Ryan Trimmer
21 Jun 2019 · Coroner James Healy-Pratt · East Sussex
This report repeats 5 earlier warnings, and was raised again 5 times later. See the linked reports.
The coroner's concerns
1. inadequate ACCT reviews
“The ACCT process was ineffective”
2. lack of first aid training among prison staff
“Prison staff are often first responders to medical emergencies of prisoners, but not all have received first aid training”
3. lack of refresher first aid training for long-serving prison staff
“One frontline prison staff member gave evidence that he had not received training in 16 years of working for HMPS and felt he needed refresher training”
Linked reports
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
“Prison staff are often first responders to medical emergencies of prisoners, but not all have received first aid training.”
Identical hazardConfidence 0.92 · high
Earlier report
“During the course of the inquest evidence was heard from two members of Prison discipline staff that they had last been trained in first aid respectively 10 and 6 years ago”
This report
“One frontline prison staff member gave evidence that he had not received training in 16 years of working for HMPS and felt he needed refresher training.”
Closely relatedConfidence 0.80 · moderate
Earlier report
“some staff were working without having received any training and some either had not had sufficient training or had forgotten it or were not applying it with”
This report
“The ACCT process was ineffective. They jury made a factual finding of inadequate ACCT reviews.”
Identical hazardConfidence 0.95 · high
Earlier report
“(4) There is no mandatory first aid training for existing (as opposed to new) prison officers.”
This 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
Earlier report
“Some Prison staff had not received any cardiopulmonary resuscitation training. Either as part of initial training or any refresher training.”
This report
“One frontline prison staff member gave evidence that he had not received training in 16 years of working for HMPS and felt he needed refresher training.”
Closely relatedConfidence 0.90 · high
This report
“One frontline prison staff member gave evidence that he had not received training in 16 years of working for HMPS and felt he needed refresher training.”
Later report
“It is not mandatory for prison officers to have basic first aid training (which includes the provision of CPR) which is in-date.”
Closely relatedConfidence 0.85 · high
This report
“The ACCT process was ineffective. They jury made a factual finding of inadequate ACCT reviews.”
Later report
“An ACCT was opened in relation to [the deceased] on the 15th January 2022 and remained open until his death. Between 15th January and 7th March 2022 there were 11 case reviews.”
Identical hazardConfidence 0.90 · high
This report
“Prison staff are often first responders to medical emergencies of prisoners, but not all have received first aid training.”
Later report
“Evidence was heard that 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 0.90 · high
This report
“The ACCT process was ineffective. They jury made a factual finding of inadequate ACCT reviews.”
Later report
“I am concerned that the ACCT process or system currently in place designed to keep women safe at HMP Styal is not working effectively, and that there is a risk of future deaths if the process is not reconsidered or amended to better suit the needs of this prison.”
Closely relatedConfidence 0.90 · high
This report
“Prison staff are often first responders to medical emergencies of prisoners, but not all have received first aid training.”
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
2019-0215-Response-by-HM-Prison-and-Probabtion-Service.pdf ↗· His Majesty's Prison and Probation Service
Stated action
“The Governors of each prison are required to ensure that there are sufficient numbers of staff trained in first aid on duty, and at HMP Lewes at least two trained nurses and one trained member of prison staff are available at all times. Two on-site first aid trainers will be delivering first aid training to staff as part of the prison's monthly training provision, and a one-day refresher course will be introduced to ensure that training levels are maintained. Custodial Managers (the most senior”