Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0012, written 15 Jan 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 15 Jan 2021 |
|---|---|
| Reference | 2021-0012 |
| Deceased | Kevin Lovatt |
| Coroner | Andrew Haigh |
| Coroner area | Staffordshire (South) |
| Category | Alcohol, drug and medication related deaths · Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Her Majesty's Coroner Staffordshire (South) Coroner's Jurisdiction Date: 15 January 2021 Case: REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Director General of Prisons 1 CORONER I am Mr Andrew A Haigh Senior Coroner for Staffordshire South 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. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made 3 INVESTIGATION and INQUEST On 27 December 2017 I commenced an investigation into the death of Kevin John LOVATT. The investigation concluded at the end of the inquest on 14 January 2021. The conclusion of the inquest was accident with the cause of Kevin’s death being obstruction of the internal airways with close temporal relationship to restrain 4 CIRCUMSTANCES OF THE DEATH a) Kevin was a serving prisoner at HMP Dovegate. He died at prison on 22.12.17 having swallowed a package of illicit drugs on which he choked. b) Probable causative issues The deliberate swallowing of too large a package of illicit drugs c) Possible causative issues i) Communication It was not communicated to officers that Kevin had something in his mouth prior to handcuffs being applied. Code Blue was not sounded immediately it was noted Kevin was choking. No one person on the scene took immediate control leading to too many people in a confined space and consequent confusion. ii) Vomiting may have had an additional causative effect. iii) Lack of ALS trained staff who had access to forceps. iv) The use of fingers in the throat in an attempt to remove the obstruction contrary to accepted 1 Staffordshire Place, Stafford, ST16 2LP Telephone: 01785 276126 or 276127 Email: sscor@staffordshire.gov.uk practice (but heavily caveated by the fact that Kevin may already have been dead and the fact that those involved were desperately trying to save his life). v) Insufficient training to ensure that medical staff were put in a position where they could make an immediate medical assessment. 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 for you is as follows. – Following the investigation by the Prisons and Probation Ombudsman a recommendation was made that you should ensure that there is clear guidance and training on the safe use of force when resistant prisoners have items in their mouth which might compromise their breathing. In evidence at the inquest I heard that suitable training on this topic did not appear to have been delivered and that it would be appreciated by prison staff. I wonder therefore if the national training you provide could include control and restraint for prisoners with items in their mouths. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe 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 12 March 2021. 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: Tuckers Solicitors who represent Kevin’s family DWF Law who represent Serco who manage HMP Dovegate Practice Plus Group (formerly Care UK) who provide healthcare at HMP Dovegate I have also sent it to the Prisons and Probation Ombudsman and to the Independent Monitoring Board for HMP Dovegate who may find it useful or 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. 15 January 2021 Andrew Haigh Senior Coroner for Staffordshire South 1 Staffordshire Place, Stafford, ST16 2LP Telephone: 01785 276126 or 276127 Email: sscor@staffordshire.gov.uk Her Majesty's Coroner Staffordshire (South) Coroner's Jurisdiction Date: 15 January 2021 Case: REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: NHS England Health and Justice Regional Team Chair 1 CORONER I am Mr Andrew A Haigh Senior Coroner for Staffordshire South 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. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made 3 INVESTIGATION and INQUEST On 27 December 2017 I commenced an investigation into the death of Kevin John LOVATT. The investigation concluded at the end of the inquest on 14 January 2021. The conclusion of the inquest was accident with the cause of Kevin’s death being obstruction of the internal airways with close temporal relationship to restrain 4 CIRCUMSTANCES OF THE DEATH a) Kevin was a serving prisoner at HMP Dovegate. He died at prison on 22.12.17 having swallowed a package of illicit drugs on which he choked. b) Probable causative issues The deliberate swallowing of too large a package of illicit drugs c) Possible causative issues i) Communication It was not communicated to officers that Kevin had something in his mouth prior to handcuffs being applied. Code Blue was not sounded immediately it was noted Kevin was choking. No one person on the scene took immediate control leading to too many people in a confined space and consequent confusion. ii) Vomiting may have had an additional causative effect. iii) Lack of ALS trained staff who had access to forceps. iv) The use of fingers in the throat in an attempt to remove the obstruction contrary to accepted 1 Staffordshire Place, Stafford, ST16 2LP Telephone: 01785 276126 or 276127 Email: sscor@staffordshire.gov.uk practice (but heavily caveated by the fact that Kevin may already have been dead and the fact that those involved were desperately trying to save his life). v) Insufficient training to ensure that medical staff were put in a position where they could make an immediate medical assessment. 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 for you is as follows. – During evidence at the inquest I heard that nursing staff at HMP Dovegate (and throughout the prison estate) are trained to an Intermediate Life Support level. I realise it would be impractical for all nursing staff at prisons to be trained to an Advanced Life Support level however I was informed that at some stage there was at least one paramedic employed at HMP Dovegate who was trained to ALS level. I wonder if there might be some limited provision of ALS trained staff in the prison estate and if this could be part of the appropriate commissioning arrangements. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe 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 12 March 2021. 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: Tuckers Solicitors who represent Kevin’s family DWF Law who represent Serco who manage HMP Dovegate Practice Plus Group (formerly Care UK) who provide healthcare at HMP Dovegate I have also sent it to the Prisons and Probation Ombudsman and to the Independent Monitoring Board for HMP Dovegate who may find it useful or 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. 15 January 2021 Andrew Haigh Senior Coroner for Staffordshire South 1 Staffordshire Place, Stafford, ST16 2LP Telephone: 01785 276126 or 276127 Email: sscor@staffordshire.gov.uk
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.
