Amarjit Singh

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

30 October 2023 

Coroner ME Hassell 
Senior Coroner 
Inner North London  
St Pancras Coroner’s Court  
Camley Street  
London N1C 4PP 

Dear Ms ME Hassell, 

Thank  you  for  your  Regulation  28  report  of  18  September  2023,  addressed  to  the  Governor  of 
HMP Pentonville following the inquest into the death of Amarjit Singh on 21 November 2021. I am 
responding  as  the  Director  General  of  Operations  for  HMPPS.  I  understand  that  Practice  Plus 
Group is responding separately to your first concern.  

I am aware that you will share a copy of this response with the family of Mr Singh, 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.  

You express concern about training for staff in the management of prisoners experiencing fits and 
more general first aid training.  

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 no requirement for all operational prison staff 
to be trained in first aid, Governors are required to ensure that there are always sufficient numbers 
of trained staff on duty, following Health & Safety Executive Guidelines to produce a detailed local 
first  aid  risk  assessment  to  determine  the  number  of  trained  staff  needed  at  the  establishment, 
ensuring that the trained staff are deployed appropriately. 

A  national  review  of  the  provision  of  first  aid  in  prison  which  included  the  consideration  on 
introducing  an  additional  custodial  first  aid  course  was  halted  due to the  pandemic,  however  we 
hope  to  be  able  to  look  at  this  again  to  see  if  it  is  needed  in  addition  to  the  emergency  first  aid 
course, and this may result in some revisions to the first aid policy and training.  

At a national level, new emergency response guides were issued to all prisons which set out the 
actions required of staff in a medical emergency, including all the circumstances listed in the PSI 
03/2013 Medical Emergency Response Codes under which a medical emergency response code 

 
 
                                                                                                                                                                              
 
 
 
 
 
 
 
 
 
 
 
 
 
 should  be  called.  In  2021,  all  Prisons  were  also  issued  with  a  supply  of  emergency  response 
pocket  cards  which  were  shared  with  staff.  The  cards  provided  an  instant  reminder  of  how  to 
respond  to  a  medical  emergency.  In  March  2022,  a  further  supply  of  the  emergency  response 
pocket cards were issued to Regional Group Safety Leads for them to share with their prisons. 

Following  the  incident  and  the  death  of Mr  Singh,  the Governor  of  HMP  Pentonville  sent  a  Staff 
Notice  reminding  staff  to  adhere  to  the  national  emergency  guidance  and  reviewed  the  local 
medical emergency response code protocol to ensure that staff training is a central focus and that 
all staff have up to date training, including refresher training for all staff.  

Training  for  prison  staff  in  how  to  deal  with  fits  is  scheduled  to  be  given  at  HMP  Pentonville  in 
October,  and  prisoners  are  given  instructions  at  their  induction  on  how  to  report  concerns 
regarding  a  cellmate  and  the  need  to  ring  the  emergency  cell  bell  in  circumstances  where  their 
cellmate is unwell so that staff can ensure healthcare attend.  

The  HMPPS  National  Health  and  Safety  Arrangements  for  First  Aid  and  Emergency  Aid  Manual 
was  published  and  introduced  in  August  2023  and  this  was  circulated  to  all  prison  staff  at  HMP 
Pentonville.  

The  findings  of  this  inquest  have  also  been  shared  with  the  national  Safety  team  so  that  further 
consideration can be given to the points you have identified when national policy is next reviewed 
and revised. 

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

 Yours Sincerely, 

Director General of Operations

Practice Plus Group 
Hawker House 
5-6 Napier Court 
Napier Road 
Reading 
Berkshire 
RG1 8BW 

practiceplusgroup.com 

Senior Coroner ME Hassell  
Inner North London  
St Pancras Coroner’s Court  
Camley Street  
London  
N1C 4PP 

6 November 2023 

Dear Madam 

The Inquest touching upon the death of Mr Amarjit Singh 

Thank you for your Report to Prevent Future Deaths issued pursuant to Regulation 28 Coroners 
(Investigations)  Regulations  2013  dated  18th  September  2023  and  following  the  inquest 
touching upon the death of Mr Amarjit Singh, who sadly passed away on 21st November 2021 
whilst residing at HMP Pentonville.   

