Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0055, written 5 Feb 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 5 Feb 2024 |
|---|---|
| Reference | 2024-0055 |
| Deceased | Liam Turner |
| Coroner | Zak Golombeck |
| Coroner area | Manchester City |
| Category | Alcohol, drug and medication related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REG ULATION 28: REPORT TO PREVE NT FUTURE DEATHS.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT 15 BEING SENT TO:
• HM Prison and Probation Service
Copied for interest to:
• Chief Coroner
• Foster Parents of the Deceased
• HMP Manchester
• Ministry of Justice
• Greater Manchester Mental Health NHS Foundation Trust
• Delphi Medical
1 CORONER
I am Mr Zak Golombeck, Area Coroner for Manchester (City) Area
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
INQUEST
A jury concluded the inquest into the death of Liam Turner on 31 st January 2024 and
recorded that he died from :
1a Toxicity of ADB-BUTINACA ("
combination with
"/ novel psychoactive substance) in
The jury returned a conclusion of Drug related death.
4 CIRCU MSTANCES OF THE DEATH
The Deceased died at HMP Manchester on 6th December 2021. His death was
caused by a mixed toxicity of a psychoactive substance and prescription medication.
There were admitted failings made by the Ministry of Justice (on behalf of HMP
Manchester) relating to the fact that a prison officer should have raised concerns that
the Deceased was under the influence of an illicit substance with healthcare earlier
than he did; however, these failings did not contribute to the Deceased 's death.
When three officers found the Deceased unresponsive in his cell, they moved him
from his bed to the floor in preparation to commence cardiopulmonary resuscitation
1
(CPR); however, CPR was not commenced until the healthcare nurses (and
subsequently paramedic) arrived .
I sought evidence about training for CPR, and I was informed by one witness that he
received training in 2006 as part of his Emergency First Aid at Work (EFAW)
training; however, he had never had any refresher training.
The training certification expires after 3 years, and it is not mandatory for prison
officers to receive refresher or additional training.
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 MATTER OF CONCERN is as follows:
It is not mandatory for prison officers to have basic first aid training (which includes
the provision of CPR) which is in-date. Once a prison officer's three-year period has
expired, whilst they may be reminded by the prison establishment that their
certification is no longer live, it is not mandatory for them to renew this. For example,
at HMP Manchester, at present 52% of prison staff received Emergency First Aid at
Work (EFAW) training within the past three years as part of their initial officer
training. Therefore, 48% of prison staff will have training certification (which includes
CPR) which has expired. The evidence admitted was that the main reason for this is
due to it not being mandatory for prison staff to have up-to-date training.
6 ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you and
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 1st April 2024. 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 Interested Persons. I
have also sent it to organisations who may find it useful or of interest.
I am also under a duty to send the Chief Coroner a copy of your response.
2
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 DATE:
NAME OF CORONER:
05/02/2024
Signed:
Mr Zak Golombeck
HM Area Coroner for
Manchester City Area
3
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 28 March 2024 Mr Zak Golombeck HM Area Coroner Manchester City Area Exchange Floor The Royal Exchange Building Cross Street Manchester M2 7EF Dear Mr Golombeck Thank you for your Regulation 28 report of 5 February 2023 addressed to His Majesty’s Prison and Probation Service (HMPPS). I am responding as Director General of Operations. I know that you will share a copy of this response with Mr Turner’s family, 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. 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. Thank you for bringing your concern to my attention. As you are aware, the HMPPS First Aid Policy Framework was re-issued nationally in August 2023. The revised policy highlights the training requirements for Emergency First Aid and First Aid in prisons, including the importance of Governors ensuring that there is an appropriate number of trained staff on duty at all times. To achieve this, a detailed local first aid risk assessment must be produced to determine the number of First Aiders at Work (FAW) and Emergency First Aiders at work (EFAW) required at an establishment at any given period, ensuring that they are deployed appropriately. At HMP Manchester, the requirement is for the provision of 21 trained first aiders and there are currently 39 officers with in-date training. Further to this, 52% of prison staff have received EFAW training within the last three years as part of their initial officer training. This is in addition to the provision of healthcare, which at HMP Manchester is 24 hours a day, 7 days a week, in line with the Category A status of the prison. As such, healthcare staff are able to provide emergency assistance should the need arise. Regular reviews will continue to be conducted to ensure that the needs of the prison are met. In respect of the EFAW training that all prison officers receive during their entry level training, all first aid training certificates are valid for three years before they can be renewed and, although not mandatory, staff are always encouraged to undertake refresher training to maintain their basic skills and keep up to date with any changes to first-aid procedures. In December 2023, HMP Manchester issued guidance as well as a presentation to all staff on circumstances that CPR (Cardio-Pulmonary Resuscitation) is appropriate. The guidance is clear in reiterating 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 your concerns to my attention. I trust that this response provides assurance that action is being taken to address. Yours sincerely, Director General of Operations
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