Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0255, written 26 Jul 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 26 Jul 2019 |
|---|---|
| Reference | 2019-0255 |
| Deceased | William Vickers |
| Coroner | Tom Osborne |
| Coroner area | Milton Keynes |
| Category | Emergency services related deaths (2019 onwards) · State Custody related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
PRIVATE AND CONFIDENTIAL Mr Tom Osborne Senior Coroner for Milton Keynes, Civic Offices 1 Saxon Gate East Central Milton Keynes MK9 3EJ 2nd September 2019 Dear Mr Osborne Northern House, 7 - 8 Talisman Business Centre, Talisman Road, Bicester, Oxfordshire, OX26 6HR Tel: 01869 365 000 Re: Inquest Touching on the Death of William Vickers Thank you for your report dated 26th July 2019 and for giving SCAS the opportunity to work with you regarding your concern. To confirm, your concerns relate to the provision of radios to private provider colleagues and assigning a paramedic to attend incidents within a prison environment. I will respond to your concerns separately below. I will also provide you with details of the work we are undertaking with our local prisons as part of this response. 1. Provision of radios to private provider staff The airwave radio system used by SCAS, and NHS Ambulance Trusts nationally, is governed by strict licence conditions. I have included a copy of the ‘Airwave Code of Practice – NHS Ambulance Service Profile’ with this letter. The licence terms (copied below) dictate that any private provider using the radio system must have their own licence. ‘5.2 TEA2 Sub-Licencing Before an organisation can procure, use or handle any Airwave Service radio terminals, it is required to hold a valid TEA2 Sub-Licence which is a ‘confidentiality and restricted usage undertaking’. It is a mandatory requirement that all individual organisations with a business requirement to handle and/use Airwave within the context of the Ambulance Radio Programme, must hold their own TEA2 sub-licences. This includes each Ambulance Trust, Air Ambulance providers (e.g. Bond and Medical Aviation Services), St John Ambulance, British Red Cross, equipment maintainers/suppliers and private companies used for Patient Transfer Services etc. This is managed by and carried out through the Airwave Accreditation Secretariat which also has the facility to provide ambulance Trusts with a list of relevant sub-licensees in each area’. (Our emphasis added). Registered Headquarters: 7 and 8 Talisman Business Centre, Talisman Road, Bicester 0X26 6HR Under section 7.4.3 of the licence, we are permitted to temporarily loan a radio to another organisation for a particular incident. However, the licence is clear that this cannot be for a period over 28 days. ‘7.4.3 Loaning Radio Terminals Under the terms of the Airwave Public Safety Radio Licence issued by OFCOM, organisations can temporarily loan terminals provided that: • It is for the purposes of carrying out public safety functions during a particular incident (i.e. for public safety related coordination and communication) and not for ‘business as usual’ public safety functions; and • The duration of the loan should not exceed twenty-eight (28) days, subject to compliance with the requirements of section 7.4.3.2’, For private provider crews to have permanent access to the radio system, they must apply for a licence for their own organisation and procure the radio equipment. Following receipt of your report, we will ensure that the private provider firms that we work with are aware of this option so they can consider whether it is an option they would like to pursue. However, it is important to note the following: a. The Airwave coverage contract for emergency services guarantees coverage in outdoor roadside locations. It does not guarantee coverage in a building or vehicle. As such the ambulance vehicle should always be in coverage but coverage is not guaranteed for handheld portable radio devices. b. The Airwaves radio system is due to be replaced by the Emergency Services Network critical communications system which will make radio use within emergency services obsolete. The initial intention of the Home Office was for this to be in place by the end of 2019. We understand this has now been postponed until 2022 due to unexpected difficulties surrounding the technology available. 