Mark Pryor

Coroner's concerns

AI summary

Healthcare Professionals in police custody suites may lack sufficient and adequate training to practice effectively or safely, potentially compromising clinical assessment and treatment for detainees.

View full coroner's concerns

I am concerned that Health Care Professionals (HCPs) may not be receiving sufficient and adequate training to enable them to practice effectively or safely in police custody suites. This is based on the evidence and findings in Mr Pryor’s inquest and my understanding that the training provided by HCRG may be very similar to that given by other providers of HCP police custody services nationally. CONTROLLED

Clinical assessment and treatment is provided to police custody detainees by HCPs with the support of an on-call doctor. Typically there will be one HCP per shift. Nationally, HCP services are provided by a number of independent providers under contract to individual police forces. Professionals eligible to be recruited as HCPs (as taken from HCRG personal specification) are registered nurses (general or mental health), or paramedics with a minimum of two years post-qualification with NMC or HCPC registration and ‘nursing experience in the following: A&E, ITU, EAU, SAU, Nurse Practitioner, Practice Nurse, EAU, SAU (other nursing backgrounds will be considered)’.

Current training provided to newly appointed HCPs (by HCRG) consists of shadowing shifts with an experienced HCP, potentially for up to six or eight shifts; a two-day induction course; a medication related course of less than a day which includes a pass or fail test. There is also formal supervision and a three-month probationary period.

The two-day induction course covers the following topics: -

Day 1 Overview of the role of HCPs in custody; Consent, confidentiality and ethics – covering topics including the relevant laws, regulations and regulatory issues, the importance and limitations of concept, assessing capacity, nature of the HCPs dual responsibility and how it affects disclosure of sensitive information. and importance of record keeping; Fitness to detain – covering topics including the need to assess detainees for injuries, illnesses, and drug and alcohol problems, formulating a care plan in custody to manage risk and identifying those who are not fit to detain who may need alternative support; Fitness to interview / charge/ transfer / release – covering topics including a recap on assessing capacity and assessing, safeguards to prevent the risk of involuntary/false confessions, overview of illnesses that might be worsened by interview and factors to consider when assessing detainees’ fitness to release; Drugs and alcohol is police custody – covering topics including examination features of alcohol and/ or opiate intoxication, examination features of alcohol or opiate withdrawal, key assessment details in the detainee with alcohol dependence, treatment of alcohol / opiate withdrawal in police custody; Mental health in custody - covering topics including the relevant sections of the Mental Health Act, the overlap of learning difficulties with mental health in police custody, the role of liaison and diversion (L&D) teams and the approved mental health professional (AMHP) and when to refer to specialist services; Mental state examination (MSE)
– covering topics including purpose of MSE, format of MSE, communicating MSE findings and risk assessments.

Day 2 Forensic science and samples – covering topics including understanding Locard’s Principle, which offences may trigger sample requests, taking non intimate and intimate samples and relevant procedural steps; Traffic Medicine – covering relevant procedures under the Road Traffic Act; Restraint, TASER and irritant sprays – covering an overview of different types of restraint and when a detainee may need hospital following restraint; Documentation of injury
– covering how to take history for injuries, how to describe, document and classify injuries; Statement writing – covering topics including overview on preparing a witness statement, format of a witness statement and information required to complete a statement and importance of good clinical notation on the assessment forms provided in custody.

I have reproduced the summary of training, which was given in evidence at the inquest, to illustrate that there are obviously a very extensive number of topics which are listed to be covered.

I find it difficult to see that necessary training can be given within the specified time to equip a paramedic or nurse who is fresh to the custody setting to practice effectively and safely. The inquest heard evidence from the more experienced HCP that when she started, with a different provider some eight years prior, she had six weeks classroom-based training before she commenced full duties as an HCP. The inquest also heard that The Faculty of Forensic & Legal Medicine recommends a five-day induction course for HCPs. CONTROLLED

Responses

2 respondents

CRG Medical Services

6 Feb 2024 PDF

Action Planned

CRG Medical Services will extend their foundation training course for new recruits from two to five days, starting in financial year 2024/25. Clinical Leads and senior HCPs will attend a training course on presentation skills, and new recruits will work five shifts under intensive supervision of a senior HCP. (AI summary)

