Nathan Forrester

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

26 June 2023 

Mr Andrew Harris  
HM Senior Coroner  
Southwark Coroners Court  
1 Tennis Street  
London  
SE1 1YD  

Dear Mr Harris, 

Thank you for your Regulation 28 report of 30 January 2023 addressed to 
General Chief Executive of His Majesty’s Prison and Probation Service (HMPPS). I am 
responding as Director General of Operations for HMPPS. I am grateful to you for granting an 
extension for this response. 

, Director 

I know that you will share a copy of this response with the family of Mr Forrester, 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 a concern that prison officers may need further training on responding to 
emergency situations where they need to move a prisoner in order to complete an assessment 
and to commence cardiopulmonary resuscitation (CPR) immediately. Thank you for bringing your 
concern to my attention. 

I can confirm that all new prison officers receive first aid training as part of their initial prison 
officer training. The training covers the requirement to move individuals to a hard, flat surface 
before commencing CPR, and as such staff are aware that anyone found unresponsive on a top 
bunk bed would need to be brought to the floor prior to commencing CPR. The Learning and 
Development team, responsible for the management and delivery of training for HMPPS staff, 
also provide training in manual handling and movement of prisoners to ensure that our staff are 
well equipped with the skills to move a prisoner in order to enable CPR and emergency first aid to 
commence.  

Manual handling training has recently been updated to a digital format and all new prison officers 
complete this during their initial training induction. In addition, there is eLearning available to all 
staff on MyLearning which is the digital learning platform used by HMPPS. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Thank you again for bringing your concern to my attention. I trust that this response provides 
assurance that the training provided to officers is sufficient. 

Yours sincerely, 

Director General of Operations

Andrew Harris,  
Southwark Coroner’s Court,  
1 Tennis Street,  
London,  
SE1 1YD 

Dear Mr Harris 

National Medical Director  
NHS England  
Wellington House 
133-155 Waterloo Road  
London 
SE1 8UG 

29 March 2023 

Re: Regulation 28 Report to Prevent Future Deaths – Nathan Forrester who 
died on 2 July 2019 

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  30 
January 2023 concerning the death of Nathan Forrester on 2 July 2019. In advance of 
responding to the specific concerns raised in your Report, I would like to express my 
deep condolences to Mr Forrester’s family and loved ones. NHS England is keen to 
assure the family and the Coroner that the concerns raised about Mr Forrester’s care 
have been listened to and reflected upon. 

NHS England is the responsible organisation for the commissioning of healthcare into 
prisons, which is devolved to regional teams. Commissioning healthcare in prisons is 
done on a principle of equivalence, which has been defined by the Royal College of 
General Practitioners (RCGP and broadly states the aim is to ensure people detained 
in prisons in England, are offered provision of and access to appropriate services and 
treatment, considered to be at least consistent in range and quality, with that available 
in the wider community. 

I have considered the concerns raised in your report and I will respond to each of them 
in turn below. 

1.  Deaths on top bunks (HMPPS)  

Responsibility for training of prison officers in respect of the management of a prisoner 
on a top bunk lies with HMPPS and I understand that they will respond to this concern 
directly.   

2.  Training of nurses in CPR (NHS England) 

NHS England is the responsible organisation for the commissioning of healthcare in 
prisons, which is done on a principle of equivalence as defined by the Royal College 
of General Practitioners (RCGP) Royal College of General Practitioners (RCGP). 
This definition, agreed by the Prison Healthcare Partnership Board, broadly states 
the aim is to ensure people detained in prisons in England are afforded provision of, 
and access to appropriate services and treatment, which is at least consistent in 
range and quality, with that available in the wider community.  

                                                                                                                       
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 The Service Specification, ‘primary care service, medical and nursing for prisons in 
England,’ published in March 2020, includes a section on unplanned and 
emergency. This outlines the requirements for the healthcare provider to develop 
and implement protocols, specific to each prison, for responding to and managing 
emergencies including training for staff in CPR. Immediate Life Support (ILS) training 
provides healthcare professionals with the skills needed to respond in an 
emergency.  

The Service Specification also details exclusion criteria of injuries or illnesses that 
require medical or emergency intervention, beyond the scope and practice of primary 
care nursing and general medical practice.  

This reflects the Resuscitation Council UK ‘Quality Standards: Primary care | 
Resuscitation Council UK’ which state:  

“training must be in place to ensure clinical staff can undertake CPR. Training and 
facilities must ensure that, when cardiorespiratory arrest occurs, as a minimum all 
clinical staff can: 

•  Recognise cardiopulmonary arrest (ABCDE approach) 
•  Summon help. 
•  Start CPR and defibrillation (manual and/or AED) and simple airway 
manoeuvres) with a minimum of delay, whenever possible within 
minutes of collapse.” 

The Resuscitation Council UK also outlines that Advanced Life Support (ALS), which 
includes the use of supraglottic airway devices such as an IGel, is appropriate for 
healthcare professionals who would undertake ALS as part of their clinical duties.  

This includes doctors, paramedics and nurses working in acute care areas such as 
Emergency Departments, Coronary Care Units, Intensive Care Units, High 
Dependency Units, operating theatres, acute medical admissions units or, on 
resuscitation/medical emergency Critical Care outreach Teams.  

This level of life support involves some specialist clinical procedures which, to be 
clinically effective and cause no harm, must be performed as a regular part of clinical 
duties.  

Healthcare professionals working in prisons (primary care), do not fall within the 
specified categories for ALS and therefore these procedures, if conducted, may lead 
to staff working outside of their registered professional clinical competencies.  

I understand shortcomings in training have been addressed locally and all nurses in 
Oxleas NHS Trust are trained annually to ILS level.  

I would also like to provide further assurances on the national NHS England work 
taking place around the Reports to Prevent Future Deaths. All reports received are 
discussed by the Regulation 28 Working Group, comprising Regional Medical 
Directors and other clinical and quality colleagues from across the regions. This 
ensures key learnings and insights around events, such as the sad death of Mr 
Forrester, are shared across the NHS at both a national and regional level and helps 

 
 
 
 
 
 
 
 us to pay close attention to any emerging trends that may require further review and 
action. 

Thank you for bringing these important patient safety issues to my attention and please 
do not hesitate to contact me should you need any further information. 

Yours sincerely, 

National Medical Director   
NHS England