Samuel Blair

Regulation 28:  Prevention of Future Deaths report 

Samuel Rodney Darren BLAIR (died 02.08.15) 

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  6  August  2015  I  commenced  an  investigation  into  the  death  of 
Rodney  Blair,  aged  40  years.  The  investigation  concluded  at  the  end  of 
the inquest earlier today.   

The  jury  made  a  narrative  determination,  which  I  attach,  concluding  that 
death  came  about  by  way  of  suicide,  with  several  contributing  factors.  
The medical cause of death was: 1a suspension by ligature. 

4 

CIRCUMSTANCES OF THE DEATH 

Rodney  Blair  was  remanded  in  custody  at  HM  Prison  Pentonville  on  30 
June  2015.    He  had  a  history  of  paranoid  schizophrenia,  alcohol 
dependency, multiple drug use and depression.   

1 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 At  no  time  did  any  member  of  staff  at  HMP  Pentonville  suspect  that  Mr 
Blair had thoughts of taking his life. 

On Sunday, 2 August 2015, he was found hanging in his cell. 

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.  

The prison officers who found Mr Blair hanging did not have current basic 
life support training and so were not able to commence cardiopulmonary 
resuscitation (CPR) before the arrival of nurses.  One officer tried to take 
Mr Blair’s pulse, but was unclear about the correct procedure for this. 

This is a situation that I have noted before at HMP Pentonville.  I have not 
made  a  prevention  of  future  deaths  report  in  the  past,  because  I  am 
aware  that  the  fact  that  there  is  no  mandatory  first  aid  (including  CPR) 
training for all prison officers is a nationally made, resource led decision.   

However,  it  seems  to  me  that  you,  as  the  decision  maker  regarding  not 
providing such training, should be aware of the impact that this may have 
on the prison population. 

6 

ACTION SHOULD BE TAKEN 

In  my  opinion,  action  should  be  taken  to  prevent  future  deaths  and  I 
believe  that  you  and  your  organisations  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  25  July  2016.    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 
  HM Prison Pentonville 
 

 Rodney Blair’s mum & stepdad 

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 

19.05.16 

3

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Coroner MS Hassell Head of Healthcare Services
Senior Coroner HMP Pentonville

Inner North London Caledonian Road

St Pancras Coroner's Court London

Camley Street N7 8 TT

London

N1C 4PP Tel no:

25 July 2016

Dear Coroner ME Hassell,

Regulation 28: Prevention of Future Deaths report, Samuel Rodney Darren Blair (died
02.08.2015)

We hereby respond to your Rule 28 report issued to Care UK following the inquest into the death
of Mr Rodney Blair. Care UK would like to express its condolences to Mr Blair's family and friends.

Care UK is the main provider of healthcare services at HMP Pentonville. There is a sub-
contracting arrangement in place with Barnet, Enfield and Haringey Mental Health Trust (BEH-
MHT) in respect of mental health services. Our response addresses the matters of concern which
relate to our staff and services. It should be read in conjunction with the separate response
provided by the BEH-MHT.

The actions below form part of the overall action plan across healthcare between both providers.
Matter of Concern 1. Although the assistant psychologist who triaged Mr Blair in prison on 2 July
2015 asked him about his alcohol dependency, she did not ask him about drug use, nor did she
record asking him about his mood or any suicidal thoughts.

Response: We refer to the response provided by BEH-MHT and we will collaborate with them to
ensure that the action plan outlined in their response is implemented and that all healthcare staff
are aware of the plan.

Matters of Concern 2, 3 & 4.

Response: We refer you to the response provided by BEH-MHT as these concerns are relating to
their services rather than the services of Care UK.

Matter of concern 5.

Response: This concern is a matter for the prison and accordingly, we will leave it for them to
respond.

Matter of Concern 6. The prison nurse on call for emergencies, call sign Hotel 7, who was called
to attend Mr Blair after he had been found hanging did not acknowledge the radio call for several
minutes, despite numerous attempts by prison control. When she finally did acknowledge the

Cofe £3

emergency, there was a delay of up to approximately 15 minutes before she was at Mr Blair's
side.

Response: Ve set out below a timeframe which we have compiled from the written evidence and
with reference to the evidence heard at the inquest hearing and which suggests that the time
taken was less than 15 minutes.

In his witness statement of 2 August 2015 EEE states tha rrived at Mr Blair's cell at
7.35pm. He states that officer was _on the landing and | and nurse were in
the cell. He states that he assisted in giving breaths and compressions with them swapping
roles. He states that he “again” makes a Call to Hotel 7 who he estimates arrives after 10 minutes
and attaches the defibrillator. He states that the first paramedic arrives at 7.50pm.

