Satheeskumar Mahatheaven
19 Sept 2014 · 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. information sharing failures
“Failures in relation to information sharing, multi agency communication procedures and inadequate training for staff at the prison services have contributed to this accident.”
2. inadequate staff training
“inadequate training for staff at the prison services”
3. multi agency communication breakdown
“multi agency communication procedures”
Linked reports
Closely relatedConfidence 0.90 · high
This report
“inadequate training for staff at the prison services have contributed to this accident.”
Later report
“Some prison officers did not seem familiar with the very important contents of the ACCT, not even the inside cover.”
Responses
2014-0412-Response-by-NOMS.pdf ↗· HMP Pentonville
Stated action
“Local policies are now in place at HMP Pentonville and HMP Thameside to ensure that information is shared appropriately and that there is effective communication between prison staff and the healthcare provider.”
Mahathevan-2014-0412a.pdf ↗· HMP Pentonville
Stated action · 28 November 2014
“Action should therefore be taken to prevent future deaths and I believe that you have the power to take such action.”