2. Skill set of crews sent to an emergency within a prison. As you will be aware, there are a number of different operational job roles within the prehospital environment. These include Specialist Paramedics, Paramedics, Ambulance Technicians and Emergency Care Assistants. Nationally there is a shortage of Paramedics which means that it is not feasible for us to guarantee a Paramedic is part of a crew on every resource. When we receive an emergency call, it is really important that we receive accurate information regarding the patient’s condition to ensure that we are able to triage the call appropriately. This is something which will be expanded on further below in the section on the work we are undertaking with our local prison services. It is not appropriate for the location of the incident to be included as part of the triage; the focus must be on the clinical condition of the patient. Therefore, we are unable to provide a different response to a call for help just because the location is a prison. To offer you assurance that a Paramedic will always be dispatched to attend immediately life-threatening incidents, within our standard operating procedures, there is already a specification for a paramedic crew to be sent to all patients who are in cardiac or respiratory arrest (see below). Registered Headquarters: 7 and 8 Talisman Business Centre, Talisman Road, Bicester 0X26 6HR It is possible that the first attending resource to a time critical event will not have a Paramedic on board if they are the closest available resource to the incident scene. However, a Paramedic will always be dispatched to attend along with them. This is to ensure that there is not a delay in a resource arriving with the patient if a Paramedic crew has a further distance to travel to the incident location. Registered Headquarters: 7 and 8 Talisman Business Centre, Talisman Road, Bicester 0X26 6HR Collaboration between SCAS and our local prison services As part of the review we are undertaking with our local prisons, we are facilitating a fixed process regarding call triaging, access to the prison and retention of our personnel’s operational radios and mobile telephones. I will detail each point separately below. 1. Call triage As detailed above, it is vital that we receive the correct information regarding a patient’s condition to ensure that an appropriate triage can take place. Within a prison setting, it is often someone within their control room which undertakes the call to the ambulance service based on a code they have been provided with by prison staff at the patient’s side. Unfortunately, their coding of a ‘red’ or ‘blue’ emergency is lacking the information required for an accurate and appropriate triage to take place. This is also often the only information that the caller has regarding the patient’s condition. As an example, the criteria for a code ‘red’ prison emergency is a prisoner who is either bleeding heavily, has sustained a severe burn or has a suspected fracture. Whilst a fracture may be painful and does require emergency medical treatment within a hospital environment, it is not a time critical event which requires an immediate ambulance dispatch. In comparison, significant bleeding or substantial burns do require an urgent response. The work we are completing will ensure that an accurate account of the medical emergency and the patient’s condition will be provided by the caller to ensure the appropriate response is provided. In the case of Mr Vickers, the person making the call was telephoning from the prison control room. Importantly, the caller was unaware of whether the patient was breathing and conscious. The only information they were able to provide was that he was a male prisoner and the incident was a code blue which indicated a possible fit or potential breathing difficulties. This resulted in a category 2 disposition requiring an ambulance response within 18 minutes. If the caller had been aware that Mr Vickers was unconscious and was not breathing, a category 1 disposition would have been reached which would have ensured a Paramedic was allocated to attend the incident. 2. Access to the prisoner (patient). Our joint working agreement will also ensure that the ambulance crew will be provided with timely access to their patient. To assist the prison with their security protocols, we will aim to provide the prison with the call sign of the resource and the number of staff on board. The call sign is visibly displayed on the outside of a resource and staff will be instructed to have their NHS photographic ID cards ready to show prison gate staff. The provision of the vehicle call sign will enable gate staff to recognise that the vehicle is expected and requires emergency access to the prisoner. 