Lewis Johnson
12 Dec 2022 · Coroner Kevin McLoughlin · West Yorkshire (Eastern)
The coroner's concerns
1. lack of nighttime healthcare staff
“HMP Wealstun does not have nurses or other healthcare staff in the prison during the night”
2. foreseeable self-harm emergencies
“The incidence of self-harm incidents amongst prisoners (both in 2019 and today) make such emergencies foreseeable”
3. untrained night staff for self-harm response
“In the absence of healthcare staff being immediately available, the night patrol staff should be trained to respond effectively to ligature or other self-harm incidents”
4. officer without CPR training
“The OSG officer who encountered the situation involving Mr [name redacted] around 04:45 hours had not been trained to carry out CPR”
5. officer assumes death without assessment
“The officer acting as attended the cell but did not think about CPR, believing Mr [name redacted] to be already dead (notwithstanding that none of the discipline officers present had anv medical qualifications to certifv death)”
6. lack of coordinated CPR response
“The four prison officers present in the cell did not discuss the need for CPR. The possibility of using a defibrillator was not mentioned. Mr [name redacted] was left in the cell in a seated position without the wisdom of placing him in the recovery position being considered”