Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0380, written 16 Sep 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 16 Sep 2015 |
|---|---|
| Reference | 2015-0380 |
| Deceased | Adil Habib |
| Coroner | Mary Hassell |
| Coroner area | Inner North London |
| Category | State Custody related deaths · Community health care and emergency services related deaths |
| Organisation named | London Ambulance Service NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: Prevention of Future Deaths report
Adil HABIB (died 31.10.14)
THIS REPORT IS BEING SENT TO:
1.
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 3 November 2014, I commenced an investigation into the death of
Adil Habib, aged 30 years. The investigation concluded at the end of the
inquest yesterday.
The jury made a determination that this was an accidental death, when
Adil Habib died in the search area of HM Prison Pentonville at 16:54
hours on 31 October 2014 by acute respiratory failure due to mechanical
obstruction of his upper airway by a foreign object.
4
CIRCUMSTANCES OF THE DEATH
Mr Habib died following a full search conducted after a visit. During the
search, he was the subject of control and restraint, but managed to put a
small package, later found to contain crack cocaine, in his mouth. He
choked on this and died.
1
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
report to you.
The MATTERS OF CONCERN are as follows.
I heard evidence at inquest that there is no training for prison officers that
specifically covers the risk of prisoners choking as a result of attempts to
conceal an item from prison officers, most especially during a search
and/or control & restraint. It seems to me that this is a significant
omission, and it would be helpful if such training were mandatory and
refreshed regularly. I have written to the National Offender Management
Service as provider of prison officer training about this but, in addition, I
wanted to bring this direct to your attention. It may be some months
before there is any change to the national training offered.
I have given a great deal of thought to reporting to you regarding the fact
that there is no mandatory first aid (including CPR) training for all prison
officers. However, I heard evidence that this is a nationally made,
resource led decision, and takes into account the 24 hour availability of
nurses within the prison. Upon reflection, it seems to me much more
important that the gap in officer training regarding choking is filled
appropriately.
The nurse who was on call as Hotel 7 at the prison did not respond to the
emergency alarm that was activated at the start of the control & restraint
of Mr Habib, as she should have. Instead, she only responded once a
Level 1 emergency was radioed. I appreciate that this nurse no longer
works at HMP Pentonville and that your team has taken steps to remind
all nurses operating as Hotel 7 of their responsibility to respond to every
alarm immediately.
The prison officer who rang 999 from the control room did not
immediately offer the LAS call handler the location of the prison gate to
which the ambulance should be driven. I understand that your team has
taken steps to remind all officers working in the control room that they
must do this. I understand also that your team has an ongoing
conversation with London Ambulance Service to enable best care to be
given to those in the prison in need of paramedic attention.
6
ACTION SHOULD BE TAKEN
In my opinion, action should be taken to prevent future deaths and I
believe that you and your organisation have the power to take such
action.
2
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date
of this report, namely by 6 November 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
parents of Adil Habib
partner of Adil Habib
and
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
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
16.09.15
3
Regulation 28: Prevention of Future Deaths report
Adil HABIB (died 31.10.14)
THIS REPORT IS BEING SENT TO:
1. Dr Fionna Moore
Chief Executive
London Ambulance Service NHS Trust
220 Waterloo Road
London SE1 8SD
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 3 November 2014, I commenced an investigation into the death of
Adil Habib, aged 30 years. The investigation concluded at the end of the
inquest earlier today.
The jury made a determination that this was an accidental death, when
Adil Habib died in the search area of HM Prison Pentonville at 16:54
hours on 31 October 2014 by acute respiratory failure due to mechanical
obstruction of his upper airway by a foreign object.
4
CIRCUMSTANCES OF THE DEATH
Mr Habib died following a full search conducted after a visit. During the
search, he was the subject of control and restraint, but managed to put a
small package, later found to contain crack cocaine, in his mouth. He
choked on this and died.
1
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
report to you.
The MATTERS OF CONCERN are as follows.