3. Operational radios and mobile telephones The joint agreement will seek to ensure that ambulance staff can keep their operational radios and work mobile telephones with them whilst they attend to the prisoner. This is to ensure that they have the ability to contact our control centre directly as well as being able to access their clinical guidelines via the Joint Royal Colleges Ambulance Liaison Committee mobile app. As detailed above, radio coverage is not guaranteed within the prison building so their mobile telephones may be required to contact our control centre. In addition, access to the guidelines via their mobile telephone is vital to ensure that the correct treatment and / or medication and doses of medication are provided to the patient. Historically crews had access to the guidelines via a pocket book which they carried on their person. With the advance of technology, these are now provided to them via a mobile app. The benefit of the app is that any updates or changes to specific topics of the clinical guidelines can be released and made available to crews almost instantaneously. Our internal clinical memos and directives are also available to our crews via the mobile app. Registered Headquarters: 7 and 8 Talisman Business Centre, Talisman Road, Bicester 0X26 6HR We will ensure that the memorandum of understanding produced will apply to our private provider colleagues undertaking work on our behalf. I hope this response has addressed your concerns. However, we would like to offer you the opportunity to meet with our Clinical Governance Leads, who are working with our local prisons, and our Head of Communications / Lead Airwave Advisor to discuss these matters with you further. If you would like to accept this offer, please ask your office to liaise with Jennifer Saunders to arrange a convenient time for a meeting to be held. Yours sincerely Will Hancock Chief Executive Enc. Airwave Code of Practice – NHS Ambulance Service Profile Registered Headquarters: 7 and 8 Talisman Business Centre, Talisman Road, Bicester 0X26 6HR
Regulation 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This from is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: Head of Health Care, HMP Woodhill 1 CORONER I am Tom OSBORNE, Senior Coroner for the area of Milton Keynes 2 CORONER’S LEGAL POWERS I 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. 3 INVESTIGATION and INQUEST On 08/08/2018 I commenced an investigation into the death of William VICKERS, aged 37. The investigation concluded at the end of the inquest on 19 July 2019. The conclusion of the inquest was a Narrative Conclusion: The deceased was detained at HMP Woodhill on 18th July 2018, on arrival he was seen by medical staff and in view of his drug addiction he was taken to the detoxification unit and placed in a double occupancy cell. At some time around 5:30 am on 19th July 2018 he suffered a cardiac arrest of unknown cause and despite resuscitation he suffered hypoxic brain damage and died at Milton Keynes University Hospital on 26th July 2018. His cause of death was confirmed following a post mortem examination as: I a Bronchopneumonia I b Hypoxic Ischaemic Encephalopathy I c Cardiac Arrest II Chronic obstructive pulmonary disease 4 CIRCUMSTANCES OF THE DEATH William Vickers was found collapsed in his cell at HMP Woodhill on the 19th July 2018. There was a delay in gaining access to his cell by prison staff and a delay in an ambulance crew gaining access to him once they had entered the prison but he was successfully resuscitated and taken to Milton Keynes University Hospital but had suffered hypoxic brain damage. He remained in hospital until he passed away on 26th July 2018. 5 CORONER’S CONCERNS The MATTERS OF CONCERNS are as follows: During the course of the evidence I was concerned that not all staff within the prison, including those within healthcare, were confident in using the AED (Automatic External Defibrillator) and believe that the training of all staff should be reviewed so all are both familiar and confident in its use. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or 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 19th September 2019. 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 Chief Coroner and to the following Interested Persons The family of Mr Vickers - - HMP Woodhill - Westminster Drug Project - Northamptonshire Police - GEO Amey I have also sent a copy of the Prison and Probation Ombudsman who may find it of interest. 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 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. 9 Tom OSBORNE Senior Coroner for Milton Keynes Dated: 26 July 2019
Regulation 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This from is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: Governor, HMP Woodhill 1 CORONER I am Tom OSBORNE, Senior Coroner for the area of Milton Keynes 2 CORONER’S LEGAL POWERS I 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. 