Mr A. A. Haig, HM Senior Coroner Staffordshire South 1 Staffordshire Place Stafford ST16 2LP National Medical Director NHS England & NHS Improvement Skipton House 80 London Road London SE1 6LH 29th July 2021 Dear Mr Haig, Re: Regulation 28 Report to Prevent Future Deaths – Mr Kevin John Lovatt; date of death 22 December 2017. Thank you for your Regulation 28 Report (hereafter ‘report’) dated 15 January 2021 concerning the death of Mr Kevin John Lovatt on 22 December 2017. I would like to express my deep condolences to Mr Lovatt’s family. Your report concludes Mr Lovatt’s death was a result of obstruction of his internal airways whilst under restraint. Following the inquest, you raised concerns in your report to NHS England and NHS Improvement (NHS E/I) about the availability within the prison estate of staff trained to Advanced Life Support (ALS) level. NHS E/I is the responsible organisation for the commissioning of healthcare into prisons, which is devolved to the seven regional teams. Commissioning healthcare in prisons is done on a principle of equivalence, which has been defined by the Royal College of General Practitioners. This definition broadly states that the aim is to ensure people detained in prisons in England are afforded provision of and access to appropriate services and treatment that is considered to be at least consistent in range and quality, with that available in the wider community. The Service Specification – primary care service, medical and nursing for prisons in England, published in March 2020, includes a section on unplanned and emergency care1. This outlines the requirements for the healthcare provider to develop and implement protocols, specific to each prison, for responding to and managing emergencies. It also details exclusion criteria of injuries or illnesses that require 1 primary-care-service-spec-medical-nursing-for-prisons-2020.pdf (england.nhs.uk) NHS England and NHS Improvement medical or emergency intervention, beyond the scope and practice of primary care nursing and general medical practice. This reflects the Resuscitation Council UK Quality Standards: Primary Care2, which states at Section 3 of its standards: “….training must be in place to ensure that clinical staff can undertake cardiopulmonary resuscitation (CPR). Training and facilities must ensure that, when cardiorespiratory arrest occurs, as a minimum all clinical staff can: recognise cardiopulmonary arrest • • summon help • start CPR • attempt defibrillation (if appropriate) with an automated external defibrillator (AED) with a minimum of delay, whenever possible within minutes of collapse.” The Resuscitation Council UK, who provide the recognised guidelines, including training, for England, outline that Advanced Life Support is appropriate for healthcare professionals who would undertake advanced life support as part of their clinical duties. This includes doctors, paramedics and nurses working in acute care areas (e.g. Emergency Departments, Coronary Care Units, Intensive Care Units, high dependency units, operating theatres, acute medical admissions units) or on resuscitation/medical emergency Critical Care outreach Teams. Advanced Life Support also involves some specialist clinical procedures which, to be clinically effective and cause no harm, must be performed as a regular part of clinical duties. Healthcare professionals working in prisons, which includes a significant proportion of mental health nurses, do not fall within the specified appropriate categories for Advanced Life Support therefore, these procedures, if carried out, may lead to staff working outside of their registered professional clinical competencies. Thank you for bringing this important patient safety issue to my attention and please do not hesitate to contact me should you need any further information. Yours sincerely, National Medical Director 2 https://www.resus.org.uk/library/quality-standards-cpr/primary- care#:~:text=All%20staff%20in%20a%20primary%20care%20organisation%2C%20including,regular %20intervals%20thereafter%20to%20maintain%20knowledge%20and%20skills.
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