Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0437, written 6 Dec 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 6 Dec 2016 |
|---|---|
| Reference | 2016-0437 |
| Deceased | Tedros Kahssay |
| Coroner | Mary Hassell |
| Coroner area | Inner North London |
| Category | State Custody related deaths · Suicide (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: Prevention of Future Deaths report
Tedros Habtom KAHSSAY (died 19.01.16)
THIS REPORT IS BEING SENT TO:
1. Mr Mike Parish
Chief Executive
Care UK
29 Great Guildford Street
London SE1 0ES
2.
Governor
HMP Pentonville
Caledonian Road
London N7 8TT
3. 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 21 January 2016, I commenced an investigation into the death of
Tedros Habtom Kahssay, aged 29 years. The investigation concluded at
the end of the inquest yesterday.
1
The jury made a narrative determination, which I attach.
4
CIRCUMSTANCES OF THE DEATH
Tedros Kahssay killed himself by hanging in HM Prison Pentonville,
having been admitted a month earlier on a charge of murdering his
pregnant partner.
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.
I list the MATTERS OF CONCERN below, though I am conscious that
some of these have now been the subject of remedial action.
Person Escort Record
1. The person escort record (PER) and appended report of the forensic
medical examiner (FME) that accompanied Mr Kahssay to HMP
Pentonville did not accompany him to nurse reception screening.
Circumstances of the Index Offence
2. The index offence is recorded on the PER (and inputted onto the
prison computer system NOMIS, though not the healthcare computer
system SystmOne), but not the circumstances. The circumstances –
perhaps from the indictment read out in court – may be potentially
helpful to healthcare and possibly also to discipline staff in prison.
This is not clear cut, because the logistics of obtaining the information
it are complex;
and making
prosecutions must not be compromised; and there is the potential for
making a prisoner’s mental state worse by probing the circumstances.
those who need
it available
to
However, it seems that this is an issue that is worthy of consideration,
preferably at a national level.
General Practitioner Records
3. The general practitioner records were never obtained (an issue that I
have raised in the past), despite there being a system in place for
Pentonville healthcare administrative staff to do this. Whilst that did
not impact upon Mr Kahssay’s care, it might for another prisoner.
2
Nurse Reception Screening
4. The first reception screen template contained questions that carried
an inherent ambiguity, in that they related to a change in personal and
family circumstances, which must always be the case when a person
is incarcerated and therefore does not assist in determining which
prisoners are at an increased risk.
(I did hear at inquest that any prisoner on a charge of murder will now
be the subject of a psychiatric assessment.)
5. Both nurses conducting reception screening talked often in evidence
about not being able to do anything other than accept the answers
given by the prisoner. They did not seem to bring any objective
analysis to the screening. The process of nurse screening appeared
at times to be a tick box exercise.
6. The second reception (well man) screening nurse did not explore the
history of depression recorded, he said because the prison general
practitioner had not prescribed any medication for depression. On
reflection, the nurse thought that he should have asked about it.
Resuscitation
7. The resuscitation led by the two nurses occupying the positions of
primary (Hotel 7) and secondary (Hotel 12) leads for emergency
healthcare in the prison that night, was significantly lacking in the
following ways.
The nurse with primary responsibility for emergency care in the
prison did not have a proper understanding of the nature of a code
red and a code blue prison medical emergency. (I have raised this
issue in the past.)
One minute and twelve seconds elapsed after nurse arrival before
any substantive care was given. The action during that one minute
and twelve seconds did not appear to progress the resuscitation
attempt.
There seemed no clear demarcation of roles and responsibilities
during the resuscitation. Of course these may change as those
giving resuscitation tire, but the changes seemed haphazard.
There was no checking for breath or airway manoeuvre at the
outset or at any time during the resuscitation.
There was no checking for pulse at the outset, before commencing
chest compressions, or at any time during the resuscitation.
3
The lead nurse attempted to justify this by saying that she had not
wanted to waste time. This was despite the first action upon
finding the casualty being to apply a blood pressure cuff, on the
basis that this was part of the nurse assessment.
