Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0012, written 10 Jan 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 10 Jan 2018 |
|---|---|
| Reference | 2018-0012 |
| Deceased | John O’Meara |
| Coroner | Sarah Ormond-Walshe |
| Coroner area | West London |
| 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. Senior Governor, HMP Wormwood Scrubs. CORONER | am Sarah Ormond-Walshe, Assistant Coroner, West London jurisdiction 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. INQUEST On 6 April 2016 the court opened an investigation into the death of John Kevin O’MEARA. He had died on 29" March 2016. The inquest was concluded on 9" October 2017 CIRCUMSTANCES OF THE DEATH A jury found: That the medical cause of death was: 1a. Respiratory Depression 1b Methadone in Conjunction with other drugs 2 History of Alcohol and Drug Misuse and Evidence of Liver Damage How, when and where: Between 12.00 and 14.20 on 29/03/16, the deceased suffered a respiratory failure whilst in cell R4-05 of the Conibeere Unit in HM Prison Wormwood Scrubs. Attempts were made to resuscitate. The deceased was pronounced dead 15.17. Mr O’Meara was housed in the Conibeere Unit of HM Prison Wormwood hol misuse on arrest. He involving prescription of hadone was prescribed detailing a history of drug and alco was undergoing a drug stabilisation programme Methadone in line with nation guidelines. The Met following an initial assessment and drug test by clinical staff on his arrival at the prison. In addition, he was prescribed multiple drugs to alleviate and manage symptoms of alcohol withdrawal and mental health issues. Mr O’Meara suffered a catastrophic respiratory failure. He died in part because: 1. Insufficient staffing levels in the Conibeere medical supervision, specifically the omiss monitoring and failure to complete full vital of his death. A missed opportunity to raise concerns ov following an interaction with prison staff al his death. Scrubs afte Unit led to inadequate ion of the medical signs checks on the day er Mr O’Meara’s health 12 midday on the day of The Con Drug Re clusion of the Jury was: ated CORONER’S CONCERNS During the course of the inquest, the evidence revealed matters giving rise to concern that in my opinion mean that there is still a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. | have sufficient concern about wide this Prevent Future Death Report (CJ Regulation 28 Coroners (Investigatio centrally. The MATTERS OF CONCERN are as This is: This inquest has raised two matters issues which warrant the writing of A 2009, Schedule 5, Paragraph 7: ns) Regulations 2013) to be sent more ollows. which | would like to highlight to the Prison Service. They are not matters, in Mr O’Meara’s case, which were necessarily causative of the death, but they are live issues very relevant to the current challenging times Prison staffed prisons: Activation of Code Blue/Red Officers are facing in busy and short- The sad facts leading up to the death of John Kevin O’MEARA have not been the first set of facts where | have heard about a death where the activation of codes has not been im mediate. | am concerned that Prison Officers are not strictly following the Code Blue/Red system which is meaning there is a delay in the London Ambulance being called. Whilst | can see in many cases that, by the time the prisoner has been found, there may be nothing that can be done to resuscitate them with the number of deaths happening relating to opiate use, the prompt administration of Naloxone is important to give the deceased the best chance: and this is only one resuscitative measure. | gather the current way that Officers are trained is by the use of Notices and Pocket-sized Cards. The Officer finding Mr O’Meara, even after questioning by myself and the Counsel for Interested Persons, left the witness stand still not understanding that by not immediately calling a Code Blue, and despite prison medical staff coming quickly, an ambulance would not have been called. Even presumably having reflected on the case, she did not appear to understand the reason why a Code is called. | am asking for more consideration to be given to ensure the right message is getting across and that Prison Officers understand the importance of and reasons for the use of the codes. Passive Dog Use The Prison GP expert in this inquest was emphatic that Novel Psychoactive Substance played a part in the death. | understand that these drugs can be brought into the prison in a number of ways and one is NPS contaminated paper or even childrens’ photographs, arriving into Prisons in the post. | appreciate how challenging it is to control the use of Novel Psychoactive Substances in prisons. So, the use of trained passive dogs is particularly helpful In fact it appears to be one of the only failsafe ways to controlling NPS use in prisons. There are only two at HMP Wormwood Scrubs whereas HMP Highdown has eight. Although dogs can be ‘borrowed’ from other London prisons when handlers are away, | wish to put on record my support for funding for more of these dogs at this current challenging time. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths. Prison Officers should receive better and/or more training on the prompt activation of Codes Red and Blue at HMP Wormwood Scrubs. More passive dogs should be available at HMP Wormwood Scrubs. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by Miss Ormond-Walshe. |, 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. If you require any further information or assistance about the case, please contact the Coroner’s Officer, COPIES and PUBLICATION | have sent a copy of my report to the following Interested Persons: 1. 2. Central London Community NHS Trust 3. North West London NHS Foundation Trust 4. Rehabilitation for Addicted Prisoners Trust | 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. 10 January 2018 Miss Ormond Wate
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.
LBHF CORONERS & MORTUARY HM Prison & Probation Service 19 MAR 2018 Michael Spurr Chief Executive HM Prison and Probation Service 8t" Floor 102 Petty France London SW1H 9AJ Email: ceohmpps@noms.gsi.gov.uk Miss Ormand-Walshe West London Coroner’s Court 25 Bagley’s Lane Fulham London SW6 2QA 06 March 2018 Dear Miss Ormand-Walshe, Thank you for your Regulation 28 Report of 10 January 2018 following the recent inquest into the death of John O’Meara at HMP Wormwood Scrubs on 29 March 2016. | know that you will share a copy of this response with Mr O’Meara’s family and | would like first to express my condolences for their loss. Every death in custody is a tragedy and the safety of those in our care is my absolute priority. Your first concern is with the failure immediately to use an emergency response code, something that has also occurred in other cases. | understand that you heard evidence about a variety of steps that are being taken locally to ensure that staff are aware of the importance of using the correct emergency code. Regular notices to staff are published, signs are displayed in all offices and information about emergency response procedures is included in the induction for all new staff. More recently, notices have been attached to all cell doors in the First Night Centre, and early indications are that staff have found this useful. Plans are in place to extend this arrangement to other high risk areas such as healthcare, segregation and the detox unit later this month. As you may know, the member of staff to whom you refer who continued not to understand the system even after giving evidence at the inquest is no longer employed at the prison. Please be assured that the Governor is seized of the importance of this issue and will keep the situation under review in order to identify any further steps that can be taken to ensure that staff are aware of the emergency codes and understand when to use them. Your second concern is that the number of passive drug dogs available at the prison is not sufficient to provide an effective response to the supply and use of psychoactive substances. | agree that we need to improve our capacity to address this issue, and | am pleased to report that the London and Thames Valley regional search team is currently recruiting additional dog handlers to increase the service provided to prisons in the region. This includes HMP Wormwood Scrubs, which will be provided with a total of seven dog handlers, with both passive and active search and patrol dogs. Thank you again for bringing these matters of concern to my attention. Yours sincerely Michael Spurr
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