  promotion  in 
the prison. 

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   The Governor should ensure that all prison staff are made aware of and understand 
PSI  03/2013  and  their  responsibilities  during  medical  emergencies  and  that 
Dartmoor  has  a  medical  emergency  response  code  protocol  based  on  the  PSI 
which: 

  Provides  guidance  to  staff  on  efficiently  communicating  the  nature  of  an 

emergency; 

  Ensures staff called to the scene bring the relevant equipment;  

  Ensures there are no delays in calling, directing or discharging ambulances. 

5. 

Trust response to the Regulation 28 Ruling 

5.1. 

5.2. 

The  Trust  recognises  that  there  were  failings  in  relation  to  Mr  Norton’s  care,  and 
agrees with both the PPO and HM Coroners view that these issues are of concern. In 
order  to  ensure  that  these  issues  do  not  reoccur  within  the  Trust  services,  an  action 
plan was put into place at the time of Mr Norton’s death, to address the issues outlined.  

The  action  plan  is  provided  at  Appendix  2,  however  it  should  be  noted  that  the  Trust 
action plan did not reflect the recommendation relating to emergency protocols and the 
requirement for the Governor to ensure a protocol be in place as this was directed at 
the Prison Service by the PPO.  

5.3. 

The  Trust  is  committed  to  ensuring  that  it  provides  a  high  quality  responsive  service. 
The following is a summary of the action taken to address the findings of this review.  

5.4.  Concern 1  - There was no record that his blood pressure was monitored  

5.4.1.  National guidelines (NICE) are in place in the Prison healthcare service and form part 
of  the  Trusts  prison  healthcare  clinical  audit  programme.  In  line  with  the  PPO  action 
plan  following  the  death  of  Mr  Norton,  GP  Clinical  Lead  Dr 
undertook  a  baseline  review  of  compliance  against  NICE  QS28  Hypertension  to 
ensure compliance. This is provided at Appendix 3 and at point of audit the Trust was 
fully  complaint.  A  further  audit  is  planned  for  July  2015  to  ensure  ongoing  monitoring 
and compliance.  

5.5.  Concern 2  - There was no record that he had been informed of screening test for 

aortic aneurysm  

5.5.1.  The Trust now provides a AAA screening programme, which is available to all patients 
with  the  Devon  prisons.  Eligible  patients  (as  defined  by  the  National  AAA  Screening 
programme) are tracked to ensure all are offered and receive screening, or reasons for 
declining are clearly documented.  

5.5.2.  The review team noted that all eligible patients are invited for screening as per national 
guidance  and  are  sent  a  letter  by  the  NHS  AAA  Screening  Programme.  All  patients 
over  the  age  of  65  are  invited  to  self-refer  for  AAA  screening  if  they  wish.  As  per 
guidance, a second offer of screening is made after a year. (see appendix 4) 

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 5.5.3.  The AAA screening is actively promoted in the prison, as noted in recent audit where of 
the 29 patients who attended for AAA screening, 18 were self-referrals. (See appendix 
5)  

5.5.4.  Screening  programmes  are  built  into  the  monthly  health  promotion  timetable  with 
Health  Promotion  posters  regarding  national  screening  programmes  displayed  widely 
around the Prison. (See appendix 6)  

5.6.  Concern 3- There was a delay in calling an emergency ambulance because HMP 
Dartmoor did not have an emergency code (unlike HMP Exeter) protocol.  

5.6.1.  Bridie  Oaks-Richards  Governing  Governor  of  HMP  Dartmoor  has  confirmed  that  the 
prison are now compliant with Prison Service Instruction (PSI) and have an emergency 
code protocol in place.  

6. 

Summary 

6.1. 

Trust is assured through robust review at the Executive Quality and Clinical Risk Group 
that  the  recommendations  made  by  the  PPO  and  HM  Coroner  have  been  addressed 
and will continue to be monitored through compliance audit and review. 

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