View full response

Dear Sir RE: REGULATION 28 REPORT FOLLOWING THE INQUEST TOUCHING THE DEATH OF MR MARK PRYOR We are providing this letter in response to the Coroner’s Regulation 28 Report issued pursuant to Regulation 28 and 29 of the Coroner’s (Investigations) Regulations 2013 dated 6th February 2024 following the conclusion of the inquest touching the death of Mr Mark Pryor. As a result of the Regulation 28 Report, the Coroner has requested that CRG Medical Services provide their response in respect of the Coroner’s concerns regarding the training for newly recruited Health Care Professionals (HCPs) who may be fresh to the custody setting. More specifically the Coroner had concerns in respect of whether the two-day induction course provided by CRG Medical Services was sufficient to adequately cover the extensive number of topics the course intended to cover. Response CRG Medical Services has been in the process of reviewing the training material for the two-day induction course, known as foundation training, to ensure it is an interactive learning experience for newly recruited HCPs. As part of this process and further to the Coroner’s concerns, as of this financial year 2024/25 the foundation training course will be provided over five days. The Clinical Leads and senior HCP’s will be attending a training course on presentation skills in May 2024, to ensure that a uniformly high-quality level of training will be provided to all new recruits during the foundation training and intensive supervision shifts from June 2024. CRG Medical Services, Suite 5, 6th Floor, Century House, Hardshaw St, Saint Helens, WA10 1QU. Tel:

The foundation training course will be scheduled to take place during the first week of each month and new recruits will not be able to work clinical shifts until they have received a certificate to show they have completed the foundation training. Certificates will be signed off by the Clinical Lead of the contract once feedback has been received from course presenters in respect of each HCP. Following the five-day foundation training course, new recruits will then work five shifts under intensive supervision of a senior HCP. Allowing them to initially observe and then carry out duties in a setting that is supportive of their learning and safe for detainees. The expectations, skills, and proficiencies to be covered during the intensive supervision shifts will be based on where each HCP will be deployed, therefore they will be set by the relevant Clinical Lead. At the conclusion of the intensive supervision shifts, the relevant Clinical Lead will receive feedback from the senior HCPs and if appropriate sign off the new recruit’s induction period. The probationary period of 3 months during which HCPs are required to have supervisory meetings with the Clinical Leads and assessments remains unchanged. In conclusion, CRG Medical Services welcomes the constructive comments made by the Coroner in his Regulation 28 Report. The contents of the report have been considered carefully, and CRG Medical Services have made changes to ensure robust training is in place to address the concerns raised by the Coroner. Should the Coroner have any queries once he has had an opportunity to consider this letter, he should not hesitate to contact us.

The Faculty of Forensic Legal Medicine

5 Mar 2024 PDF

Action Taken

The FFLM has highlighted the coroner's report to its members, re-confirmed the importance of education and training, and is exploring additional training in the management and care of detainees dependent on drugs or alcohol. They have also published recommendations and guidance on their website to support education and training in Forensic Medicine. (AI summary)

View full response

Dear Mr Nieto

Re: Copy of Regulation 28 Prevention of Future Death Report following the conclusion of the Inquest into the death of Mr Mark Pryor.

On behalf of the Faculty, I wanted to thank you very much, for sending a copy of this report to me. We particularly noted your comprehensive and insightful comments on the 2 days’ training which the HCPs’ employing organisation had provided.

The FFLM is a charity set up to develop and maintain the highest possible standards of competence and professional integrity in forensic and legal medicine. The specialty covers professionals working in the following disciplines: forensic medical practitioners (forensic physicians, forensic pathologists, forensic psychiatrists, forensic odontologists); medico-legal and dento-legal advisers; clinicians working in secure and detained settings and medically qualified coroners. Our membership includes a number of different healthcare professionals in forensic roles: doctors, nurses, midwives and paramedics.

Although we describe a specialty above, at present, forensic and legal medicine is not recognised as a specialty in the UK, as, for example, Paediatrics, Obstetrics and Gynaecology and Surgery are. We are working hard to achieve specialist recognition.

The FFLM has been recognised by the Home Office as being responsible for the standards to be expected from all healthcare professionals involved in custody healthcare and forensic examination; (see Hansard, March 18th 2009, Column 1164W Forensic Science - Hansard - UK Parliament ).

Our aims are: Raising standards in forensic and legal medicine; protecting vulnerable people.

