Source · Prevention of Future Deaths

Stephen Sleaford

Ref: 2024-0550 Date: 14 Oct 2024 Coroner: I M Cartwright Area: Leicester City and South Leicestershire Responses identified: 1 / 2 View PDF

There's a severe lack of first aid and CPR training for prison officers, including new recruits, creating critical response gaps. Routinely obscured cell observation panels and unclear guidance on emergency cell entry further compromise prisoner safety.

Date 14 Oct 2024

56-day deadline 9 Dec 2024 est.

Responses identified 1 of 2

State Custody related deaths

Coroner's concerns

AI summary

View full coroner's concerns

1) 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’). Officers who had completed prison officer training between approximately April 2018 and April 2024 did have first aid training, but there had been no refresher training, subsequently, for that cohort.
2) Evidence was heard that after April 2024, basic first aid training (including CPR training) has been omitted from the foundation training programme for those training to be prison officers, meaning that NO new prison officers will have first aid/related training. I am gravely concerned that this situation (i.e. a lack of such training provided as foundation training), if it prevails, will probably lead to future deaths in prison custody.
3) Following the conclusion of the Inquest, I remain concerned that prison officer staff have an unrealistic expectation that prison healthcare staff will be willing and able to react timeously to any emergency unfolding, meaning there are obvious and crucial gaps in the extent and adequacy of the first/earliest response to any emergency unfolding.
4) The evidence revealed that despite clear instruction to officers, by way of Notices to Staff from senior management at the prison, to the effect that obscuring cell door observation panels on the inside by prisoners was not permitted practice and was to be challenged and remedied, routine practice by prison officers meant observation panels were permitted to be obscured, without challenge or sanction. This means that a situation prevailed whereby prison officers were unable to routinely see into all cells to check prisoner welfare, but were/are reliant on, and accepted, a verbal response only, which is and remains a significant concern.
5) I am concerned that there is no, or no adequate, clear understanding by, and/or clear guidance and training provided to, prison officers around when they should enter a prison cell when it is reasonably believed that a prisoner requires immediate care or assistance due to an emergency, medical or otherwise. Evidence indicated that a ‘dynamic risk assessment’ could be undertaken by any officer who was acting/operating alone, when considering necessary and immediate entry into a cell, whereas the majority of evidence aired was that officers would ‘never’ enter a prison cell when working alone, due to fears for own safety.

Responses

1 respondent

HMPPS received by CCO Central Government

9 Dec 2024 PDF

Action Taken

HMPPS re-issued the First Aid Policy Framework in August 2023, re-issued a notice to staff in October 2024 reminding them of the importance of challenging prisoners who block their observation panels, and issued a new film, ‘Responding to emergency situations’. (AI summary)

View full response

Dear Mr Cartwright,

Thank you for your Regulation 28 report of 14 October 2024, addressed to the Ministry of Justice, following the inquest into the death of Stephen Sleaford on 27 October 2022 at HMP Gartree. I am responding on behalf of His Majesty’s Prison and Probation Service (HMPPS) as Director General of Operations.

I know that you will share a copy of this response with Mr Sleaford’s family, and I would first like to express my condolences for their loss. Every death in custody is a tragedy and the safety of those in our care is my absolute priority.

Following evidence heard at the inquest, you have raised concerns regarding First Aid training for staff, the initial response of prison officers in medical emergency situations and the blocking of observation panels. Thank you for bringing your concerns to my attention.

The HMPPS First Aid Policy Framework was re-issued nationally in August 2023. The revised policy highlights the training requirements for Emergency First Aid and First Aid in prisons, including the importance of Governors ensuring that there is an appropriate number of trained staff on duty at all times. To achieve this, a detailed local first aid risk assessment must be produced to determine the number of First Aiders at Work (FAW) and Emergency First Aiders at work (EFAW) required at an establishment at any given period, ensuring that they are deployed appropriately.

At HMP Gartree, the requirement is for the provision of 14 trained first aiders per week and there are currently 50 officers with in-date training. Further to this, there are a total of 95 prison staff currently trained in EFAW to fulfil the requirement of 42 per week. This is in addition to the provision of healthcare, which at HMP Gartree is 24 hours a day, 7 days a week. As such, healthcare staff are able to provide emergency assistance should the need arise.

In relation to First Aid training for all new officers, I would like to reassure you that Emergency First Aid is a mandatory requirement and delivered as part of the foundation

training syllabus that all new officers undertake. This training remains valid for three years and although not mandatory, staff are able to undertake refresher training to maintain their basic skills and keep up to date with any changes to first-aid procedures.

Additionally, First Aid Awareness training videos have been developed by the HMPPS Health and Safety Function in conjunction with St John Ambulance as a tool to promote awareness and refresh key elements of first aid for staff, in particular those staff who do not completely refresh the Emergency First Aid or First Aid at Work certified training packages. This is expected to be launched in November 2024.

In respect of staff response in a medical emergency, HMP Gartree has issued a Notice to Staff reminding staff of the process of unlocking a cell at night when working alone and the need to take immediate action to preserve life. Staff were reminded of the need to immediately raise the alarm by calling a medical emergency response code and inform the control room of the exact location so staff, including healthcare staff, can respond. Before entering a cell alone staff must undertake a dynamic risk assessment, which includes assessing the situation in the cell (for example if there is more than one occupant), considering the condition of the prisoner, and any risk to the safety and security of the prison and themselves. If they consider it is safe to do so, staff must enter the cell immediately and take action to preserve life. In addition to the Notice to Staff, the requirements above will be reiterated via wing briefings and during the Governor’s full staff briefing.