When giving evidence, the lead nurse appeared to conflate the
casualty who is in cardiorespiratory arrest with the casualty who is
merely unconscious. She repeatedly talked about the need to give
cardiopulmonary resuscitation (CPR) to an unconscious casualty.
She said that, at the time she started chest compressions, she did
not know whether Mr Kahssay was breathing or not breathing.
When CPR was given, chest compressions were ineffective, being
too quick and too shallow.
There was only one brief attempt to use an ambubag, the majority
of the resuscitation taking place without airway assistance or with
a non rebreathe oxygen mask.
It appeared that one oxygen cylinder was empty, as it had to be
changed for another.
The nurse leading the resuscitation described it as chaotic. That is
indeed how it appeared to me from her description and from viewing
the bodycam footage.
I was and remain very gravely concerned, not in this respect for Mr
Kahssay who was
resuscitation
commenced, but for anyone else in the prison in need of first aid.
fact already dead when
in
6
ACTION SHOULD BE TAKEN
In my opinion, action should be taken to prevent future deaths and I
believe that you 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 February 2017. 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.
4
8
COPIES and PUBLICATION
I have sent a copy of my report to the following.
HHJ Mark Lucraft QC, the Chief Coroner of England & Wales
HM Inspectorate of Prisons
friend of Tedros Kahssay
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
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
find
9
DATE SIGNED BY SENIOR CORONER
06.12.16
5
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.
Core HM Prison Pentonville Caledonian Road London N7 8TT www.careuk.com Coroner ME Hassell Senior Coroner Inner North London St Pancras Coroner’s Court Camley Street London NC1 4PP 27 January 2017 Dear Madam, Regulation 28: Prevention of Future Deaths report The inquest touching the death of Tedros Habtom Kahssay Deceased HMP Pentonville Date of death: 19" January 2016 Thank you for your Regulation 28 Prevention of Future Deaths Report dated 6 December 2016 issued to Care UK following the inquest into the death of Mr Tedros Kahssay. Care UK is the provider of primary healthcare and mental health services at HMP Pentonville. The matters of concern to you in so far as they relate to healthcare are highlighted in bold with the response set out below each concern. Concern 1. The person escort record (PER) and appended report of the forensic medical examiner (FME) that accompanied Mr Kahssay to HMP Pentonville did not accompany him to nurse reception screening. As you heard in evidence at the inquest, the reception screening template has been changed. The change that has been implemented is a control question in the first reception screen which is a mandatory field so the nurse needs to stop and answer the question. It asks if the nurse has seen the PER. All nursing staff have been instructed and are aware that they are not to screen any prisoner without a CSRA and PER as minimum requirement to aid screening. Concern 3. The general practitioner records were never obtained (an issue that I have raised in the past), despite there being a system in place for Pentonville healthcare administrative staff to do this. Whilst that did not impact upon Mr Kahssay’s care, it might for another prisoner. As you heard in evidence, consent for the obtaining of general practitioner records is now sought as part of the reception screen and it is also a mandatory field that needs to be completed by the member of healthcare prior to finishing the screen. When consent is taken, the screening tool requires a task be sent to the Administrative staff to make them aware that Care UK Clinical Services Limited - Registered in England No 03462881 Registered Office: Connaught House, 850 The Crescent, Colchester Business Park, Colchester, Essex CO4 9B consent has been gained and that a request for notes needs forwarding to the patient’s general practitioner. There is now an auditable process as it is sent by task on SystmOne. Whilst we have a system in place to request medical records and follow up, it is important to highlight that we cannot ensure that a GP practice will send records to us. It is anticipated that this is an issue which will be eased once the new clinical IT system is in place providing access to the NHS spine and patients Summary Care Records. Concern 4. The first reception screen template contained questions that carried an inherent ambiguity, in that they related to a change in personal and family circumstances, which must always be the case when a person is incarcerated and therefore does not assist in determining which prisoners are at an increased risk. You heard evidence at the inquest as to how the first night reception template and part 2 reception template have been completely changed. There is now a referral pathway which is task driven and can be audited and gives more accountability to the person undertaking the screening. These