I  would  like  to  take  the  opportunity  on  behalf  of  Practice  Plus  Group  to  offer  my  sincere 
condolences to Mr Singh’s family and friends for their loss.  

This letter addresses the matters of concern insofar as they relate to Practice Plus Group.  

Matter of Concern  

Below are the concerns quoted in the PFD report: 

1.  The completion of the cell sharing risk assessment was described by the extremely 

experienced nurse who completed it, as careless. 

2.  Though I was told that training for prison staff in how to deal with fits is to be given at 
HMP Pentonville in October 2023, I heard that there is only a hope that prisoners will 
also receive some guidance in what to do if their cellmate suffers a fit. Apparently, this 
has already been implemented in HMP Brixton. 

3.  Whilst the fact that not all prison officers receive ongoing first aid training is a national 
resourcing issue, the level of first aid understanding of some prison officers at HMP 
Pentonville seemed surprisingly low. 
One officer told me that it did not cross his mind to start CPR in the three minutes it 
took nurses to arrive after Mr Singh was found not breathing. (Mr Singh had been 
assessed by a custodial manager as having died, but the other officer did not know this 
at the time.) 

Practice Plus Group Health and Rehabilitation Services Limited. Registered in England No 10498997 
Registered Office: Hawker House, 5-6 Napier Court, Napier Road, Reading, Berkshire RG1 8BW 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 A different officer told me he did not know that there is a difference between a person 
who is unconscious and a person who is dead. 

Response 

Only  number  1  above  relates  to  healthcare,  and  therefore  PPG,  so  we  do  not  propose  to 
respond to points 2 and 3, which no doubt will be addressed by the Prison. 

This letter is to be read in conjunction with the written submissions made by PPG during the 
inquest dated 6 September 2023.  

Under paragraph 7, Schedule 5 of the Coroners and Justice Act 2009 Act, and Regulations 28 
and 29 of the Coroners (Investigations) Regulations 2013, where an investigation gives rise to 
concern that future deaths will occur, and the investigating coroner is of the opinion that action 
should be taken to reduce the risk of death, the coroner must make a report to the person that 
they believe may have the power to take such action. 

Chief Coroner’s Guidance 5 at [7] outlines that in considering their duty to make a PFD report, 
the coroner should focus on the current position, including any relevant changes made since 
death. It is a fact sensitive decision and relevant factors include:  

a.  The nature of the commitment to take action;  
b.  Any evidence in support of it;  
c.  The  coroner’s  assessment  of  the  organisation’s  understanding  of,  and 

commitment to addressing, the area of concern. 

During the course of the inquest, His Majesty’s Senior Coroner (“HMSC”) heard evidence from 
the Head of Healthcare for HMP Pentonville about a number of healthcare processes in place 
at HMP Pentonville to address any deficiencies or inaccuracies in completing cell sharing risk 
assessment forms for patients who suffer from epilepsy. That evidence is summarised below. 

The reception screening process 

The Inquest heard evidence about the process of performing an initial healthcare screening at 
reception for a patient arriving at HMP Pentonville. 

 made an error in 
The evidence from both 
completing a form without having conducted the assessment screening. The correct procedure, 
, was that the initial reception screening should have been completed 
described by 
by 
  who  should  only  have  completed  the  form  on  completion  of  that 
screening.  

 was that 

 and 

This  is  an  extract  from  counsel’s  note  of  the  inquest,  recording  Ms  Barratt’s  responses  to 
questions from HMSC.  

Q:  Part  of  initial  process  heard  for  every  prisoner  cell  sharing  risk  assessment.  The reverse 
page wasn’t completed by the person who saw Mr Singh (“AS”), instead completed by 
. He 
describes completing those assessments for most of the time at Pentonville but ticked the box 
for no increased risk, wrote the words ‘single cell’, and did not specify AS needed a lower bunk. 
 said that he hadn’t read the first page, then said that he had skim read it. When it was put 

to him that that was careless, he agreed. In the healthcare system, how can that happen?  

A: The form absolutely should be completed by the person seeing the patient and if a thorough 
assessment  by  the  nurse  is  done,  they  can  fill  it  out.  Reception  nurses  undergo  specially 

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 designed training specifically just for the reception process, which is a two day training. Which 
Antonio has been on recently.  

