John Williams
28 Mar 2017 · Coroner ME Hassell · London Inner (North)
This report repeats 4 earlier warnings, and was raised again 8 times later. See the linked reports.
The coroner's concerns
1. lack of proper reception screening and mental health referral
“The first reception nurse who saw Mr [name redacted] when he entered HMP Pentonville gave evidence that he had no thoughts of self harm or suicide, but she recorded that he had. It appears she may benefit from additional training and/or supervision. . There was no second reception screen conducted. If Mr [name redacted] was not brought to healthcare staff for his second reception screen then healthcare staff needed to follow this up. . The first reception nurse did not make the referral to the mental health team”
2. inadequate understanding of ACCT protocol and risk documentation
“Mr [name redacted] said to several members of staff that he would self harm or hang himself if he wanted something done and it was not happening quickly enough (rather than because he actually wanted to die.) This was recorded on his assessment, care in custody, teamwork (ACCT) document. Some prison officers did not seem familiar with the very important contents of the ACCT, not even the inside cover. The senior officer in charge on the weekend of Mr [name redacted]' death did not look at the inside cover or”
3. lack of knowledge about emergency response codes
“The issue of the difference between a code blue and a code red is one about which | have written before. One senior prison officer said in evidence that if she did not know the difference between a code blue and a code red, then there would be some serious concerns. She did not. She had been given a small card describing code blue and code red (a card which another officer kept about her person and even produced from the witness box), and she still retained that card. However, she had never”
4. absence of basic emergency medical training among prison officers
“The prison officers did not have even the most basic first aid and cardiopulmonary resuscitation (CPR) training. | am aware from other inquests that this is not provided at a national level. | have written about this before. It seems a significant gap, even allowing for the fact that there are always two trained nurses on site.”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“inadequate training for staff at the prison services have contributed to this accident.”
This report
“Some prison officers did not seem familiar with the very important contents of the ACCT, not even the inside cover.”
Identical hazardConfidence 0.90 · high
Earlier report
“Witnesses confirmed that they often did not read much of the ACCT document prior to the ACCT review and relied more upon input of other attendees”
This report
“Some prison officers did not seem familiar with the very important contents of the ACCT, not even the inside cover.”
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
“The prison officers did not have even the most basic first aid and cardiopulmonary resuscitation (CPR) training.”
Identical hazardConfidence 0.90 · high
Earlier report
“The lack of a process for following up non- attendance at the Reception Healthcare first night screening”
This report
“There was no second reception screen conducted. If Mr [name redacted] was not brought to healthcare staff for his second reception screen then healthcare staff needed to follow this up.”
Identical hazardConfidence 0.90 · high
This report
“The prison officers did not have even the most basic first aid and cardiopulmonary resuscitation (CPR) training.”
Later report
“There is no mandatory first aid training for existing (as opposed to new) prison officers.”
Identical hazardConfidence 0.90 · high
This report
“. The prison officers did not have even the most basic first aid and cardiopulmonary resuscitation (CPR) training. | am aware from other inquests that this is not provided at a national level.”
Later report
“(1) Some Prison staff had not received any cardiopulmonary resuscitation training. Either as part of initial training or any refresher training.”
Identical hazardConfidence 0.90 · high
This report
“The prison officers did not have even the most basic first aid and cardiopulmonary resuscitation (CPR) training. | am aware from other inquests that this is not provided at a national level.”
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. Once a prison officer's three-year period has expired, whilst they may be reminded by the prison establishment that their certification is no longer live, it is not mandatory for them to renew this.”
Closely relatedConfidence 0.90 · high
This report
“The issue of the difference between a code blue and a code red is one about which | have written before.”
Later report
“relevant training and guidance to equip staff to understand when and how to enter a cell in a medical emergency, and the appropriate use of Code Blue and Code Red communications in a medical emergency”
Identical hazardConfidence 0.90 · high
This report
“The prison officers did not have even the most basic first aid and cardiopulmonary resuscitation (CPR) training.”
Later report
“Evidence was heard that the majority of those prison officers who had commenced in their roles prior to 2018 had no first aid/basic life-saving skills and no ability/training in undertaking cardiopulmonary resuscitation ('CPR').”
Identical hazardConfidence 0.95 · high
This report
“The prison officers did not have even the most basic first aid and cardiopulmonary resuscitation (CPR) training.”
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 0.90 · high
This report
“Some prison officers did not seem familiar with the very important contents of the ACCT, not even the inside cover.”
Later report
“When Prison Officers and/or Healthcare staff are given ACCT induction training at HMP Wandsworth, there is no training in the principles of risk formulation”
Identical hazardConfidence 0.90 · high
This report
“The prison officers did not have even the most basic first aid and cardiopulmonary resuscitation (CPR) training.”
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”
Responses
2017-0094-Response-from-Care-UK.pdf ↗· Care UK
Stated action
“The nurse has been reminded of the process of giving evidence at an inquest and to listen carefully to the question that is being and to take time in considering her answer. Enquiries have been made by the Interim Head of Healthca re who is satisfied that the nurse in giving evidence at the inquest was confused and made a mistake in response to your question.”