Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0318, written 23 Oct 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 23 Oct 2018 |
|---|---|
| Reference | 2018-0318 |
| Deceased | Nicola Lawrence |
| Coroner | Jonathan Leach |
| Coroner area | West Yorkshire (East) |
| 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.
ANNEX A
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)
NOTE: This form is to be used after an inquest.
1 | CORONER
‘| REGULATION 28 REPORT TO PREVENT FUTURE DEATHS ~]
THIS REPORT IS BEING SENT TO:
1. Michael Spurr, National Offender Management Service, 102 Petty France,
London, SW1H 9AJ
lam JONATHAN DAVID LEACH, Area Coroner, for the Coroner area of West Yorkshire
(Eastern) district
ny
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.
_|
INVESTIGATION and INQUEST
On 26" September 2016 | commenced an Investigation into the death of Nicola Jayne
Lawrence, aged 38 years. The Investigation concluded at the end of the Inquest on 17"
May 2018. The conclusion of the Inquest was a Narrative. She died from 1(a)
Methadone Toxicity 2. Multi Drug Administration.
al
CIRCUMSTANCES OF THE DEATH
At the time of her death the deceased was an Inmate at HMP New Hall. She arrived on
the 9" September 2016. She was taking a considerable amount of medication including
methadone. She was seen by a number of Health Care staff. No consideration was
given by them to the anti-respiratory/depressant effects of the medication on her. On
the 24" September 2016 she was found unresponsive. Notwithstanding the efforts of
Prison staff, Health Care staff and ambulance staff she died.
6 | ACTION SHOULD BE TAKEN
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. —
(1) Some Prison staff had not received any cardiopulmonary resuscitation training.
Either as part of initial training or any refresher training. Evidence was received that
good quality CPR within the first few minutes of those who stopped breathing or heart
stopped was critical.
—|
In my opinion action should be taken to prevent future deaths and | believe you
[AND/OR your organisation] have the power to take such action. |
{| __
YOUR RESPONSE |
You are under a duty to respond to this report within 56 days of the date of this report,
namely by 18 December 2018. I, the Area 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.
—
{u
COPIES and PUBLICATION
| have sent_a copy of my report to the Chief Coroner and to the following Interested
Person ee and Care UK Limited.
| 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.
23" October 2018 Maar Wn
JONATHAN DAVID LEACH
Area Coroner
West Yorkshire (Eastern)
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.
ap HM Prison & Probation Service Michael Spurr Chief Executive HM Prison & Probation Service 8" Floor 102 Petty France London SW1H 9AJ E-mail: ceohmpps@noms.gsi.gov.uk Mr Jonathan Leach Area Coroner, West Yorkshire (Eastern) Coroner's Office and Court 71 Northgate Wakefield, WF1 3BS E-mail:hmcoroner@wakefield.gov.uk 21 November 2018 Dear Mr Leach, Inquest into the death of Nicola Lawrence Thank you for your Regulation 28 Report of 23 October addressed to the Governor of HMP New Hail, following the conclusion of the inquest into the death of Nicola Lawrence. As Chief Executive Officer | am responding on behalf of Her Majesty's Prison and Probation Service (HMPPS). | know that you will share a copy of this response with Nicola’s mother and | would first like to express my sincere condolences for her loss. Every death in custody is a tragedy and the safety of those in our care is my absolute priority. | am grateful to you for bringing to my attention your concem that some prison staff at HMP New Hall have not received cardiopulmonary resuscitation (CPR) training, either as part of initial training or as refresher training. You may be aware that our approach is set out in PSI 29/2015 First Aid, which does not mandate first aid training for alt staff, but requires Governors of public sector prisons to ensure that there are at all times sufficient suitably trained first aiders available. The appropriate number must be determined by conducting a first aid risk assessment, and first aiders must be trained to levels which are appropriate to the circumstances - to either First Aid at Work (FAW) level or Emergency First Aid at Work (EFAW) level. The Governor at HMP New Hall has reviewed the band/grade and number of staff who need to be trained in first aid, and the number of such staff required on duty at times throughout the day. The prison currently has 40 staff trained in FAW and 48 in EFAW, and these numbers are considered to be sufficient to ensure that an appropriate response can be provided in any emergency situation that may arise at any time. In April 2018. a notice was issued by the Govemor to all staff trained in first aid reminding them of the importance of responding promptly to an emergency. Thank you again for bringing these matters of concern to my attention. | hope that this response provides assurance that lessons have been learned from the circumstances of Nicola Lawrence's tragic death. Yours sincerely Hichoe Spur Michael Spurr
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