changes to the Reception templates took place in early December 2016. You referred to evidence you heard at the inquest that any prisoner on a charge of murder will now be the subject of a psychiatric assessment. | can confirm this requirement is posted on the opening page of the First Night Reception Screen. The psychiatric assessment will take the form of an assessment with both a member of the prison mental health in-reach team and a psychiatrist. The need for an assessment will be identified via a task on SystmOne which can be audited. Concern 5. Both nurses conducting reception screening talked often in evidence about not being able to do anything other than accept the answers given by the prisoner. They did not seem to bring any objective analysis to the screening. The process of nurse screening appeared at times to be a tick box exercise. Both members of nursing staff, who were not directly employed by Care UK no longer work at HMP Pentonville or any Care UK establishment. You heard evidence with regard to the new reception screening template and process. The scoring system in relation to the risk of self-harm and or suicide has now gone as this was found to be too prescriptive. The focus is now placed on the member of healthcare who is screening the patient to explore the presentation and look into factors that may be relevant to suicide and or self-harm. To support this, a new risk assessment is currently in development by the national team and is based on learning from previous deaths in custody, concerns raised by the Learned Coroner, national reports and best available evidence. In addition training has been delivered to clinical leads across the country on suicide and self-harm risk assessment and the materials from this training are available on the Care UK Health in Justice intranet pages. Concern 6. The second reception (well man) screening nurse did not explore the history of depression recorded, he said because the prison general practitioner had not prescribed any medication for depression. On reflection, the nurse thought that he should have asked about it. We accept that the nurse could have explored the history of depression in greater detail. Our secondary reception screening process provides more time for this and we are in process of rolling out our wellbeing wheel assessment to support this assessment. The wellbeing wheel provides a structure for clinical staff to explore mental health issues in more depth alongside their physical health and substance misuse issues. Training, both online and face to face, has been developed to support the use of the wellbeing wheel and the Pentonville team are expected to have completed the implementation by end of March 2017. Concern 7. The resuscitation led by the two nurses occupying the positions of primary (Hotel 7) and secondary (Hotel 12) leads for emergency healthcare in the prison that night, was significantly lacking. The Hotel 7 agency nurse no longer works in any Care UK establishment. The Second Nurse who was designated Hotel 12 is subject to an investigation which is being undertaken locally within the organisation in the first instance. You heard that all nursing staff are given training by senior nurses who discuss scenarios and staff are issued with a card as an aide memoir. Both Nurses had attended that training which was delivered in July 2016. The use and meaning of Code Red and Code Blue has again been strongly reinforced to the nursing staff. Training sessions have taken place for all the staff and attendance sheets have been collected. Posters re-affirming the criteria of Code Red and Code Blue were displayed in clinical areas in December 2016. Furthermore, Safer Custody have been requested to re-order 250 of the aide-memoire cards for distribution across the establishment All clinical staff that are employed by Care UK have ILS as a mandatory training requirement. A check has been undertaken to ensure that all Care UK clinical staff are receiving the ILS training. This has been confirmed to be the case. Guidance from NHSE regarding the resuscitation of patients where there is rigor mortis present has been circulated to staff and is accessible on the Care UK Health in Justice intranet pages. Where staff are not confident in recognising rigor mortis they should proceed with resuscitation until someone arrives who is competent to recognise life extinct. Recognition of Life Extinct (ROLE) training is being considered by the Care UK resuscitation committee as an ‘add on’ to the ILS training. In addition to this, the healthcare team plan to discuss issues relating to resuscitation and use of emergency bags regularly in their Friday afternoon training sessions. A SOP for emergency response is in development by the national team and is due for circulation shortly. We trust that the above response provides the information that you require but please do not hesitate to contact us if Care UK can be of any further assistance. Yours faithfully. Head of Healthcare
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