PCO | | is the first officer to arrive at Mr Blair’s cell. In his PPO evidence, he states that he
discovers Mr Blair at 7.30 pm. PCO Eiistates that he shouted at the top of his voice because
he did not have a radio and that PCO [arrived in around a “minute or two”. PCO [i does
not call a level 1 (code blue) because he did not have a radio.

PCO Bi states that she hears PCO ME calling her name and asking her to go to Mr Blair's cell.
She asks him why and he asks her to rush down. According to he unt, by thetime that she
arrives, PCO i has entered the cell and cut the ligature. PCO asks econ: raise a
level 1 incident which she st e does. PCO then states that officers rush down.
mentions PCO an ee she_says radios to request an ambulance. PCO
says that she then calls to nurse iii! PCOIfilllcays that responds and states that he
has to go and get the bag - which he does before going to Mr Blair's cell. Once he arrives, PCO
Soli’s account is that Mr Blair is moved to the landing.

In PCO_Haslam’s PPO statement, he says that after arriving, going into the cell and talking to
PCO about whether Mr Blair had a pulse, he runs upstairs and explains to Xavier what has
happened.

In his PPO interview, —_ states that around 7.30 p.m., he hears his name being called and that
he responds by asking what the matter is. He is asked to “come down” to Mr Blair’s cell and the
tone causes him to go upstairs to get his bag and oxygen before going back downstairs to the cell.
HEB assesses Mr Blair, checks for a pulse, eases him to the floor S compressions. He
then asks the officers to call another member of healthcare staff. |e that he does
compressions for 2 or 3 minutes before an officer asks about a mask and that they had_been
doing compressions and using the mask for around 7 minutes before Hotel 7 arrived.

states that he then goes to get the defibrillator. He states that they then attach the defibrillator for
instructions “several times’ (and it advises to continue compressions). He estimates that the
paramedics arrives 10 or 15 minutes later.

In oral evidence at the inquest hearing, HEB statec that it took him about 2 minutes to arrive at
Mr Blair's cell after hearing his name being called and collecting the emergency bag.

In oral evidence, PCO [stated that it was at 7.34pm that PCO Hr =<: a call to the prison
control room to call for assistance regarding an imminent threat to life. However, we know that
PCOBEdid not have a radio and so he could not have made such a call.

PCO J stated that he attempted to contact Hotel 7 and that it took her 3-4 minutes to
respond. PCO HB was aware that th d been another incident at the prison where a
prisoner had set fire to their cell and P was aware that there was already another nurse
in attendance at Mr Blair's cell. PCO ites that the first paramedic arrived at the prison
within 6 or 7 minutes at 7.46pm.

Cofe &

At the time, Hotel 7 was attending another ingident and treating another patient on a different
wing. Upon acknowledging the call from PCO eB her PPO interview, Hotel 7 states that she
went via A wing to collect the emergency response bags and that it took her five minutes to arrive
at Mr Blair’s cell.

According to LAS records, the call for an ambulance connected at 7.40 p.m. and paramedic G199
was with Mr Blair at 7.50pm. When he arrived, there was a nurse and an officer carrying out CPR,
another nurse (presumably Hotel 7) was maintaining an airway and the defibrillator was attached.

Although in her statement Hotel 7 states that she received a code blue at approximately 7.30pm,
according to the written and oral evidence, this time is inaccurate.

In summary, PCO[fiiarrives at Mr Blair's cell at 7.30 p.m. This time appears to be consistent
across the PPO interviews. The LAS records show that the first paramedic arrives in the cell at
7.50 p.m. The window is therefore one of 20 minutes.

Having arrived at the cell at 7.30 p.m, PCOI finds Mr Blair hanging. He enters the cell and
cuts the ligature although the evidence indicates that he does not enter the cell until a colleague
arrives. Upon discovering Mr Blair, he shouts for help but does not say why and he does not have
his radi issue the relevant level 1/code blue call. PCO [i arrives within a few minutes and
PCO tells her what has happened and asks her to radio the alert. It is not clear whether this
is the code blue that Hotel_7 hears but this call must have been made several minutes after
7.30pm. According to PCO | | the earliest this call was made is 7.34 p.m. By 7.50pm, only 16
minutes later, when the paramedics arrive Il, Hotel 7 has already arrived, is maintaining
an airway and the defibrillator is reais is that he collects the defibrillator
after Hotel 7 arrives. It therefore appears that the time it took Hotel 7 to arrive at the cell was less
than 15 minutes. If it was Mr instructions to the control room that resulted in the code
blue (and the 999 call as per PCO account), then he arrived at the cell after | who
states that he arrived at 7.35 p.m. If the code blue call went out at around the same time as the
999 call (7.40 p.m.) then Hotel 7 must have arrived in less than 10 minutes.

