Martin Brown

Director General Prisons 
HM Prison and Probation Service 
8th Floor Ministry of Justice 
102 Petty France 
London SW1H 9AJ 

08 February 2022 

Mr Nicholas Rheinberg 
Assistant Coroner 
Coroner's Court 
Faraday Court 
Faraday Drive 
Fulwood 
Preston 
PR2 9NB 

Dear Mr Rheinberg, 

Thank you for your Regulation 28 report of 15 December 2021 following the inquest into the 
death of Martin Brown at HMP Lancaster Farms on 10 December 2018.  I am responding 
on behalf of HMPPS as the Director General of Prisons. 

I know that you will share a copy of this response with the family of Mr Brown and I would 
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. 

Following  evidence  heard  at  the  inquest  you  have  raised  three  concerns.  The  second 
concern  is  addressed  solely  to  the  Head  of  Healthcare  who  will  be  providing  a  separate 
response.  I will be addressing the two concerns that relate to the prison: the need for prison 
staff to be trained in relation to medical emergency responses and the familiarisation of the 
ERIC  (Emergency  Response  in  Custody)  system,  and  better  communication  between 
healthcare personnel at the scene of a medical emergency and the prison control room. 

In January 2022 the Governor instructed that ERIC cards be distributed to all existing staff 
to  provide  a  pocket  guide  on  how  to  deal  with  emergency  responses.  Additional  ERIC 
training has also commenced and is being delivered by the Head of Healthcare to all staff. 
This training is being delivered weekly until all staff have been trained or had any necessary 
refresher  training.  All  new  staff  will  now  receive  ERIC  training  and  ERIC  cards  as  part  of 
their induction. 

A new process has been implemented at HMP Lancaster Farms to ensure healthcare staff 
can communicate efficiently and effectively with the prison control room and the ambulance 
service  during  medical  emergencies.  By  utilising  a  spare  radio  channel  available  on  the 
prison radio network clinicians will now have the ability to speak directly to  the ambulance 
service  via  the  communication  room  when  an  emergency  is  underway.  This  will  enable 
them  to  relay  information  and  answer  any  questions  posed  by  the  ambulance  service 
without disruption or delay, as well as receive progress reports on the ambulance’s arrival. 

 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 Also, the radio network will only be accessible to the communications room, healthcare and 
those first on scene to safeguard any confidential information. 

Thank  you  again  for  bringing  your  concerns  to  my  attention.  I  trust  that  this  response 
provides assurance that action is being taken to address the matters that you have raised.  

Yours sincerely 

Director General of Prisons

(1) For the attention of the Governor, the evidence disclosed a need for the training of prison staff in relation to
responses to medical emergencies and familiarisation with the ERIC (Emergency Response in Custody) system

Although this recommendation has been made to the Governor, Spectrum wish to provide the following information 
which may assist.  

An Emergency Response in Custody  (ERIC) presentation with added audio has been developed to address training 
needs for both healthcare team members and prison officers. The Head of Healthcare presented the ERIC training 
presentation at a prison induction on the 13th January 2022, a training session for Officer Support Grades who work 
in the prison communication room and custodial managers was held on the 20th January 2022. Further Sessions have 
been held with prison staff on the 27th of January and 3rd of February. There is a plan to roll this training out to all, 
the training will also be delivered at healthcare handovers.  

ERIC training and the appropriateness of emergency calls will be discussed with Governor at Local Delivery Board 
meetings to support the process of training is embedded with HMP Lancaster Farms.  

Healthcare will ensure compliance is maintained via reporting on staff induction and via the appraisal process.  

From an organisational perspective, Spectrum are supporting this process, we will be working with our training 
facilitators to launch a quality training day which links into our corporate induction for all new staff. These sessions 
will also be used for the support of any staff requiring an update and be provided by the cooperate quality team.  

The teams will continue to use the process of the newly induced site safety huddles to reflect and evaluate any 
incidents that arise. This will support reflective practice and mitigation of any issues that may arise e.g., training, 
awareness and education.  

All incidents related to emergency response will be reviewed via the incident reporting system (Datix) by the Head of 
Healthcare and appropriate level of investigation will be completed, this may include the completion of a root cause 
analysis.   

Assessment of training compliance as per ERIC standards will take place following the completion of emergency calls. 
Feedback will be provided to the team and individual as needed to provide continued support and learning.  To 
provide further assurances, spot audits for ERIC competences will take place at least annually via team level 
professional development sessions. 

(2) For the attention of the Head of Healthcare, the evidence disclosed a need for healthcare to liaise with North
West Ambulance Service over the handling of medical emergencies involving the ambulance service

The Head of Healthcare has contacted Northwest Ambulance Service (NWAS) to discuss training needs and scope 
training provision for clinicians within Spectrum prisons. This will ensure that the quality and content of the 
information passed to the control room ensures accurate categorisation of ambulances.  
A meeting was held with NWAS on the 14th January 2022 to discuss these training options. NWAS have provided 
information (embedded in action plan) which we can use to develop a staff training package.  This information has 
been incorporated into the new emergency response procedure at HMP Lancaster Farms, this is outlined in the 
attached below Governors notice staff, code red and blue. 

 Following incidents, debriefs occur jointly with the Prison and healthcare. This is an opportunity to consider the 
communication taken place between healthcare, the communication department and NWAS. Any emerging  lesson 
learnt will be captured at this early stage .  

Organisationally, Spectrum  are commencing a Task and Finish Group led by the Patient Safety lead and will invite 
key partners from the Emergency service response, including paramedics who work within Spectrum. The objective 
for the group is to streamline all education material and ensure this is systematically applied. This group will focus on 
the PPO and Clinical Review recommendations. The first meeting of the Task and Finish Group is planned for 10th 
February 2022. This is a new approach to support continued integration and shared learning. The group will work 
within TOR agreed by all parties.  

(3) For the attention of the Governor in partnership with the Head of Healthcare, the evidence disclosed a need to 
devise a better means of communication between healthcare personnel at the scene of a medical emergency and 
the prison control room / ambulance control. 

Work on integration and shared objectives for patient safety had commenced prior to the inquest and a meeting had 
taken place between the healthcare team, the previous Safer Custody Governor, and the Governing Governor at 
HMP Lancaster Farms to develop actions to address this recommendation.  

Potential solutions were discussed, and these included accessing the wing phone to make the call, however, it was 
noted that this would mean the clinician leaving the patient to ring an outside line. Prison telecommunication 
systems require a phone code to access an outside line which further increases the time taken to make a call. The 
patient may then be left without a nurse in attendance whilst this telephone call is taking place.  

An alternative solution was the provision of a mobile phone for healthcare to utilise to make the call, however, the 
phone signal in HMP Lancaster Farms is not reliable.  
Following the inquest, the Head of Healthcare met with the new Safer Custody Governor, and it was agreed that a 
spare radio net will be utilised so that the clinician can speak directly to the prison’s communications room (rather 
than via Oscar 1) to provide more information directly which can then be relayed to the clinician, who would also be 
able to answer any questions posed by the ambulance service. The clinician can also contact the communications 
room directly to ask for progress reports. As the net will only be accessible to the communications room and 
healthcare, this will mean confidential and sensitive information can be relayed.  

This new system was trialled in an exercise on the 18th January 2022. This approached proved to be successful. This 
went live on the 31st of January.  Supportive training regarding the new process has been provided to relevant staff 
and will now form part of the response process for all emergencies. 
This new system will be monitored via staff feedback and review of healthcare incidents which are logged for each 
Code Red/ Blue. This will be shared at the safety huddles and within the wider organisation to share best practice.