3 INVESTIGATION and INQUEST On 08/08/2018 I commenced an investigation into the death of William VICKERS, aged 37. The investigation concluded at the end of the inquest on 19 July 2019. The conclusion of the inquest was a Narrative Conclusion: The deceased was detained at HMP Woodhill on 18th July 2018, on arrival he was seen by medical staff and in view of his drug addiction he was taken to the detoxification unit and placed in a double occupancy cell. At some time around 5:30 am on 19th July 2018 he suffered a cardiac arrest of unknown cause and despite resuscitation he suffered hypoxic brain damage and died at Milton Keynes University Hospital on 26th July 2018. His cause of death was confirmed following a post mortem examination as: I a Bronchopneumonia I b Hypoxic Ischaemic Encephalopathy I c Cardiac Arrest II Chronic obstructive pulmonary disease 4 CIRCUMSTANCES OF THE DEATH William Vickers was found collapsed in his cell at HMP Woodhill on the 19th July 2018. There was a delay in gaining access to his cell by prison staff and a delay in an ambulance crew gaining access to him once they had entered the prison but he was successfully resuscitated and taken to Milton Keynes University Hospital but had suffered hypoxic brain damage. He remained in hospital until he passed away on 26th July 2018. 5 CORONER’S CONCERNS The MATTERS OF CONCERNS are as follows: During the course of the evidence I was concerned that once the ambulance was admitted through the main gate it then took 11 minutes for the ambulance to be escorted through 5 sets of gates to the incident. Consideration must be given to a robust system of ensuring that all gates are opened and manned by security staff so that the ambulance is not in any way hindered in getting to their patient. The present system in my view puts prisoners’ lives at risk. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or 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 19th September 2019. 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 Chief Coroner and to the following Interested Persons The family of Mr Vickers - - HMP Woodhill - Westminster Drug Project - Northamptonshire Police - GEO Amey I have also sent a copy of the Prison and Probation Ombudsman who may find it of interest. 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 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. 9 Tom OSBORNE Senior Coroner for Milton Keynes Dated: 26 July 2019
Regulation 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This from is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: South Central Ambulance Service 1 CORONER I am Tom OSBORNE, Senior Coroner for the area of Milton Keynes 2 CORONER’S LEGAL POWERS I 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. 3 INVESTIGATION and INQUEST On 08/08/2018 I commenced an investigation into the death of William VICKERS, aged 37. The investigation concluded at the end of the inquest on 19 July 2019. The conclusion of the inquest was a Narrative Conclusion: The deceased was detained at HMP Woodhill on 18th July 2018, on arrival he was seen by medical staff and in view of his drug addiction he was taken to the detoxification unit and placed in a double occupancy cell. At some time around 5:30 am on 19th July 2018 he suffered a cardiac arrest of unknown cause and despite resuscitation he suffered hypoxic brain damage and died at Milton Keynes University Hospital on 26th July 2018. His cause of death was confirmed following a post mortem examination as: I a Bronchopneumonia I b Hypoxic Ischaemic Encephalopathy I c Cardiac Arrest II Chronic obstructive pulmonary disease 4 CIRCUMSTANCES OF THE DEATH William Vickers was found collapsed in his cell at HMP Woodhill on the 19th July 2018. There was a delay in gaining access to his cell by prison staff and a delay in an ambulance crew gaining access to him once they had entered the prison but he was successfully resuscitated and taken to Milton Keynes University Hospital but had suffered hypoxic brain damage. He remained in hospital until he passed away on 26th July 2018. 5 CORONER’S CONCERNS The MATTERS OF CONCERNS are as follows: Firstly, I was told during the course of the evidence that the ambulance crew who attended the prison in response to the emergency call, do not have access to the radio system of SCAS. The ambulance which attended is operated by Jigsaw Medical Services which is denied access to the system. consideration given to ensure that all ambulance crews have access to the radio system. I believe this policy should be reviewed urgently and Secondly I am concerned that the first response did not include a “paramedic”. I believe that consideration should be given to a review to ensure that the first responder to an emergency at the prison should always include a fully qualified paramedic. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or 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 19th September 2019. 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 Chief Coroner and to the following Interested Persons The family of Mr Vickers - - HMP Woodhill - Westminster Drug Project - Northamptonshire Police - GEO Amey I have also sent a copy of the Prison and Probation Ombudsman who may find it of interest. 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 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. 9 Tom OSBORNE Senior Coroner for Milton Keynes Dated: 26 July 2019
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.