In any event, any delay on the part of Hotel 7 was as a result of her being located in a different
wing and treating another patient following another incident. It would therefore have been entirely
correct to ensure that her patient was clinically stable before leaving to attend another incident
where a clinician was already in attendance.

Matter of Concern 7. The substance misuse nurse in the detoxification wing did respond
immediately. He took the emergency bag with him to Mr Blair's cell, but did not take the
defibrillator stored in the same room as the bag. He later had to leave Mr Blair to retrieve the
defibrillator, because it is stored in the nurses’ room and only nurses have the key.

Response & Actions:

As can be seen from the PPO interviews and as was heard during the inquest hearing, the nurse
was called for assistance but not informed by the officers as to what the nature of the emergency
was. He was also not aware of any code blue call at the time. He therefore collected the
emergency bag. After attending Mr Blair's cell and identifying the nature of the emergency, he
went back to the nurses’ room to collect the defibrillator. Hotel 7 had already arrived at this point
and was assisting Mr Blair when the nurse left Mr Blair’s cell to collect the defibrillator.

However, to ensure that there is no misunderstanding of emergency procedures in the future, we
have implemented the actions outlined in the table below for all healthcare staff.

Matter of Concern 8. The nurse (a mental health nurse rather than a general nurse) began
resuscitation. He gave evidence that he started chest compressions and continued these for two
minutes until a custodial manager arrived, without the intention of ever stopping to re-check Mr
Blair's pulse. He said that, whilst his basic life support certification was current at the time of Mr
Blair's death, his intermediate life support certification was not, and is still not. It is currently at
least three years out of date.

Response & Actions:
Care UK Cardiopulmonary (CPR) Resuscitation Policy in the Training section (section 7) states:

e ‘As a minimum, all staff within Care UK should be provided with Basic life Support (BLS)
training on induction. This should be maintained by participating in regular practice
sessions within the workplace and by mandatory annual updates in BLS’.

e« ‘The resuscitation team members will immediately mobilise to the location and perform
BLS, ILS or ALS according to their ability’.

e ‘All Healthcare staff are expected to recognise cardiac arrest, call for help and initiate BLS’.

The nurse concerned was trained in Basic Life Support (BLS) but not Intermediate Life Support
(ILS). As such, staff trained to BLS level are not expected to check a pulse as per the
Resuscitation Council UK 2015 guidelines. The nurse was therefore acting within the scope of his
practice and competence. However, as detailed in the table below, we have implemented a
training plan to ensure that, by December 2016, most healthcare staff will be ILS trained and that
refresher trainings will occur yearly.

Matter of Concern 9. That nurse gave a description of the code blue and code red system of
describing an emergency that was markedly different from the understanding given by the prison
governor and the London Ambulance Service. | heard that the codes blue and red are even
described on posters within the prison. It therefore appears that a nurse within the prison
healthcare team has the wrong understanding of basic prison healthcare emergency procedures.

London Ambulance Service NHS|

NHS Trust

MsMaryEHassell 8  [Locccccorcn-----
Her Majesty's Senior Coroner

Inner North London

St Pancras Coroner's Court

Camley Street

London

N1C 4PP

Our Ref ==
Your Ref:

14 July 2016

Dear Ms Hassell

Executive Office
Headquarters

220 Waterloo Road
London

SE1 8SD

RE: Regulation 28: Prevention of Future Deaths Report arising from the

inquest into the death of Samuel Rodney Darren Blair

Thank you for your Regulation 28 Report to Prevent Future Deaths, dated 19
May 2016, bringing to my attention the matters of concern arising from the death
of Mr Samuel Rodney Darren Blair on 2 August 2015 not 2 August 2016 as

stated in the title and paragraphs 5.5 and 6 of your Report:

“After Mr Blair was found hanging, the officer in the prison control room did not
give the prison gate location for the ambulance at the very outset of the 999 call
to London Ambulance Service, but instead did so part way through the call.

The LAS controller did not ask at the very outset.

The ideal would be for the information to be given at the very beginning of any
emergency call.

(l wrote to HMP Pentonville on 16 September 2016 in connection with the death
of another prisoner about this issue. | appreciate that work on this matter is on-
going.)”

