Thomas Moffett

Dear Mr Rheinberg, 

I am writing in response to the Regulatory Notice 28 received at HMP Preston on the 27/01/2022.  

Spectrum CIC in conjunction with our HMPPS partners are taking significant steps to address the recommendations, 
as f ar as possible. Below is an outline of the actions we have taken for each recommendation and attached for your 
inf ormation is our action plan.  

(1) 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.

(2) Similar communication difficulties have already been reported in relation to the inquest into the death
of Martin Brown who died at HMP Lancaster Farms and the Prison and Probation Ombudsman has
highlighted a delay in the provision of essential information to Ambulance Control in the case of Mr
Trevor Mark Ferguson at HMP Garth who died on 9th December 2020.

(3) The fact that communication difficulties have arisen between healthcare and the ambulance service in

three recent cases involving prisons in Lancashire may indicate a potentially national problem.

Firstly, based on the number of occurrences of communication issues identified above, the issue of communication 
between prison healthcare teams, the communications room and the ambulance s ervice, is clearly a national problem. 
The accessibility to mobile phones or alternative methods to improve communication remain in the gift of our HMPPS 
partners. The same issues arises for the use of Code Blue and Code Red with Spectrum Healthcare hav e no 
inf luence to change and may continue to be a wider concern 

Despite this local resolution has been undertaken as follows:- 

Work on integration and shared objectives for patient safety have been held and a meeting took place between the 
healthcare team, the Safer Custody Governor, and the Governing Governor at HMP Preston 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. This system requires the caller to enter the relevant number and then 
the caller is asked to enter a code. In the event where the caller dials 999 the code is not requested and instead this 
call goes directly to the communication room. 

An alternative solution was the provision of a mobile phone for healthcare to utilise to make the call, however, the 
phone signal in HMP Preston is not reliable.  

Following the inquest, the Head of Healthcare at HMP Preston met with the Safer Custody Governor, and discussions 
took place between the Head of Healthcare at HMP Lancaster farms and Head of Healthcare at HMP Preston 
regarding the potential of utilising the pathway put into place following a similar Regulation 28 issued to HMP 
Lancaster Farms. However, it was determined that a spare radio net would not be effective at HMP Preston due to 
certain areas within the prison having poor radio signal.  

It was theref ore decided that Healthcare at HMP Preston would revise the Emergency Response Standard Operating 
Procedure to allow a second healthcare staff member to also attend any emergency codes or Hotel 2 calls.  The 
second healthcare member of staff would carry Hotel 3 radio and would be responsible to immediately completing an 
SBAR at the scene and then use the wing phone to ring communications to speak directly with the ambulance to 
provide accurate updates.  

The Initial request for an ambulance will be either initiated by the calling of a code where the PSI/2013 will be 
f ollowed, or if the situation does not meet the code blue/red criteria, but healthcare require an emergency ambulance 
due to f indings from assessment, then Hotel 3 will call over the net ‘MTOP from Hotel 3 - ambulance is required’. Hotel 
3 will use the SEND protocol to deliver information over the net to ensure no delays in the dispatch of the ambulance. 

 Hotel 3 will then ring the communications team directly using the wing phone to speak directly to ambulance and give 
the SBAR update from the scene. Communications will be responsible to immediately inform Oscar 1 of the 
ambulance request, to allow all appropriate paperwork and risk assessments to be completed.  

The Healthcare team will receive training in ambulance categorisation to be able to effectively challenge if they feel it 
has been incorrectly categorised by the ambulance call handler. The Head of Healthcare at HMP Preston has 
contacted the Head of Healthcare at HMP Lancaster farms who has spoken directly to North West Ambulance Service 
(NWAS) to discuss training needs and scope training provision for clinicians within Spectrum prisons.  NWAS have 
provided Spectrum with information (embedded in the action plan) which we can use to develop a staff training 
package. This information has been incorporated into the new Emergency Response Standard Operating Procedure 
at HMP Preston. 

The  Governing Governor also sent a Governor’s Order on medical emergency codes to staff to clarify the process in 
line with the PSI 03/2013.   

The new system explained above was trialled in an exercise on the (18/03/2022) . This approach proved to be 
successful. There are plans for this to go live on the (20/03/2022). 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. Any learning will be shared at the safety huddles and within the wider organisation to share best 
practice as part of the Patient Safety agenda led by the Patient Safety Recognising the medical emergency response 
is an area that is challenging within Health and Justice sites Spectrum is having an organisational approach to 
understanding the wider issues, reviewing all the recommendations and actions and are taking this forward with a 
Task and Finish group led by the patient safety lead for spectrum .Quality leads will be involved with audit which will 
f eed into local and organisational governance boards for reporting and escalation as appropriate. 

Attached link:   1- Revised Standard Operation Procedure