Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0390, written 19 Nov 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 19 Nov 2021 |
|---|---|
| Reference | 2021-0390 |
| Deceased | Robert Ellery |
| Coroner | David Regan |
| Coroner area | South Wales Central |
| Category | State Custody related deaths · Wales prevention of future deaths reports (2019 onwards) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. 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.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
The Governor of HM Prison Cardiff
1 CORONER
I am David Regan, Area Coroner, for the Coroner’s area of South Wales
Central
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
A Coronial investigation was commenced on 8th November 2016 into the death
of Robert Ellery. The Investigation concluded at the end of an inquest which I
conducted with a jury on 8th – 18th November 2021. The conclusion of the jury
was that Mr Ellery died as the result of
intentions could not be ascertained. The medical cause of death was
in circumstances where his
4 CIRCUMSTANCES OF THE DEATH
These were recorded as :-
in his cell on 31st October 2016. Robert
“Robert Ellery was found
had recently self harmed, An ACCT was not opened, zopiclone was prescribed
but not administered to him. In addition, there was 19 minutes between the
first 999 call and the ambulance service being informed that Mr Ellery had
been found
contributed to Robert's death.”
. It cannot be concluded that such issues caused or
1
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 MATTERS OF CONCERN are as follows. –
(1) The prison control room was not able to provide the Welsh Ambulance
Service with any specific information as to the reason why an ambulance
in his
was required for 19 minutes after Mr Ellery was found
cell. This delayed the ability of the ambulance service to despatch a
response. While this was not, on the evidence heard by the jury,
causative of Mr Ellery’s death, it gives rise to a concern that a risk that
other deaths will occur.
(2) There was no method of communication to allow the Ambulance
Service call centre staff to communicate directly with the nurse and
officers who were providing basic life support to Mr Ellery. This
delayed the relaying of specific information with respect to Mr Ellery’s
condition by the prison to the Welsh Ambulance Service. It also
impeded the ability of the ambulance service operator to provide
guidance to those attempting to resuscitate Mr Ellery. This may affect
the use of a defibrillator. In circumstances where not all prison staff
are trained in the provision of CPR, it might also prevent the
ambulance service operator providing instruction to first responders, or
reduce the effectiveness of the same.
6 ACTION SHOULD BE TAKEN
In my opinion action should be taken to improve communication between staff
at the side of the patient and the ambulance service to prevent future deaths
and I believe you and 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 21st January 2022. 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
2
I have sent a copy of my report to Mr Ellery’s family and to the following,
who may find it useful or of interest: The Chief Executive of the Welsh
Ambulance Service; The Cardiff and Vale University Health Board
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
19th November 2021 SIGNED:
D Regan
Area Coroner
3
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.
HMP Cardiff.
1 Knox Road.
Cardiff
CF24 0UG
Date: 18th Jan. 2021.
Mr Robert Ellery – DOB 16/05/1986
Dear Mr Regan.
Thank you for your Regulation 28 Report dated the 19th November 2021 addressed to HMP Cardiff,
following the inquest into the death of Mr Robert Ellery at the prison on 31 st October 2016. I am
responding on behalf of Her Majesty’s Prison Cardiff.
I know that you will send a copy of this response to the family of Mr Ellery and I would first like 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 have expressed concern surrounding the communication between staff at the side of the patient
and the ambulance service.
At a local level, in recognition of the concerns raised by yourself, a Local Operating Protocol has
been devised. HMP Cardiff will pilot the use of a mobile phone carried by the Orderly Of ficer and
Night Orderly Officer to enable direct communication with the Welsh Ambulance Service. This will
ensure updates from the scene can be provided or to allow the Ambulance Service call centre staff
to communicate directly with the nurse and officer providing basic life support to a patient.
Our Local Operating Protocol sets out the following operational objectives:
• To assist communication between the Ambulance Service call centre and the staff
providing basic life support to a patient.
• To allow the Ambulance Service operator to provide guidance to those attempting to
resuscitate the patient. Including the use of a defibrillator.
• To communicate updates from the scene direct to the Ambulance Service call
centre and not via a third party.
• To offer assistance and guidance to both healthcare and prison staff at the scene
who would be unable to leave the patient to communicate direct with the
Ambulance call centre (especially at night).
Thank you again for bringing your concerns to my attention, and I hope that this response provides
assurance that action is being taken.
Yours sincerely
Head of Res. and Safety.
HMP Cardiff.
cc:
(Governing Governor, HMP Cardiff).
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