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Christine McDonald

Ref: 2024-0278 Date: 21 May 2024 Coroner: Charlotte Keighley Area: Cheshire Responses identified: 1 / 2 View PDF

Failure to use emergency response codes left first responders unprepared for critical situations, compounded by training difficulties in simulating unexpected emergency scenarios.

Date 21 May 2024
56-day deadline 16 Jul 2024 est.
Responses identified 1 of 2
Suicide (from 2015)

Coroner's concerns

AI summary
Failure to use emergency response codes left first responders unprepared for critical situations, compounded by training difficulties in simulating unexpected emergency scenarios.
View full coroner's concerns
I heard evidence during the course of this Inquest in respect of the process for using the emergency response codes, this is something which arises in many cases of this type. I heard evidence in this case that the emergency response code was not used and as a consequence, those responding to the call were not prepared in the sense of emergency equipment, nor were they prepared mentally for the situation they had been asked to attend. I heard evidence in respect of the training and integrity testing that is now conducted to try to simulate the unexpected nature of an emergency, the evidence being that it is very difficult and that no training can fully prepare those staff who are first on scene for what they may find. I also heard evidence relating to measures within the control room, which might assist those first on scene in terms of the use of emergency codes and provide additional safeguards for those whose lives are at risk.

Responses

1 respondent
HM Prison and Probation Service Central Government
26 Jul 2024 PDF
Action Taken

HMPPS launched a video in January 2024 demonstrating how staff should respond to a medical emergency, including the use of Code Blue and Code Red communications, which has been delivered to all new officers via foundation training. HMP Styal are committed to showing the video to all current operational members of staff by November 2024. (AI summary)

View full response
Dear Ms Keighley,

Thank you for your Regulation 28 report of 21 May 2024, addressed to HMP Styal. 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 Ms McDonald’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.

You have expressed concerns regarding the use of medical emergency codes, the effectiveness of training in this respect, and measures taken within the control room during incidents of this nature.

Nationally, a video was launched in January 2024 that demonstrates how staff should respond to a medical emergency. This includes instructions on when to enter a cell in an emergency and the appropriate use of Code Blue and Code Red communications. This video has been made available to all HMPPS staff, including Officer Support Grades (OSGs) and staff completing night duties who may need to respond to a medical emergency. Since January 2024, the video has been delivered to all new officers via foundation training and has been shared locally with Governing Governors.

Staff are directed to utilise either Code Blue or Code Red communications in the event of discovering a prisoner whose life is at risk. Most staff have not experienced a traumatic event, therefore, to prepare them, a demonstration of a prisoner being discovered having ligatured has been included within the video to illustrate a traumatic situation they may sadly witness.

As per PSI 03/2013, staff who discover a medical emergency are required to use either Code Red or Code Blue, which will alert the communication room staff. It is mandatory for the

communication room staff to automatically call an ambulance and await updates from the scene. The staff present at the scene must provide relevant information about the condition of the prisoner to the communication room staff, so that it can be relayed to the ambulance service for use in the triage process. These directions are reiterated within the Responding to Emergency Situations video.

HMP Styal are committed to showing the video to all current operational members of staff by November 2024, which will aid in preparing staff for being first on scene at an unexpected or traumatic medical emergency. In the interim, staff are regularly issued Emergency Response Information Cards, which provide convenient and accessible information on when it is necessary to call an emergency code and are also regularly briefed on the importance of utilising the code system in the event of a medical emergency. Additionally, communication room staff have been issued a notice to staff that reinforces their duties in a medical emergency.

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

Report sections

Investigation and inquest
On 08 March 2019 I commenced an investigation into the death of Christine MCDONALD aged 55. The investigation concluded at the end of the inquest on 10 May 2024. The conclusion of the inquest was that: Narrative Conclusion - Suicide - Contributed to by:
- Failings in communication and/or information sharing between healthcare staff at HMP Styal.
- Failings in communication and/or information sharing between prison staff at HMP Styal.
- Failings in communication and/or information sharing between healthcare staff and prison staff.
- Failure to pass on information in respect of Christine's daughter's wellbeing.
- Failure to assess Christine on her return from Wythenshawe Hospital.
- Failure to action Christine's request to see a nurse.
- Failures by healthcare to follow the clinical guidance in respect of the assessment and/or treatment of Christine's drug dependency.
- Neglect It was also found that the emergency response codes were not used which led to a delay in bringing the required emergency medical equipment, namely oxygen and the emergency bag and there was a significant delay in locating the defibrillator, although these issues did not contribute to Christine’s death.
Circumstances of the death
Christine McDonald was 55 years old at the time of her death on the 3rd March 2019. On the 1st March 2019 Christine was arrested at her home address and around the time of her arrest had witnessed her daughter fall from third-floor window and was concerned about her. Christine was taken to Blackpool Magistrates Court and sentenced to 12 weeks imprisonment to be served at HMP Styal. Christine had a long history of drug dependency and at the time of her arrest she was known to be a user of Heroin, Crack Cocaine and Amphetamine. On the 2nd March 2019 Christine was taken to Wythenshawe Hospital following concerns raised during a healthcare assessment in HMP Styal. Christine discharged herself from hospital and was returned to HMP Styal. Just after 11pm on the 2nd March 2019 Officers went to speak to Christine in her cell and found her unresponsive, having tied a ligature . The emergency response codes were not used and consequently, when Healthcare attended, they were unaware that they were attending an emergency and did not have the necessary emergency equipment with them. Although the failure to use the emergency response codes was not a contributory factor in the death, it caused a delay in providing the necessary medical treatment. Christine was taken to Wythenshawe Hospital but sadly passed away the following day with her family by her side.

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Report details

Reference
2024-0278
Date of report
21 May 2024
Coroner
Charlotte Keighley
Coroner area
Cheshire

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: 16 Jul 2024 (estimated).

Sent to

HMP Styal
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.