Source · Prevention of Future Deaths

Anthony Smith

Ref: 2023-0187 Date: 7 Jun 2023 Coroner: Nicholas Rheinberg Area: Lancashire and Blackburn with Darwen 1 response identified · 1 indexed addressee View PDF

AI-generated concerns summaryThe coroner raised concerns regarding the lack of readily available mouth protection for resuscitation in the prison, which posed a risk of blood-borne virus transmission to officers and could deter the provision of rescue breaths.

Date 7 Jun 2023
56-day deadline 3 Aug 2023 stated in the report
Responses identified 1 of 1
State Custody related deaths

Coroner's concerns

AI summary
The coroner raised concerns regarding the lack of readily available mouth protection for resuscitation in the prison, which posed a risk of blood-borne virus transmission to officers and could deter the provision of rescue breaths.
View full coroner's concerns
(1) An officer attempting resuscitation carried out mouth to mouth resuscitation without the safeguard of mouth protection which was not available in the prison at the time. Mr Smith was a regular drug user who on occasions injected drugs. Performing mouth to mouth resuscitation carried with it the risk of transmission of blood born viruses with possible fatal consequences.

(2) The lack of available protection not only carried with it a risk to those who performed resuscitation but potentially also to the person suffering a cardiac arrest in that without protection the would-be resuscitator might decline to provide rescue breaths (3) Consideration should be given to informing prison governors of the need to secure a readily accessible supply of protection masks. PSI 29 of 2015 on the subject of First Aid is currently under review and might be a vehicle for providing appropriate direction.

Responses

1 respondent

HM Prison and Probation Service

Central Government
Letter dated 28 Jul 2023 PDF
AI-classified response stance Action Taken
AI-generated response summary

• HM Prison and Probation Service stated that the First Aid Policy Framework is under review and will include requirements for resuscitation face shields in all prison first aid kits. • The revised policy will also emphasise training requirements for the correct use and availability of face masks. • At HMP Preston, face shields have been purchased, added to first aid boxes, and staff were advised of their location and importance.

View full response
Dear Mr Rheinberg,

Thank you for your Regulation 28 report of 7 June 2023 following the inquest into the death of Anthony Smith at HMP Preston on 16 May 2022.

I know that you will share a copy of this response with Mr Smith’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.

Your concerns relate to the availability and use of protective face masks for staff when performing CPR.

As you are aware, the First Aid Policy Framework is currently under review and is due to be re- issued by August 2023. The revised policy document will include instructions on the use of face shields including the requirement for all first aid kits in prisons to contain resuscitation face shields and for these to be monitored and replenished when required. The policy also emphasises the training requirements for Emergency First Aid and First Aid at Work, including the importance of using the face masks correctly and of these being available at all times.

At HMP Preston, face shields have been purchased and added to the existing first aid boxes on all residential units and will be monitored by the Health and Safety Team. A Notice to Staff was also issued in June 2023 to advise staff of the location of the face shields and the importance of using these when administering CPR.

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
An investigation into the death of Anthony George Smith aged 34 was commenced on 16th May 2022. The investigation concluded at the end of the inquest on 7th June 2023. The conclusion of the inquest was that Mr Smith died as a result of self-suspension but his intention in doing so could not be determined
Circumstances of the death
Mr Smith at the time of his death at HMP Preston was suffering an acute relapse in respect of his schizophrenia. He was delusional, hallucinating and hearing voices. On 4th May 2022 he was found hanging in his cell. He was cut down and officers commenced cardio-pulmonary resuscitation

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Report details

Reference
2023-0187
Date of report
7 June 2023
Coroner
Nicholas Rheinberg
Coroner area
Lancashire and Blackburn with Darwen

Responses identified

Responses identified 1 of 1
All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 3 Aug 2023 (stated in the report).

Sent to

HM Prison and Probation Service

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