Carlington Spencer
28 Aug 2020 · Coroner Timothy Brennand · Lincolnshire
This report repeats 1 earlier warning, and was raised again 1 time later. See the linked reports.
The coroner's concerns
1. presumption of drug influence not challenged
“The existence of "confirmation bias" or "confirmatory bias" when dealing with detainees with a known history of recreational use of drugs in such a way that when a detainee presents in a manner that is interpreted as being presumed and/or assumed to be under the influence of drugs, this presumption and/or assumption is not challenged or tested or verified”
2. co-detainee concerns ignored
“Concerns of co-detainees are not appreciated or noted or actively sought”
3. inaccurate record keeping
“Record keeping and purported observations of detainees who are incapacitated by reason of presumed self-induced intoxication are inaccurate, irregular and unavailable for inspection by health care personnel”
4. lack of training on new psychoactive substances
“Discipline staff have no meaningful training on the categories of self-induced intoxication and in particular "new psychoactive substances" such as the synthetic cannabinoid known as "Spice”
5. inadequate escalation protocols
“There is no adequate communication or working protocols as between Discipline staff and healthcare staff for clear escalation pathways when dealing with a presumed "Spice" related incident”
6. inadequate escalation for medical emergencies
“There is no adequate communication or working protocols as between Discipline staff and healthcare staff for clear escalation pathways when dealing with an incident that may have commenced as a drug related incident but develops into a potential medical emergency”
Linked reports
Closely relatedConfidence 0.80 · moderate
Earlier report
“That the use of New Psychoactive Substances (NPS) remains rife within the prison, and presentations such as Mr [name redacted] are not diminishing, and that the Substance Misuse Team requires further staff to be effective in future.”
This report
“Discipline staff have no meaningful training on the categories of self-induced intoxication and in particular "new psychoactive substances" such as the synthetic cannabinoid known as "Spice"”
Closely relatedConfidence 0.80 · moderate
This report
“Record keeping and purported observations of detainees who are incapacitated by reason of presumed self-induced intoxication are inaccurate, irregular and unavailable for inspection by health care personnel;”
Later report
“a) That there remain potential issues of poor record keeping. b) There are concerns over the level of communication between professionals within the Trust and communication with patients.”
Responses
No published response was found on judiciary.uk.