Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0397, written 12 Dec 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 12 Dec 2022 |
|---|---|
| Reference | 2022-0397 |
| Deceased | Lewis Johnson |
| Coroner | Kevin McLoughlin |
| Coroner area | West Yorkshire (Eastern) |
| Category | State Custody related deaths · Suicide (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Governor, HM Prison Wealstun 1. The Rt Hon Dominic Raab MP, Secretary of State for Justice 1 CORONER I am Kevin Mcloughlin, Senior Coroner, for the Coroner area of West Yorkshire (E). 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 On 23rd December 2019 an investigation was commenced into the death of Lewis Steven Johnson, aged 34. The investigation concluded at the end of the Inquest on 2nd December 2022. The conclusion of the Inquest was a Narrative Conclusion that Mr Johnson died due to 1(a) Hypoxic-ischaemia Encephalopathy 1(b) Hanging after being found suspended by a neck ligature at approximately 04:45 hours on 12th December 2019 at HMP Wealstun. 4 CIRCUMSTANCES OF THE DEATH Lewis Steven Johnson was held at HMP Wealstun from May 2019 until his death 7 months later. He had been seen frequently by healthcare staff, a keyworker, other prison officers and had been subject to an ACCT for a brief period in October 2019. When found with a neck ligature around 04:45 on 12th December in an unresponsive condition, he was cut down, but the various prison officers present then left him in the cell in a seated position without considering CPR, using a defibrillator or considering whether to place him in the recovery position. Approximately five minutes later another prison officer mentioned CPR. Prison officers then returned to his cell and conducted CPR until paramedics arrived. The paramedics succeeded in restoring Mr Johnson's circulation. He was taken to hospital but following a further cardiac arrest, was pronounced dead at 10:56 on 12th December 2019 at Leeds General Infirmary. 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) HMP Wealstun does not have nurses or other healthcare staff in the prison during the night. (2) The incidence of self-harm incidents amongst prisoners (both in 2019 and today) make such emergencies foreseeable. (3) In the absence of healthcare staff being immediately available, the night patrol staff should be trained to respond effectively to ligature or other self-harm incidents. (4) The OSG officer who encountered the situation involving Mr Johnson around 04:45 hours had not been trained to carry out CPR. (5) The officer acting as attended the cell but did not think about CPR, believing Mr Johnson to be already dead (notwithstanding that none of the discipline officers present had anv medical qualifications to certifv death). He had undertaken defibrillator training "many years ago". (6) The four prison officers present in the cell did not discuss the need for CPR. The possibility of using a defibrillator was not mentioned. Mr Johnson was left in the cell in a seated position without the wisdom of placing him in the recovery position being considered. (7) The medical evidence available at the Inquest indicated "Effective CPR more than doubles the chance of someone surviving a cardiac arrest". Furthermore, the Resuscitation Council UK advises "provide chest compressions as soon as possible after cardiac arrest is confirmed". (8) The value of all night patrol staff (particularly in a prison without 24 hour healthcare provision) being trained to provide effective CPR and use a defibrillator competently was recognised at the inquest, along with the wisdom of this being refreshed annually. (9) The inquest noted that there is currently no express direction in PSI 03/2013 or other instruction to carry out CPR pending the arrival of paramedics or other qualified medical professional, when a prisoner is found in an unresponsive condition following a ligature incident. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe 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 Monday 13th February 2023 (allowing for the forthcoming holiday period). 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 (mother) (2) Persons (1) (father). I have also sent it to or of interest. , Governor, HMP Wealstun who may find it useful 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 :¥.(w~ M0~~L , KEVIN McLOUGHLIN Senior Coroner West Yorkshire (E) Dated: 2nd December 2022
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 of Operations
HM Prison and Probation Service
8th Floor Ministry of Justice
102 Petty France
London SW1H 9AJ
Mr Kevin McLoughlin
Senior Coroner for the Coroner area of West Yorkshire (E)
HM Coroner’s Office
71 Northgate
Wakefield
West Yorkshire
WF1 3BS
9 February 2023
Dear Mr McLoughlin
Thank you for your Regulation 28 report of 2 December 2022, addressed to the Governor of HMP
Wealstun and the Secretary of State for Justice, following the recent inquest into the death of Lewis
Johnson at HMP Wealstun on 12 December 2019. I am responding as Director General of Operations
for HMPPS.
I know that you will share a copy of this response with Mr Johnson’s family and I would like to first
express my condolences for their loss. Each 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 some concerns regarding the first aid
training for staff particularly in relation to the use of CPR, and I will address these below.
It may be helpful for me to clarify the requirements currently in place for all establishments around the
provision of first aid trained staff. Whilst there is currently no requirement for all prison staff to be
trained in first aid, all prison officers receive emergency first-aid at work (EFAW) training, including
how to administer CPR, during their entry level training, for use in their duties. Governors are required
to ensure that there are sufficient numbers of trained staff on duty at all times. They do this by
producing a detailed local first aid risk assessment to determine the number of first aid at work (FAW)
and EFAW trained staff needed at the establishment, and by ensuring that they are deployed
appropriately.
At HMP Wealstun the local risk assessment was last reviewed in October 2022. Consideration was
given to the risk profile across all areas of the prison, paying particular attention to the night provision,
due to there being no healthcare staff available during that time to provide emergency assistance
should the need arise. Regular reviews will continue to be conducted to ensure that the needs of the
prison continue to be met.
In respect of the EFAW training all prison officers receive during their entry level training, all first aid
training certificates are valid for three years and although not mandatory, staff are encouraged to
undertake refresher training to maintain their basic skills and keep up to date with any changes to
first-aid procedures. The initial training for staff includes an HMPPS video which shows how to
respond to an emergency situation where a prisoner has attempted suicide. This is currently being
updated to reflect changes to policy and equipment available since the original video was produced.
This video covers the use of prison issue ligature tools, emergency response codes, placing someone
in the recovery position and considerations such as when to initiate first aid and the use of
defibrillators. Once complete, the updated video will be made available to all training centres for new
staff and for prisons. It is anticipated that this will be available to staff by Spring 2023.
While the delivery of staff training has been severely impacted as a result of restrictions put in place
due to the COVID-19 pandemic, with prisons only being able to deliver limited safety critical training,
from April 2023 HMP Wealstun will be able to resume the delivery of FAW and EFAW training locally,
and will prioritise all those on the dedicated night group, which includes Operation Support Grade
staff. The intention is also for all Custodial Managers to receive this training, as well as a significant
proportion of the wider officer group, to ensure that an effective emergency response can be provided
when required.
Looking ahead, HMPPS is currently reviewing the first aid policy with the view to replacing this with
updated guidance. As the new the guidance develops, collaboration will take place amongst teams to
ensure there is reference to the commencement of CPR and to ensure we signpost the current safer
custody guidance available on the HMPPS intranet which sets out the circumstances in which CPR
should be commenced. This is designed to be read in conjunction with the current the Prison Service
Instruction which makes clear that all staff must be aware of their responsibilities and of the local
procedures that are in place to enable an effective response to medical emergencies.
Thank you again for bringing these matters of concern to my attention and I hope this provides
you with the reassurances that you seek.
Yours Sincerely,
Director General of Operations
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