Samuel Blair
19 May 2016 · Coroner ME Hassell · London Inner (North)
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. inadequate mental health triage and documentation
“the assistant psychologist who triaged Mr [name redacted] in prison on 2 July 2015 asked him about his alcohol dependency, she did not ask him about drug use, nor did she record asking him about his mood or any suicidal thoughts”
2. absence of multidisciplinary management plan for schizophrenia
“There is no record from that meeting of any discussion or management plan for Mr [name redacted] schizophrenia.”
3. lack of depression management documentation
“There is no record from that meeting or any other time, of any consideration of or management plan for Mr [name redacted] depression”
4. failure to recognise and continue prescribed antidepressant treatment
“there is no record that it was ever recognised by the healthcare staff at HMP Pentonville that Mr [name redacted] had been prescribed and had been compliant with the prescription of an anti depressant before his incarceration”
5. delayed emergency ambulance dispatch information
“After Mr [name redacted] was found hanging, the officer in the prison control room did not give the prison gate location for the ambulance at the very outset of the 999 call to London Ambulance Service, but instead did so part way through the call.”
Linked reports
Closely relatedConfidence 0.90 · high
This report
“There is no record from that meeting or any other time, of any consideration of or management plan for Mr [name redacted] depression.”
Later report
“The second reception (well man) screening nurse did not explore the history of depression recorded”
Responses
2016-0196-Response-by-Care-Uk.pdf ↗· Care UK
Stated action
“we will collaborate with them to ensure that the action plan outlined in their response is implemented and that all healthcare staff are aware of the plan.”
2016-0196-Response-by-London-Ambulance-Service-NHS-Trust.pdf ↗· London Ambulance Service NHS Trust
Stated action · November 2016
“in early May 2016, when the refresher training for 2016/17 for staff in EOC began, a session was included that made specific reference to HMP Pentonville and of the requirement that when a call from HMP Pentonville was received, at the start of the call the emergency medical dispatcher was to seek confirmation of the gate the LAS should attend. This training is in process and due to be completed in November 2016.”
2016-0196-Response-by-NOMS.pdf ↗· His Majesty's Prison and Probation Service
Stated action
“prison will continue to work with the healthcare provider f ensure that all staff are aware of the steps that they are required to take when responding to an emergency call.”
Blair-2016-0196a.pdf ↗· London Ambulance Service NHS Trust