INHS| Central and North West London NHS Foundation Trust Executive Office Tel: 020 3214 5760 13 September 2019 Mr Thomas Osborne HM Senior Coroner for Milton Keynes Civic Offices 1 Saxon Gate East Central Milton Keynes MK9 3EJ Dear Mr Osborne, Regulation 28 Report to prevent future deaths following the Inquest of Mr William Vickers | am writing in response to the Regulation 28 Report issued on 26 July 2019 following the inquest into the death of Mr William Vickers. We are saddened by the untimely death of Mr Vickers and our deepest condolences are offered to his family. Our aim in addressing the Regulation 28 Report is to provide assurance to both you and to Mr Vickers’ family on the steps that we are taking to ensure that staff and the Trust, as an organisation, learn from Mr Vickers’ death and that measures are put into piace with the aim of ensuring that such issues can be avoided in the future. The concern raised in the Regulation 28 report is set out below in bold followed by details of the actions taken by the Trust. During the course of the evidence, | was concerned that not all staff within the prison, including those within healthcare, were confident in using the AED (Automatic External Defibrillator) and believe that the training of all staff should be reviewed so all are both familiar and confident in its use. New AED’s with data cards are now in place at HMP Woodhill, which record activity during its use. This data will include the following: ° Incident duration - Elapsed time of the recorded incident from when the AED was turned on. ° Shocks delivered - The total number of shocks that were delivered during the recorded incident. Trust Headquarters, 350 Euston Road, London NW1 3AX Telephone: 020 3214 5700 www.cnwi.nhs.uk “aed PARTNERSHIP London Milton Keynes Kent Surrey DPS ee SS 3 for life Hampshire * First shock time - Elapsed time to first shock delivery from when the AED was turned on. e Presenting ECG - Up to 15 seconds of the presenting ECG from the time the pads were applied to the patient. In July 2019, with the introduction of the new AEDs there have been a number of training sessions held to ensure CNWL Offender staff are competent and confident in their use. The Trust Resuscitation Lead has confirmed that all emergency response training (BLS, ELS, ILS) includes information on the verbal instructions (and their meaning) that is given by an AED. The meaning of the wording ‘shock cancelled’ has been added with immediate effect to the training delivered. We have, with immediate effect, ensured that all Offender Care Services including Woodhill will have: . Monthly refresher sessions held locally for familiarisation and training on the use of the AED and emergency equipment. * Attendance by clinical staff to a refresher session at least quarterly. ° Records of attendance at the refresher sessions which will be monitored locally. . A requirement for staff to complete a signed statement of competence following refresher sessions. ‘Know your AED’ posters have been developed and are displayed throughout HMP Woodhill to maintain familiarisation with it. A ‘How to use the AED’ guide has also been sent to all healthcare staff at HMP Woodhill and will be used as part of the refresher training sessions. It has been agreed with the Governor that CNWL will offer AED training sessions to officers at HMP Woodhill. Officers will be able to attend the refresher sessions scheduled each month. In addition to the above, all CNWL Offender Care staff are required to complete mandatory emergency response training (e-learning annually and face to face bi- annually) at a level appropriate to their role. . Basic Life Support (BLS) - administrative staff ° Emergency Life Support (ELS) — non-qualified clinical staff (e.g. Healthcare Assistants) ° Immediate Life Support (ILS) — qualified clinical staff (e.g. Nurses, Paramedics) Compliance is monitored by the Trust and 100% compliance has been achieved at HMP Woodhill. All new CNWL staff at HMP Woodhill complete a detailed local induction which includes location of emergency equipment and its use. In December 2018, the Offender Care Directorate established a Resuscitation Review Group with the purpose of sharing best practice, standardising emergency equipment and response and to review the training needs of staff. The review group is led by the Lead Nurse for Offender Care and includes senior clinicians from services and the Trust Resuscitation Lead. A ‘resuscitation/medical