HMPPS recently issued a new film: ‘Responding to emergency situations’, designed to help staff to understand what they need to do when they find a prisoner who has ligatured. The film has been made available to all prisons and is targeted at all staff who have face-to-face contact with prisoners, including OSGs and staff completing night duties who may need to respond to a medical emergency. All new officers are shown the film during their foundation training and HMP Gartree intends to show it to groups of staff in briefing sessions.

In respect of prisoners blocking observations panels, a notice was re-issued to all staff in October 2024 reminding them of the importance of challenging prisoners who block their observation panels and setting out the process for doing so, which includes an escalation process where a prisoner continues to block their observation panel. All operational staff are now required to read and acknowledge their understanding of this process and this is retained by the respective line managers. Operational staff are also asked about their understanding of and knowledge of the correct procedure during their regular performance conversation with their line manager, as a performance expectation.

Thank you again for bringing your concerns to my attention. I trust that this response provides assurance that action is being taken to address.

Report sections

Investigation and inquest

On 31 October 2022 I commenced an investigation into the death of Stephen Anthony SLEAFORD aged 49. The investigation concluded at the end of the inquest on 26 September 2024. The conclusion of the inquest was (by way of a narrative conclusion) that: “On the 27th of October 2022, Stephen Anthony Sleaford was found hanging by ligature in his cell at HMP Gartree at 07:12 where he was a serving prisoner. Prior to this, Stephen complained of pains and health issues, including mental health issues. Due to failings of the prison system, not following the adequate protocols, Stephen was unable to receive the health care and support he required and was pronounced dead on the 27th of October 2022 at 08.01.” The cause of death was established as: I a Hanging by Ligature I b I c II

Circumstances of the death

Stephen Sleaford was born on 15 February 1973 in the Boston area of Lincolnshire and he died on 27 October 2022, at Gartree Prison near Market Harborough, Leicestershire. He was 49 years of age when he died. Mr. Sleaford was a prisoner at Gartree and had been for around 11 years prior to his death. He had been accommodated at a number of prisons, but predominantly at Lincoln and Gartree Prisons. In late May 2022, Mr. Sleaford was transferred to Lincoln Prison, for the purpose of accumulated visits, a process whereby he was moved closer to his family, including his father who was unwell and with whom he was very close, so that visiting would be easier for all. He returned to Gartree Prison on 11 August 2022. Mr. Sleaford saw a prison GP on 25 October 2022, when he complained of struggling with right ankle pain, and had been struggling to sleep since his last co-codamol prescription had ended. On that day, he was prescribed a short course of medication to try to restore sleep. On the same date, a prison healthcare nurse was asked to see Mr. Sleaford due to the suspicion that he was under the influence of an illicit substance, although he was assessed as not being under the influence. A substance misuse worker went to see him the following day, 26 October 2022, because he had been found with fermenting liquid (brewed alcohol) in his cell and an improvised smoking device. He was spoken to by that worker, when Mr. Sleaford declined formal substance misuse intervention. In the afternoon of the same day, that is 26 October 2022, Mr. Sleaford was seen by a supervising prison officer and his prisoner status was downgraded from ‘enhanced’ to ‘basic’ level. He did not react well to that news and told the officer that he would “show [him] basic behaviour” before returning to his cell. Later that evening, the Prison Officer on duty on Alpha wing (where Mr. Sleaford was accommodated) who knew him and appeared to have a good rapport with him, spoke with him at around 9pm and they had a conversation, when he was seen and appeared to be in a good mood. The following morning, that is 27 October 2022, during her shift, the same officer re-attended outside the cell around 5:45am, when she did not see Mr. Sleaford, due to the cell door’s observation panel being obscured internally, but she did receive a verbal acknowledgment from him. Later the same morning, when the day staff were on duty, another officer was unable to get a verbal response from Mr. Sleaford, when outside his cell, so that officer went to obtain advice and colleague assistance. He returned with other staff and entered the cell, where Mr. Sleaford was discovered with a ligature around his neck and was believed to be unresponsive. Prison officer staff waited for several minutes while further staff, including healthcare staff, attended at the cell, followed later by paramedics. Mr. Sleaford could not be revived and his death was confirmed at the scene by one of the attending paramedics, at 08:01 hours on 27 October 2022.

Copies sent to

2) Nottinghamshire Healthcare NHS Foundation Trust, as providers of in1) The Governing GovernorHMP Gartree, Leicestershire2) Practice Plus Group Limited, as current providers of in

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Report details

Reference: 2024-0550
Date of report: 14 October 2024
Coroner: I M Cartwright
Coroner area: Leicester City and South Leicestershire

Responses identified

Responses identified 1 of 2

1 response not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 9 Dec 2024 (estimated).

Sent to

HM Prison and Probation Service

Ministry of Justice

Non-response list

The Chief Coroner has confirmed the following did not respond within the required period:

Ministry of Justice

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.