The letter to HMP Pentonville on 16 September 2015, relating to Mr H was also
addressed to me. In my reply of 13 November 2015 | confirmed the actions
taken by the London Ambulance Service NHS Trust (LAS) after the death of Mr
H to ensure that the LAS attend the correct prison gate when called to HMP
Pentonville. Shortly before the inquest into the death of Mr H changes were
made to the LAS's Computerised Gazetteer, used in the Emergency Operations
Control (EOC), to record that there was more than one vehicular entrance to
HMP Pentonville, namely the Roman Way Gate and North Wall Gate. The postal
address of both entrances, were added to the Gazetteer. Following the inquest
into the death of Mr H it was requested that HMP Pentonville staff were prompted
and reminded to say at the beginning of a 999 call which entrance LAS staff were
to use. Unfortunately these actions occurred after the call to Mr Blair on 02
August 2015.

| have i the LAS’s Deputy Director of Operations (Control
Services), that in early May 2016, when the refresher training for
2016/17 for staff in EOC began, a session was included that made specific
reference to HMP Pentonville and of the requirement that when a call from HMP
Pentonville was received, at the start of the call the emergency medical
dispatcher was to seek confirmation of the gate the LAS should attend. This
training is in process and due to be completed in November 2016.

On 26 May 2016 our Senior Quality Assurance Manager, Control Services, and
other LAS senior managers, met senior prison staff to discuss matters of mutual
interest for the LAS and HMP Pentonville to promote effective communication
and joint working. | am advised that these meetings will continue.

Our Medical Director, La ETSY has confirmed that the Regulation 28
Report from the inquest into death of Mr Blair will be shared with the National
Ambulance Service Medical Directors Group to facilitate wider learning by UK
Ambulance Services.

| hope that this reply is helpful to you and to Mr Blair's family in explaining all that
we have done to address your matters of concern.

We offer our sincere condolences to Mr Blair's family.

Yours sincerely

(ins
ia

Dr Fionna Moore MBE, 8Sc, FRCS, FRCSEd, FRCEM, FIMC RCSEd
Chief Executive Officer, Consultant in Emergency Medicine and Pre-Hospital
Care

enior Caseworker: Safer Custody
asework

quality, Rights & Decency Group
ational Offender Management Service
-15 Clive House

(0 Petty France

ondon SW1H 9EX

Ministry of
JUSTICE

National Offender
Management Service

Coroner ME Hassell

Senior Coroner for Inner North London
St Pancras Coroner’s Court

Camley Street

London

N1C 4PP

15 August 2016

Dear Ms Hassell

Thank you for your Regulation 28 Reports to Prevent Future|Deaths addressed to
Michael Spurr, Chief Executive Officer at the National Offender, Management Service
(NOMS), and FL ans gel Governor of HMP Pentonville, concerning the
recent inquest into the death of Samuel Rodney Blair at HMP Pentonville on 2
August 2015. | am very grateful to you for agreeing an extension to the statutory
deadline so that we could finalise our response to your reports. This response is
sent on behalf of NOMS and HMP Pentonville, and has been formulated following
consultation with the London Ambulance Service NHS Trust. |l am aware that Care
UK will reply separately concerning the matters of concern in|your report that were
addressed to them.

The report that you addressed to NOMS expresses concein that the staff who
discovered Mr Blair had not received cardiopulmonary resuscitation (CPR) training.
It correctly states that the NOMS position is that such training ig not mandatory for all
prison staff. However, it is not correct to characterise this as a ‘resource-led’
decision. NOMS is committed to ensuring that that a sufficient number of suitably
trained first aiders is always available in prisons to enable First Aid to be given to
employees, prisoners and visitors. Prison Service Instruction 29/2015 First Aid,
issued on 16 November 2015, requires every establishment to carry out a First Aid
risk assessment to identify the number of trained first aiders required to provide cover
throughout the day. Trained first aiders must hold an up to date, valid certificate of
competence in either First Aid at Work (FAW) or Emergency First Aid at Work
(EFAW), and the number of staff trained is dependent on a number of factors which
are considered during the risk assessment process. Colleagues at Pentonville have
confirmed that their local risk assessment is up to date, and that, in accordance with
it, there is a sufficient number of staff trained in first aid, including all night staff and
all managers who undertake the role of Orderly Officer. As you know, the healthcare
provider at Pentonville provides 24 hour cover, so the prison’s gwn arrangements are
supplemented by the presence of trained healthcare staff at all times.

The separate report addressed to the Governor raises concern about the fact that the
prison’s control room did not immediately provide the London Ambulance Service
(LAS) with the gate location when they requested the attendance of an ambulance. |
can confirm that since Mr Blair's death, colleagues at Pentonville have met the LAS
to discuss this issue, and it has been agreed that the prison) gate location will be

provided at the beginning of the call. Prison control room staff have been made
aware of this requirement through verbal briefings.

This report also brings to the attention of the Governor the inadequate response of a
nurse to the emergency call from the control room. As you point out in your report,
the local protocol on action to be taken in response to emergency response codes is
well publicised trroushout the prison. The prison will continue to work with the
healthcare provider to ensure that all staff are aware of the steps that they are
required to take when responding to an emergency call.

| am grateful to you for raising these concerns with NOMS and the Governor, and |
hope that this response provides assurance that appropriate action is being taken to
prevent future deaths)

Yours sincerely