Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0146, written 4 Jan 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 4 Jan 2024 |
|---|---|
| Reference | 2024-0146 |
| Deceased | Stephen Coster |
| Coroner | Rachel Redman |
| Coroner area | East Sussex |
| Category | State Custody 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.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 HM Prison and Probation Service 1 CORONER I am Rachel REDMAN, Assistant Coroner for the coroner area of East Sussex 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 13 May 2022 I commenced an investigation into the death of Stephen COSTER aged 43. The investigation concluded at the end of the inquest on 04 December 2023. The conclusion of the inquest was that: Stephen was detained at HMP Lewes on 26.4.2022 on remand. Stephen was found in his cell on the floor naked between 5am-5.30am on the morning 3rd May 2022. Prison officers called for health care to attend Stephen’s cell. Medical staff attended, very limited examination was made. At this time no treatment was given. Stephen was left in his cell in the same condition. Health care staff advised Prison staff to undertake observations. It was recorded Stephen was under the influence. At approximately 8.30am, Stephen was checked in his cell. His condition had deteriorated. Prison staff asked for healthcare to attend. Healthcare staff deemed it necessary for an ambulance to be called. Following assessment ambulance staff advised Stephen should immediately be taken to hospital. There is evidence that delays to paperwork resulted in the ambulance being unable to leave the prison grounds. The Paramedic clearly stated that Stephen should be taken to hospital immediately with life threatening conditions. Paperwork was eventually completed. The ambulance was able to leave prison at 10.29am, Stephen arrived at hospital at 10.45am. Stephen was taken to resuscitation, and received treatment at the hospital. 4 CIRCUMSTANCES OF THE DEATH Stephen Coster died as a result of 1a Meningo encephalitis owing to Streptococcus pneumoniae at Royal Sussex County Hospital, Brighton. The jury found that delay by the prison staff and healthcare staff in enabling the correct treatment to be given to Stephen Coster in HMP Lewes more than negligibly, minimally and trivially contributed to his death. 5 CORONER’S CONCERNS During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) a. Evidence was heard relating to poor and inadequate record keeping by prison staff. Regulation 28 – After Inquest Document Template Updated 30/07/2021 b. A failure by healthcare staff to carry out adequate observations and to properly assess Stephen Coster's condition as well as a failure to escalate his case. c. Healthcare staff failed to provide the prison staff with an adequate care plan so that Stephen Coster could be monitored effectively. Evidence was heard that there was no protocol or policy in place regarding communication between Healthcare staff and Prison staff for the monitoring of sick prisoners on the wing at night. d. There was inadequate understanding amongst prison staff about when to call Code Blue. e. There was a breakdown in communication between healthcare staff and prison staff regarding transferring a sick prisoner to hospital as an emergency. Further, there was inadequate information included on the paperwork prepared by healthcare staff about Stephen Coster's condition resulting in delay in arranging for his urgent escort and transfer to hospital. f. An inadequate understanding amongst prison staff about the local policy to transfer emergency cases to hospital with a retrospective risk assessment. g. Inadequate leadership by prison staff leading to a breakdown in communication amongst junior prison staff which caused the delay in transferring Stephen from the prison to hospital. Having heard evidence from Practice Plus Group about the improvements in its service delivery which have been implemented and which are being monitored, I have decided not to send a copy of this PFD report to PPG on the understanding that action is being taken to prevent future deaths such as Stephen Coster's. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or 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 February 13, 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 the following Interested Persons Family of Stephen Coster Practice Plus Group I have also sent it to South East Coast Ambulance Service NHS Foundation Trust HM Inspectorate of Prisons Prisons and Probation Ombudsman Independent Advisory Panel on Deaths in Custody who may find it useful or of interest. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. 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 Regulation 28 – After Inquest Document Template Updated 30/07/2021 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 Dated: 04/01/2024 Rachel REDMAN Assistant Coroner for East Sussex Regulation 28 – After Inquest Document Template Updated 30/07/2021
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 Operations HM Prison and Probation Service 8th Floor Ministry of Justice 102 Petty France London SW1H 9AJ 29 February 2024 Rachel Redman Assistant Coroner for East Sussex Unit 56 Innovation Centre Highfield Drive St Leonards on Sea TN38 9UH Dear Ms Redman Thank you for your Regulation 28 report of 4 January 2024 addressed to the Minister of State for Prisons, Parole and Probation following the inquest into the death of Stephen Coster at HMP Lewes on 5 May 2022. I am responding on behalf of HMPPS as Director General of Operations. I know that you will share a copy of this response with the family of Mr Coster, 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. Following evidence heard at the inquest you raised concerns directed to both HMPPS and Practice Plus Group (PPG). I am responding to those relating to HMPPS. Following the Fact-Finding report on 16 May 2022 HMP Lewes undertook a review of record-keeping practices which identified a generally very good approach by staff. Issues identified, such as the need for staff to record smaller interactions, have been addressed, with staff being reminded of the need to record all relevant information. The prison has also conducted a further review, together with healthcare, to consider how best to manage the care and monitoring of unwell prisoners. An agreed system is now in place which clarifies that prison staff are responsible for welfare checks and medical staff are responsible for clinical observations. Healthcare staff inform prison staff of the need for checks on a particular prisoner and what level of check is required. Where healthcare feel it is clinically appropriate, a move to the inpatient unit at the prison will be facilitated so that healthcare staff are present to undertake all observations. The prison continues to brief staff regularly regarding the appropriate use of Code Red and Code Blue, and the importance of using them to ensure the emergency services are called immediately. Shortly after Mr Costers death, a Notice to Staff was sent out to raise awareness and remind staff of their responsibilities. This was followed up by reminders in the Safety Newsletter later in the year and the Safety Nudge the following year. A number of training events have also taken place, delivered by the Safety Team, on the emergency codes. Every person was also issued with a business card-sized pocket guide as a handy reminder, which all new staff now receive as part of their training. Following the death of Mr Coster and the PPO’s recommendations, the Deputy Governor and Head of Safety conducted a review into the circumstances of the prison escort to hospital. Their findings identified a need for improved communication with and greater clarity from healthcare staff to ensure that urgency of the matter is made clear to prison staff. This has been shared with healthcare. Custodial Managers have the authority to dispatch an emergency escort without the relevant risk assessment where the life of a prisoner is in danger. The Local Operating Procedure for Hospital Escorts and Bedwatches refers to escorts being dispatched without the relevant risk assessment where there is an ‘emergency.’ The policy on emergency escorts as a whole is being actively reviewed. Following a review into incident management the Assistant Orderly Officer now attends each Code Blue/Red to personally oversee, provide direction, and ensure standards are kept, ensuring effective leadership during the management of the incident. Thank you again for bringing your concerns to my attention. I trust that this response provides assurance that action is being taken to address the matters that you have raised. Yours sincerely Director General of Operations
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