When a prison officer at HMP Pentonville rang 999 to ask that
paramedics attend the prison, the caller did not immediately offer the
location of the prison gate that London Ambulance Service should attend.
Whilst there is of course an issue for the prison in terms of offering the
information, it would be helpful for LAS call handlers to be provided with a
drop down menu showing the alternative gates when they input the prison
details.
I understand that the LAS computer system has been augmented in this
respect since Mr Habib’s death for HMP Pentonville, but not for the other
London prisons. Perhaps that would be a useful exercise?
6
ACTION SHOULD BE TAKEN
In my opinion, action should be taken to prevent future deaths and I
believe that you and your organisation 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 6 November 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
Association of Ambulance Chief Executives (AACE)
National Ambulance Service Medical Directors (NASMeD)
, parents of Adil Habib
partner of Adil Habib
and
2
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
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
16.09.15
3
Regulation 28: Prevention of Future Deaths report
Adil HABIB (died 31.10.14)
THIS REPORT IS BEING SENT TO:
1. Mr Michael Spurr
Chief Executive
National Offender Management Service
Clive House
70 Petty France
London SW1H 9EX
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 3 November 2014, I commenced an investigation into the death of
Adil Habib, aged 30 years. The investigation concluded at the end of the
inquest yesterday. The jury made a determination that this was an
accidental death, when Adil Habib died in the search area of HM Prison
Pentonville at 16:54 hours on 31 October 2014 by acute respiratory
failure due to mechanical obstruction of his upper airway by a foreign
object.
4
CIRCUMSTANCES OF THE DEATH
Mr Habib died following a full search conducted after a visit. During the
search, he was the subject of control and restraint, but managed to put a
small package, later found to contain crack cocaine, in his mouth. He
choked on this and died.
1
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
report to you.
The MATTER OF CONCERN is as follows.
I heard evidence at inquest that there is no training for prison officers that
specifically covers the risk of prisoners choking as a result of attempts to
conceal an item from prison officers, most especially during a search
and/or control & restraint. It seems to me that this is a significant
omission, and it would be helpful if such training were mandatory and
refreshed regularly.
6
ACTION SHOULD BE TAKEN
In my opinion, action should be taken to prevent future deaths and I
believe that you and your organisation 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 6 November 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
and
partner of Adil Habib
, parents of Adil Habib
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
2
find
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
9
DATE SIGNED BY SENIOR CORONER
16.09.15
3
2 responses 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.
Headquarters
220 Waterloo Road
London
SE1 8SD
Tel: 020 7783 2000
Fax: 020 7783 2265
www.londonambulance.nhs.uk
Ms ME Hassell
Senior Coroner
Inner North London
St Pancras Coroners Court
Camley Street
London
N1C 4PP
Date:13 November 2015
Our ref : INQ/10225/14
Dear Ms Hassell,
Regulation 28; Prevention of Future Deaths Report arising from the inquest into the
death of Adil Habib
Thank you for your Regulation 28 Report to prevent future deaths, dated 16th September
2015, bringing to my attention the matters of concern:
When a prison officer at HMP Pentonville rang 999 to ask that paramedics attend the prison,
the caller did not immediately offer the location of the prison gate that London Ambulance
Service should attend. Whilst there is of course an issue for the prison in terms of offering
the information, it would be helpful for LAS call handlers to be provided with a drop down
menu showing the alternative gates when they input the prison details.
I understand the LAS computer system has been augmented in this respect since Mr
Habib’s death for HMP Pentonville, but not for the other London prisons. Perhaps that would
be a useful exercise?
Before responding to the matter of concern I would like to apologise to Mr Habib’s family for
not being able to reach Mr Habib earlier than we did and to offer my condolences.
