Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0118, written 23 Apr 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 23 Apr 2021 |
|---|---|
| Reference | 2021-0118 |
| Deceased | Guy Paget |
| Coroner | Kevin McLoughlin |
| 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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
41. HE Governor, HMP Leeds
2. Secretary of State for Justice, the Rt. Hon. Robert Buckland, QC MP
CORONER
lam Kevin McLoughlin, Senior Coroner for the Coroner area of West Yorkshire (East)
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 09/04/21, | commenced an investigation into the death of Guy Clifton Paget, aged
73. The investigation concluded at the end of the Inquest on 23/04/21. The conclusion of
the Inquest was that Mr Paget died from natural causes due to 1a oesophageal cancer
and 2 urinary sepsis.
CIRCUMSTANCES OF THE DEATH
Mr Paget was a serving prisoner at HMP Leeds. In December 2020, he was diagnosed
with terminal cancer of the oesophagus. On 16/3/21 around 13:00 hours, he was found
in a confused state in his cell in the hospital wing of the prison. The clinicians
responsible for his care decided he should be taken to an outside hospital for treatment.
An ambulance was duly brought into the prison. The ambulance could not convey Mr
Paget to hospital, however, due to incorrect paperwork being available at the prison
gate, which delayed the authorisation for it to leave the prison. In addition, the vehicle
gate in the prison malfunctioned and could not be opened. Mr Paget's condition
deteriorated and he was pronounced dead at 15:06 hours that day in the ambulance,
which was effectively trapped at the prison gate.
CORONER’S CONCERNS
During the course of the Inquest, 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. The prison should have effective systems to facilitate the exit of an emergency
ambulance from the prison.
2. In this case a decision was made shortly after 13:00 that Mr Paget needed to be
taken to hospital. It should have been made clear to the prison managers that
the necessary authorisation to exit needed to be prepared as a matter of
urgency. At approximately 15:00 hours, however, this was not in place.
3. Itis foreseeable that prisons nationally will need to admit paramedics and
ambulance vehicles to attend to prisoners at times of emergency — and may
then need to leave with the prisoner in the ambulance. An efficient and tested
system to manage this process is essential, in order that serving prisoners are
provided with an equivalent level of care to that which they could expect inthe |
{ community.
ACTION SHOULD BE TAKEN
i
; In my opinion action should be taken to prevent future deaths and | believe you and your
| organisation have the power to take such action.
a;
7 [YOUR RESPONSE
i
You are under a duty to respond to this report within 56 days of the date of this report,
| namely by 17/06/21. |, the Coroner, may extend the period. i
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
| | have sent a copy of my report to the Chief Coroner and to the following Interested
Persons:
; MR rother of the deceased
| Yorkshire Ambulance Service.
| 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. i
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.
23rd April 2021 Kou- Sy |
9
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.
Director General Prisons HM Prison and Probation Service 8th Floor Ministry of Justice 102 Petty France London SW1H 9AJ Mr Kevin McLoughlin HM Senior Coroner West Yorkshire (Eastern) 71 Northgate Wakefield WFI 3BS 18 January 2021 Dear Mr McLoughlin at Thank you for your Regulation 28 Report of 23 April 2021 addressed to HMP Leeds and the Secretary of State for Justice, at the time the Rt Hon Robert Buckland QC MP following the recent inquest into the death of Guy Clifton Paget at HMP Leeds on 16 March 2021. I am responding as Director General of Prisons at HM Prison and Probation Service (HMPPS). You have shared a copy of this response with Mr Paget’s brother, and I would like first to express my condolences for his loss. Every death in custody is a tragedy and the safety of those in our care is my absolute priority. You have expressed concern about the arrangements for facilitating the exit of emergency vehicles from HMP Leeds, on the basis that there was a delay in preparing the necessary authorisation for the exit in Mr Paget’s case and that this was due to the urgency not being made clear to prison managers. You also consider that nationally, an efficient and tested system to manage this process is essential in order that serving prisoners are provided with an equivalent level of care to that which they could expect in the community. Regrettably HMPPS appears not to have been notified in advance of the inquest into the death of Mr Paget taking place, and we would have welcomed the opportunity to fully engage with the Coroner’s investigations in order to assist in clarifying the circumstances of Mr Paget’s death. Once inside the ambulance, I am informed that Mr Paget’s condition deteriorated quickly, to such an extent that ambulance staff were reluctant to take him to hospital because a Do Not Resuscitate (DNR) order was in place – you will be aware that practice in the community is for a patient to be allowed to remain at home in such circumstances. There was an initial delay whilst ambulance staff sought advice from their managers, and a decision was taken that Mr Paget would still be escorted to hospital, albeit that it was expected that he would pass away due to his condition. There was then an issue with the time taken to open the gate because it required a manual override. The Local Security Strategy (LSS) at HMP Leeds has been revised and now clearly outlines the system that allows staff to utilise a manual override to facilitate emergency vehicle entry or exit in the event of any mechanical failure. This is necessarily a somewhat slower process, but still allows entry or exit within a reasonable time period. This is in accordance with the National Security Framework, which is clear that each prison must have an LSS that describes a contingency plan for a manual override; that staff should be trained to operate it; and that it should be tested regularly. Sadly in Mr Paget’s case, once the manual override had been authorised his condition had further deteriorated, and the ambulance staff took the decision not to leave the prison, but to reverse into the establishment’s sterile area, where they were better able to provide end of life comfort to him (rather than to continue, with the likelihood that he would pass away in transit to hospital). With regard to the paperwork needed to authorise Mr Paget’s move to hospital, our records do not indicate that there was a delay: it was generated as soon as the emergency code was called and was in the possession of the escorting officer, who was at the healthcare centre before the ambulance. I hope that this response has explained how our understanding of the circumstances of Mr Paget’s death differs from what you have described. I trust that I have also provided reassurance that measures are in place at HMP Leeds, and in all other prisons, to facilitate the prompt entry and exit of ambulances. I once again would like to offer my sincere condolences to Mr Paget’s brother. Yours sincerely Director General of Prisons
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