On the basis of that evidence we make the following submissions:  

•  We  appreciate  HMSC’s  concern  that  if 

  could  have  completed  the 
assessment in the manner that he did in 2019, the same might be said for 2023. We 
respectfully draw HMSC’s attention to the fact that the nursing staff undergo specialised 
, 
training on the correct reception process, and the nurse in question, 
has revisited the risk assessment form training.  

•  There is no evidence from any other witness that they would have completed the form 

carelessly or incorrectly in the same manner. 

 evidence supported this.  

•  The nurse completing the initial assessment should have completed the risk assessment 
form: this is the correct procedure. Evidence was heard from a number of witnesses that 
the initial reception screening completed by nursing staff is designed to be a thorough, 
comprehensive  survey  of  a  patient’s  healthcare  needs.  The  completion  of  the  risk 
assessment form during or following the initial reception screening should ensure that 
the forms are completed in an accurate and considered manner.  

All new nurses shadow reception screenings and other EDIC (Early Days in Custody) processes 
comprehensively  before  starting  out  themselves.  The  two  day  reception  training  also  runs 
periodically for staff to attend and get refreshers. The risk assessment part of the process is 
also explained clearly as part of their induction period and shadowing. 

The Early Days process 

The second  process  in place  to  ensure  an  accurate  risk  assessment form for  patients  is the 
Early Day Passport and Early Days process. 

 evidence on this process is set out below.    

Q:  What  strikes  me  is  if  that  happened  on  that  day,  what  is  happening  with  all  the  other 
prisoners?  
A: Since then [AS’s death] changes have been made to the reception process, on each side. 
There  has  been  a  big focus on  early  days  in custody,  recognising that the  first  14  days  and 
particularly the first couple of days are the most important period in someone’s stay in prison. 
One of things that would identify poor completion of cell sharing risk assessment is early day 
passport.  This  is  overseen  by  custodial  managers  and  nursing  staff.  There  is  a  checklist  to 
ensure that everything mandatory within the process has been completed and completed to a 
good standard. Certainly if not completed to good standard would expect that to be flagged to 
me.  
Q: Who is doing this?  
A:  Custodial  managers.  And  nurses,  with  oversight,  are  required  to  complete  healthcare 
sections 
Q: Do you think that such a poor standard would not exist today?  
A: I do 
Q: This was only two years ago?  
A: That’s one element of the changes that we have made. The other side to that is in the past 
year we have re-modelled healthcare across London. We have moved to new models of care. 
The sole purpose of new model and reason why it has been redesigned is to reduce deaths in 
custody. There is very much a heavy focus on early days in custody team. What is happening 
now  is  as  follows.  If  someone  comes  to  Pentonville  this  evening,  they  are  the  subject  of  a 

Page 3 of 5 

 
 
 
 
 
 
 
 
 
 
 
 
 meeting  the  next  day.  A  group  of  staff  will  look  through  every  patient  that  came  through  the 
previous night. People in that meeting have dedicated roles. There is a chair, someone writing 
notes on standardised template, someone checking medical records. Someone from pharmacy 
looking out for medications and checking reconciliation. We have someone from mental health 
and substance misuse teams looking at notes to ascertain anything important to be picked up. 
Out of that meeting a care plan is generated for that patient. That is for every patient now. There 
was  a  referral  meeting  but  that  is  based  on  referrals  only.  The  key  difference  now  is  that 
everyone is screened in this meeting.  

[…] 

Q: What’s the reason staff didn’t [complete a F35 form]? Is it about culture?  
A:  It’s  about  thoroughness,  conducting  a  thorough  assessment  of  the  patient  and  ensuring 
factors are covered off. It is something I expected them to have asked.  
Q: Has that culture changed?  
A: Yes.  
Q: How do you know?  
A:  There  are  more  opportunities  now  to  safety  net  patients  and  catch  patients.  This  is  the 
purpose of the Early Days process. Part of that process in the meeting is looking at the Prison 
Escort Record […] and also looking at the cell sharing risk assessment to make sure that it was 
filled out correctly and make any recommendations if not yet done at this stage. I can confidently 
say  that  if  Mr  Singh  came  in  this  evening  then  everything  would  be  picked  up  at  meeting 
tomorrow morning.  