FACULTY OF FORENSIC & LEGAL MEDICINE of the Royal College of Physicians of London

Registered Charity No 1119599

E-mail

Website www.fflm.ac.uk

As a result, we have developed and published recommendations and guidance to support education and supervised training in Forensic Medicine, including for the police custodial setting, which can be found on our website, and I highlight, below:

• FFLM Quality Standards in Forensic Medicine - FFLM
• FFLM Quality Standards for Nurses and Paramedics - General Forensic Medicine (GFM) - FFLM
• Recommendations - Introductory Training Courses in General Forensic Medicine (GFM)
- FFLM

We have contacted our membership via the bulletin, highlighting your report, which is now available on the Chief Coroner’s website. We have re-confirmed the importance of initial and continuing education and supervised training and all forensic clinicians have access to senior advice, at all times; this is a responsibility of the clinician and the employer. In addition, we are looking at offering additional training, particularly, in the management and care of detainees who are dependent on drugs or alcohol, or both.

Thank you again for ensuring we were aware of your report.

Kind regards,

Report sections

Investigation and inquest

On 07 September 2020 I commenced an investigation into the death of Mark PRYOR aged 46. The investigation concluded at the end of the inquest on 01 February 2024. The conclusion of the jury was: - Mr Pryor suffered an alcohol withdrawal related seizure whilst detained in police custody which caused cardiorespiratory arrest and death. There were deficiencies in the health care professionals’ assessment and treatment of Mr Pryor’s alcohol withdrawal which probably made a more than minimal contribution to his death.

Circumstances of the death

Mr Pryor died at the emergency department of the Royal Derby Hospital on 5th September 2020, shortly after being taken there from police custody where he had gone into cardiorespiratory arrest due to alcohol withdrawal. He had a long-term history of drug and CONTROLLED alcohol misuse and was alcohol dependent. He had been arrested and detained in police custody on 4th September.

Mr Pryor was seen in police custody by Health Care Professionals (HCP's) due to his documented opiate misuse, methadone usage and alcohol dependency. Mr Pryor was attended on four separate occasions by two different HCP's whilst in custody. He was recognised to be dependent on alcohol and when he began to exhibit symptoms of withdrawal a HCP began a course of alcohol withdrawal medication to reduce the symptoms and guard against possible alcohol withdrawal related seizure.

The inquest jury returned the following conclusion: -

‘Mr Pryor suffered an alcohol withdrawal related seizure whilst detained in police custody which caused cardiorespiratory arrest and death. There were deficiencies in the health care professionals’ assessment and treatment of Mr Pryor’s alcohol withdrawal which probably made a more than minimal contribution to his death’.

The jury recorded the following findings: -

‘The HCP assessments were not of a reasonable standard due to the following reasons:

- Assessments provided were substantially shorter than the recognised accepted practice and consistently shorter than would have been required to properly assess Mr Pryor effectively. In addition to this the time between assessments was too long, particularly after the critical dose of the withdrawal medication was administered, to ascertain the effectiveness.

- Assessments were lacking in consistent information i.e. BP, pulse, heart rate and history. Previous assessments were not referenced prior to each visit, changes in vital signs were not acted upon.

- Assessment records were inadequate and lacking in detail.

There was a point at which an increase in the withdrawal medication dose should have been considered when Mr Pryor's BP and pulse were not taken and found to be elevated. …..

Although not demonstrably contributory to Mr Pryor's death, the jury records the following matters:

There were inadequacies in the training and induction provided to the lesser experienced HCP who attended Mr Pryor.

It is also clear that the lesser experienced HCP did not have suitable experience and skills to work as an HCP’.

The lesser experienced HCP had previously worked as a mental health nurse.

Action should be taken

NB – I am unclear where ministerial responsibility may lie regarding health care provision in police custody and hence I am sending this report to the MoJ and the Dept for Health and Social Care so that the relevant department/s will provide a response.

Copies sent to

Derbyshire Police ConstabularyIndependent Office of Police Conduct (IOPC)Chief Cons. , Chair, National Police Chiefs’ Council, 50 Broadway, London, SW1H 0BL, President, The Faculty of Forensic & Legal Medicine 11 St Andrews Place London NW1 4LE

Similar PFD reports

Shared signals

Coroner's concerns

Responses

Report sections

Similar PFD reports

Related inquiry recommendations

Report details

Responses identified

Sent to

Non-response list

Source links