Amarjit Singh
18 Sept 2023 · Coroner Mary Hassell · Inner North London
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. cell sharing risk assessment
“The completion of the cell sharing risk assessment was described by the extremely experienced nurse who completed it, as careless”
2. outstanding issues
“some points remain outstanding”
3. lack of staff training on seizure response
“training for prison staff in how to deal with fits is to be given at HMP Pentonville in October 2023”
4. inadequate first aid training for prison officers
“not all prison officers receive ongoing first aid training is a national resourcing issue”
5. delayed CPR response
“it did not cross his mind to start CPR in the three minutes it took nurses to arrive after Mr [name redacted] was found not breathing”
6. misunderstanding of medical status
“did not know that there is a difference between a person who is unconscious and a person who is dead”
Linked reports
Closely relatedConfidence 0.70 · moderate
This report
“One officer told me that it did not cross his mind to start CPR in the three minutes it took nurses to arrive after Mr [name redacted] was found not breathing.”
Later report
“I heard evidence describing the care given to [the deceased] after his collapse as chaotic, with faulty equipment and incorrect CPR technique.”
Responses
2023-0342-Response-from-HM-Prison-and-Probation-Service.pdf ↗· Practice Plus Group
Stated action · October
“Training for prison staff in how to deal with fits is scheduled to be given at HMP Pentonville in October”
2023-0342-Response-from-Practice-Plus-Group.pdf ↗· Practice Plus Group