The evidence submitted to the Court during the inquest outlined the actions the London
Ambulance Service NHS Trust (LAS) had taken since the death of Mr Habib to ensure that
we attend the correct prison gate at HMP Pentonville. At the time of the 999 call to attend
Mr. Habib, the Gazetteer in the Emergency Operations Centre (EOC) only held the main
postal address in Caledonian Road for HMP Pentonville and the prison officer making the
999 call did not volunteer that a different prison gate was to be used. After being advised
that a second gate was operated in Roman Way the address was added to the Gazetteer
with accurate GPS information so that when selected, ambulance staff would be guided to
the address by satellite navigation.
Following the inquest HMP Pentonville’s Head of Residence,
to the LAS’s Senior Quality Assurance Manager,
continue to operate two prison gates. We requested that staff at HMP Pentonville are
prompted to give the address of the prison gate ambulance staff are to attend at the
beginning of the emergency call to the LAS.
, that HMP Pentonville will
has confirmed
1
With the assistance of the National Offender Management Service (NOMS) we have
obtained a list of postal addresses for all prisons and young offender institutions in the UK
and have been assured that the Local Safer Custody Leads have been asked to contact
their respective local Ambulance Service Trusts to advise if there are additional or temporary
gates to be used, either on a temporary or longer term basis, to those held by NOMS. We
have made contact with the Safer Custody Lead for Greater London and established that
aside from HMP Pentonville the thirteen prison and young offender institutions operate with
a single vehicle access gate.
To share the learning about the call to attend Mr Habib with EOC staff, the November
Control Services Team Talk disseminated on 6 November 2015, see copy enclosed, asked
staff to confirm the address to attend when taking a call from any prison or young offender
institution. Further, as is our practice, a copy of this reply will be shared with the Association
of Ambulance Chief Executives and the National Ambulance Service Medical Directors to
share our learning with other ambulance services.
I hope that this reply is helpful to you and to Mr Habib’s family in explaining what we have
done to address your matters of concern.
Yours sincerely,
Dr Fionna Moore
Chief Executive London Ambulance Service NHS Trust
Enclosure : November 2015 Control Services Team Talk
2
National Offender Management Service Equality, Rights & Decency Group. 4th Floor (post point 4.12), Clive House 70 Petty France London SW1H 9HD Her Majesty’s Coroner M E Hassall Senior Coroner Inner North London Dear Ms Hassall 10 November 2015 Thank you for your Regulation 28 report dated 16 September and addressed to the Governor of HMP Pentonville concerning the recent inquest into the death of Adil Habib who died on 31 October 2014. Your report has been passed to the Equality, Rights and Decency Group (ERDG) in the National Offender Management Service (NOMS), as we have responsibility for the policy on suicide prevention and self-harm management and for sharing learning from deaths in custody. In your letter you raise concern that the national training for search and restraint does not cover those situations where a prisoner is at risk of choking after attempting to conceal an item during control and restraint procedures. You will be aware that the Chief Executive of NOMS accepted the Prisons and Probation Ombudsman’s recommendation that clear guidance and training be given on the safe use of force, including pain compliance techniques, when resistant prisoners have items in their mouths, which might compromise their breathing. In the response, NOMS confirmed that a DVD was being produced to aid staff training in the safe use of force, in conjunction with current medical advice, and that NOMS would consider the best way to include specific guidance within the DVD on what action should be taken where items are concealed in a resistant prisoner’s mouth. I can confirm that the DVD has been completed and that the accompanying training material has been prepared and is out for consultation with key stakeholders. I can also confirm that the DVD includes medical advice related to the use of control and restraint and covers: Principles of safe restraint Medical complications of restraint Mechanics of breathing Restraint asphyxia Medical conditions and risk factors Medical emergencies The DVD will be sent to all prison Governors by Christmas along with a Notice to Governors advising them of the content and that it should be made available for all operational staff to view. The content will be reinforced in due course when all operation staff receive updated control and restraint training from the National Control & Restraint Instructors. It is expected that the roll out of training will commence in January 2016. All Prison Officer Entry Level Trainees (POELTs) will receive training relating to the contents of this DVD from in December. I hope you find the contents of this letter have been helpful in providing some assurance that the concerns that you have raised have been, or are being, addressed by NOMS. Yours sincerely
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