Derrick Rose-Fowler
21 Apr 2016 · Coroner John Ellery · Shropshire, Telford and Wrekin
A similar concern from this report was raised again 3 times later. See the linked reports.
The coroner's concerns
1. lack of first aid training among prison officers
“it is a matter of concern that in December 2010 only one of four officers were first aid trained and in February 2012 one was still untrained”
2. failure to investigate bullying allegations
“there has been one other self- inflicted death at Stoke Heath, in the last 4 years - in March 2013. In the investigation into that death we found that the prison did not investigate allegations of bullying”
3. inadequate bullying policy implementation
“there was some evidence that he was. The prison has a Tackling Bullying Behaviour (TBB) policy but there is concern as to how effective it was implemented on the complaints raised by the deceased himself that he was, in terms, being bullied.”
4. lack of support for non-cooperating prisoners
“The TBB did not explicitly allow for or record that a prisoner, such as the deceased, who was not prepared to name names could nevertheless still be offered support”
5. missed opportunity for MASH referral
“It could not be said that any such referral would have changed the outcome but there was evidence that something would have been done”
Linked reports
Closely relatedConfidence 0.90 · high
This report
“Although on the facts of this case it made no difference to the outcome, the first prison officer on the scene was not first aid trained.”
Later report
“There was clearly a delay between Mr [name redacted] being found unresponsive by the prison officers and the commencement of CPR by members of the healthcare staff.”
Identical hazardConfidence 0.90 · high
This report
“it is a matter of concern that in December 2010 only one of four officers were first aid trained”
Later report
“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
“it is a matter of concern that in December 2010 only one of four officers were first aid trained and in February 2012 one was still untrained”
Later report
“No ongoing training had been provided to prison officers since initial training on basic life support or first aid, meaning that officers confronted with discovery of a ligature situation were unable to provide immediate and basic life support due to a lack of confidence”
Responses
No published response was found on judiciary.uk.