emergency’ audit form has been introduced to enable a review of care delivered during a medical emergency. These audit forms are reviewed at the Offender Care Resuscitation Review Group and any learning shared across services in their local Care Quality Meetings. Any concerns are reported and monitored by the monthly Business and Performance Meeting by the Offender Care Senior Management Team. Any learning is shared through Learning Lessons Circulars which are disseminated to staff and discussed in local quality and team meetings. On 27 June 2019, the CNWL Primary Care Lead at HMP Woodhill, who is a senior paramedic, completed a ‘Train the Trainer’ course which will enable local emergency response and refresher training detailed above to be carried out on a regular basis within the Woodhill Team. An external independent review has been commissioned to review the practice of emergency response within Offender Care and make recommendations for policy, practice and training. The findings will form the basis of a detailed action plan to ensure staff are equipped by the training provided and equipment available to respond to a medical emergency according to their role and expertise. These actions are expected to improve patient safety and outcomes. | hope this provides you with sufficient assurance that the Trust has taken action following the death of Mr Vickers, and has accepted your recommendation and continues to work to improve the service we provide both in HMP Woodhill and in our wider Offender Care Services. If you have any questions or comments, please do not hesitate to contact me directly on the number above. Yours sincerely, Claire Murdoch Chief Executive
Phil Copple Director General Prisons HM Prison and Probation Service ‘ 8" Floor Ministry of Justice Y 102 Petty Franca London SW1H 9AJ HM Prison & Email:DirectorGeneralPrisons@justice.gov.uk Probation Service Mr T Osborne Senior Coroner HM Coroner's Office, Civic Centre, 1 Saxon Gate East, Milton Keynes, MK9 3EJ Date: 30" September 2019 Dear Mr Osborne Thank you for your Regulation 28 Report dated 26 July 2019 following the inquest into the death of Mr William Vickers at HMP Woodhill. | am also grateful to you for granting a short extension to the usual deadline for reply. | know that you will share a copy of this response with Mr Vickers’ 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. You raised one matter of concern for Her Majesty’s Prison and Probation Service (HMPPS): that, once the ambulance was admitted through the main gate, it took eleven minutes for it to be escorted through five sets of gates to the incident. You asked that consideration be given to a robust system for ensuring that all gates are opened promptly by staff so that the ambulance is not in any way hindered in getting to the patient. Since Mr Vickers’ inquest the contingency plans at HMP Woodhill have been updated to ensure that there are no delays to the process of receipt of any emergency vehicle, including ambulances during night state. When a code red or blue is called, the control room contacts South Central Ambulance Service (SCAS) immediately. When this occurs during night state, members of staff report to the prison gate to await the arrival of the ambulance, and to assist the responding dog handler with opening the gates to the units. An additional Operational Support Grade (OSG) also attends the gate to assist with receiving the emergency vehicle into the prison and searching. The level of search of the vehicle is determined on the basis of an assessment of the circumstances of the emergency, to avoid any unnecessary delay. in the meantime, staff arriving at the scene and entering the cell give further details of the person’s name and current condition to the control room who pass this on to SCAS so that the attending ambulance staff are informed and prepared on arrival. All Custodial Managers will have had the opportunity to take part in a live test of the arrangements for the receipt of emergency vehicles. Training for OSGs is being delivered on the establishment's bi-monthly training afternoons, and all will have completed it before the end of 2019. Thank you again for bringing this matter of concern to my attention. I hope this response has provided reassurance that it is being fully addressed by the Govemor at HMP Woodhill and HMPPS. Yours sincerely, Vo Capple PHIL COPPLE Director General for Prisons
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