Mark Doyle
18 Dec 2017 · Coroner Heather Williams · London Inner (North)
This report repeats 3 earlier warnings, and was raised again 6 times later. See the linked reports.
The coroner's concerns
1. identifying and recording trigger factors for a particular prisoner on their ACCT inside front cover
“Although recent developments regarding multi-disciplinary involvement in ACCT case reviews and quality assurance ACCT checks are encouraging (as described to me by , Head of Safer Custody), I remain concerned that the following failings were apparent in the ACCT case reviews concerning Mr [name redacted] conducted on 10 and 20 March 2017, but are not addressed / adequately addressed by the recent initiatives (including the new Weekly Quality Assurance Check): - Insufficient appreciation of the importance of”
2. lack of relevant information sharing
“Although, , Head of Healthcare, described how healthcare staff have received recent encouragement to make entries on a prisoner's ACCT in relation to matters that could bear on risk, I am concerned that this does not go far enough to change past practice and ensure that relevant information is shared, in light of the prison staff's lack of access to System One records and the infrequent occasions that Care UK staff made entries on Mr [name redacted] ACCT daily record”
3. lack of clear criteria for assessing when a prisoner is fit for transfer
“Decisions that prisoners are fit to be transferred from F Wing are made and conveyed to prison staff by the charge nurse on duty that morning annotating by hand a list of the prisoners on the Wing”
4. lack of mandatory first aid training for existing prison officers
“There is no mandatory first aid training for existing (as opposed to new) prison officers”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“There was a clear breakdown in sharing of information known to the mental health team with other members of some ACCT reviews.”
This report
“Although, , Head of Healthcare, described how healthcare staff have received recent encouragement to make entries on a prisoner's ACCT in relation to matters that could bear on risk, I am concerned that this does not go far enough to change past practice and ensure that relevant information is shared, in light of the prison staff's lack of access to System One records and the infrequent occasions that Care UK staff made entries on Mr [name redacted] ACCT daily record.”
Identical hazardConfidence 0.90 · high
Earlier report
“Action is required to ensure that Prison Officers and Staff with direct access to prisoners have basic first aid training, CPR training and familiarisation with the use of a defibrillator.”
This report
“(4) There is no mandatory first aid training for existing (as opposed to new) prison officers.”
Identical hazardConfidence 0.90 · high
Earlier report
“The prison officers did not have even the most basic first aid and cardiopulmonary resuscitation (CPR) training.”
This report
“There is no mandatory first aid training for existing (as opposed to new) prison officers.”
Closely relatedConfidence 0.85 · high
This report
“I am concerned that this does not go far enough to change past practice and ensure that relevant information is shared, in light of the prison staff's lack of access to System One records”
Later report
“A past spelling error meant that there were two sets of NOMIS prison records for Mr [name redacted]. This meant that there were then two sets of SystmOne healthcare records.”
Identical hazardConfidence 0.95 · high
This report
“(4) There is no mandatory first aid training for existing (as opposed to new) prison officers.”
Later report
“Prison staff are often first responders to medical emergencies of prisoners, but not all have received first aid training.”
Closely relatedConfidence 0.90 · high
This report
“I am concerned that this does not go far enough to change past practice and ensure that relevant information is shared, in light of the prison staff's lack of access to System One records”
Later report
“In evidence it was clear that the ACCT document was the only written document used for sharing information between the healthcare staff employed by the NHS trust and the prison security staff”
Closely relatedConfidence 0.90 · high
This report
“(4) There is no mandatory first aid training for existing (as opposed to new) prison officers.”
Later report
“after April 2024, basic first aid training (including CPR training) has been omitted from the foundation training programme for those training to be prison officers”
Closely relatedConfidence 0.92 · high
This report
“There is no mandatory first aid training for existing (as opposed to new) prison officers.”
Later report
“The Governor of the prison told the court that no refresher CPR training had been provided to prison staff since 2023 notwithstanding the 5 deaths of prisoners by ligature suspension that have occurred since.”
Closely relatedConfidence 0.92 · high
This report
“There is no mandatory first aid training for existing (as opposed to new) prison officers.”
Later report
“After prison officers and prison staff carry out their induction training which covers basic first aid training including the delivery of cardio pulmonary resuscitation (CPR), there is no further mandatory refresher training on first aid or CPR.”
Responses
2017-0375-Response-from-Care-UK.pdf ↗· Care UK
Stated action
“Following the inquest I have reflected and reviewed healthcare processes and there have been discussions within the healthcare team. Going forward we will ensure that the Local Operating Procedures (LOPs) are embedded, with senior management undertaking audits, to ensure that where any relevant risks and triggers are identified, we will share information with the prison in the following ways:- - Update on C nomis - entry to be made by allocated healthcare staff - Update the ACCT document and”
Stated action · immediate effect
“We agree that the system described above requires improvement. We have therefore, with immediate effect, implemented a Patient Wing Movement Assessment. This is similar system to what we have in the in-patients unit as follows. All prisoners who are deemed necessary to be admitted to the Substance Misuse Unit will remain on the unit for a period of stabilisation and until it is deemed safe for them to be moved off this unit and to be placed on normal location. By default, prisoners should not be”