On cross-examination by counsel, 
 described how a list would be created within the 
Early Days meeting of tasks to be completed for the patient. These patients and any associated 
tasks would appear on an Early Days ledger. At the end of a patient’s first 14 days in prison, 
they cannot be transferred out of the Early Days system until each of their required actions is 
marked as complete by a member of the healthcare staff. Outstanding tasks would reappear on 
the ledger every day until the tasks were complete.  

By way of summary of the Early Days process and its role in quality assuring a patient’s risk 
assessment form: 

•  Every  patient  has  an  Early  Days  passport  as  part  of  the  Early  Days  process,  which 
requires custodial managers and nurses to check off that items like the risk assessment 
form had been completed and completed to a sufficient standard. This requires a nurse 
to  ensure  that  the  risk  assessment  has  been  correctly  completed,  and  sign  off  the 
passport. 

•  Care for every new arrival is transferred to a multi-disciplinary team. That team meet the 
next  day  and  discuss  a  patient  holistically.  This  occurs  for  every  patient.  Holding  the 
Early Days meeting ensures that if a reception screening form is absent, incomplete or 
completed incorrectly for a patient with a medical history of epilepsy or seizures, it would 
be  addressed  in  the  Early  Days  meeting  by  the  multi-disciplinary  team  and  correctly 
completed. These meetings are conducted 5 days a week and are started earlier on a 
Monday to account for the weekend admissions. 

• 

If a patient had not had the risk assessment form completed during the initial reception 
screen or the Early Days meeting, that patient would not be able to transfer out of the 
Early Days patient ledger until all outstanding tasks (e.g. completing or reviewing a cell 
sharing risk assessment form) had been marked as complete.  

Page 4 of 5 

 
 
 
 
 
 
 
 
 
 
 
 •  There is an EDIC checklist of tasks/ procedures that must be carried out in the first two 
days of a patient’s admission which is ticked and signed off by the EDIC Lead to ensure 
completion. The risk assessment forms part of this checklist. 

Other checks in the system 

There  are  several  other  aspects  of  Ms  Barratt’s  evidence  that,  we  submit,  substantiate  her 
assertion that a deficient risk assessment would be identified earlier and corrected. This is again 
taken from Counsel’s note. 

Q: We know that by time of death he was sharing cell and on upper bunk. Is it the case that 
because this was missed in the risk assessment that is it? Nobody ever looks back and checks?  
A:  The  risk  assessment  form  is  the  initial  way  of  communicating  that  to  discipline  staff.  Any 
senior clinician or GP when they see a patient with needs can commission an F35. This is a 
special recommendation form which we hand over to operational staff to say ‘this man on bottom 
bunk’, ‘single cell’, ‘allowed two showers a day’. That’s us giving that notice to operational staff. 
The clinicians that saw Mr Singh subsequently to his reception screening should have checked 
as part of their assessment if he was sleeping on bottom bunk. If the risk assessment form said 
‘no’ then they should have issued the F35 which was in place at time.  

 also described the process in place for managing long term conditions. 

On the basis of that evidence provided, we make the following assurances: 

•  A  patient  like  AS  would qualify  for  long  terms  conditions  monitoring  through  the  long 

term condition (“LTC”) ledger and clinic appointments.  

•  This would result in AS having more frequent contact with clinical staff, each equating to 
an additional opportunity for staff to consider cell sharing risk issues and issue a F35 
form if required. 

Finally, we provide the HMP Pentonville prison team with a list of patients with epilepsy/seizures 
to ensure that custodial staff are also able to identify cell-sharing issues. This list is provided to 
all governors and custodial managers working in the establishment. We also have the Safety 
Intervention Meeting (SIM) and prison safety meeting where these issues can be discussed. If 
we wish to have an impromptu MDT (Multi-Disciplinary Team meeting) with the prison in regards 
to a patient then we will arrange this directly with wing managers and governors and any other 
relevant stakeholders. 

I hope that the above information provides you with reassurance that action has been taken and 
cell sharing risk assessments would not be completed as it was in this case. 

Practice Plus Group is committed to ensuring the high quality provision of healthcare services 
to all prisoners at HMP Pentonville. We will also ensure that the lessons learnt as a result of this 
inquest are shared across all of Practice Plus Group’s services.  

I  do  hope  that  this  letter  provided  the  necessary  reassurance  sought  and  if  I  can  be  of  any 
further assistance you should not hesitate to contact me directly. 

Yours sincerely 

National Medical Director, Health in Justice, Practice Plus Group 

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