Source · Prevention of Future Deaths

Alexander Braund

Ref: 2022-0407Deceased Date: 20 Dec 2022 Coroner: Laurinder Bower Area: Nottingham City and Nottinghamshire Responses identified: 3 / 1 View PDF

There are continuous failures in applying the NEWS2 system for acutely unwell patients in a secure setting due to insufficient training, guidance, and robust compliance auditing, risking deaths from unrecognized deterioration.

Date 20 Dec 2022

56-day deadline 1 Mar 2023 est.

Responses identified 3 of 1

State Custody related deaths

Coroner's concerns

AI summary

View full coroner's concerns

1.(HEALTHCARE) Lack of safe system, supported by training, guidance, and compliance auditing, for the provision of physical healthcare assessment and monitoring by NEWS2 for acutely unwell patients in a secure setting.

The Jury found shortcomings in the healthcare afforded to Alex at HMP Nottingham in the form of "continuous failures to provide adequate healthcare, which probably more than minimally contributed to his death".

I heard evidence that staff were not consistently assessing acutely unwell patients using the NEWS2 system, despite the scoring system having been adopted across the NHS over the past decade and having been adopted by this Trust many years prior.

In 2017, when relaunching the NEWS system, the Royal College of Physicians noted, "Every so often, someone comes up with an idea that is so obvious, no one can understand why it wasn’t thought of before. I am proud that the RCP’s National Early Warning Score (NEWS) is one of those initiatives – not just a chart (or iPad) at the end of the bed to record the patient’s physical signs and symptoms, but the chart at the end of the bed – a single point of truth to unify recording of symptoms across the NHS, consolidate training for doctors and nurses in the recording of symptoms, and thereby improve patient safety. When the RCP launched the NEWS in 2012, we hoped to see the score adopted across the NHS. What has been more astonishing is the adoption of the score internationally, with requests to use NEWS coming from health services across the world from Europe to India and the USA, including the US Naval Air Forces!"

I heard evidence of an inconsistent application of NEWS2 by staff, an inconsistent awareness of NEWS2 across the staff body, and an absence of clear and robust training supported by guidance, ensuring staff were aware of the expectations of their employer with regards to the use of NEWS2 in monitoring acutely unwell patients.

Sadly, Alex's is not an isolated case. I have been repeatedly assured at a senior level from Nottinghamshire Healthcare NHS Foundation Trust that they are seeking to embed NEWS2 across their Directorates, yet successive inquests have heard of patients failed by the lack of use of the system by the clinical staff responsible for their medical care. If this issue is not addressed across the Trust, with sufficient urgency, patients will continue to die in Trust settings due to a failure to recognise the deteriorating patient, and to arrange for timely healthcare intervention. Further, I heard evidence that the newly implemented compliance audit plans for NEWS2 are not safe or robust because the audit is limited to monitoring the emergency review template on Systmone, which staff are routinely failing to utilise, instead preferring to add free text entries to the running record, which cannot be audited with ease. If the Trust is incapable of monitoring compliance with the initiative, there will be repeated missed opportunities to provide support and guidance to Directorates, wards or individual staff who are deviating from expected practice with regards to NEWS2.

2. (HEALTHCARE AND HMP) The absence of a safe joint system of care (between discipline and healthcare staff) for supporting and managing acutely unwell patients who remain in the prison setting, rather than being transferred to a dedicated healthcare facility.

The very nature of incarceration curtails the prisoner's free movement and ready access to healthcare. Instead, their incarceration places them wholly reliant on the communication between discipline staff on the wing, and healthcare staff available elsewhere within the setting, to obtain timely healthcare assessment and monitoring.

I heard evidence that Alex had been told to "press his cell bell" if he "felt worse". Both Alex and his cell mate did so repeatedly between 9 and 10 March 2020, with varying degrees of success regarding healthcare attendance at his cell.

Despite discipline and healthcare staff knowing that Alex was suffering with an acute illness, and in the knowledge that there was no plan for him to be transferred to a hospital, there was an absence of agreed joint plan between health and discipline staff as to how often Alex would be seen by each profession, what constitutes a deterioration for him, and what to do in the event of such a deterioration, to seek to detect and manage his risk of physical healthcare deterioration.

In contrast, in circumstances whereby a prisoner is thought to be at risk of self-harm or suicide, there is an agreed joint care planning system (ACCT Version 6) which sets out the clear expectations placed on each profession to seek to keep the prisoner safe (enshrined in Prison Service Instruction). There is no such equivalent system in operation nationally with regards to the risk of physical healthcare deterioration, but that does not absolve each service from ensuring acutely unwell patients are kept safe by way of robust joint local care planning.

If acutely unwell patients continue to be managed in the prison setting without an agreed joint plan of care between health and discipline staff, deaths will continue to occur in these circumstances.

3. (HM PRISON SERVICE) There continues to be a misunderstanding across discipline staff as to what constitutes a CODE BLUE/CODE RED situation, and in what circumstances a cell can be entered by a prison officer for the purpose of preserving life, despite this having been enshrined in Prison Service Instruction for many years.

I heard evidence from the PCO that he erroneously believed it was necessary for 3 discipline staff to be present before a cell door could be opened during night state even in circumstances where Alex was collapsed and unresponsive on the floor.

This is not the first-time issues of this nature have been identified at HMP Nottingham. Indeed, successive Prison and Probation Ombudsman reports have recommended that the Governor take action to address these issues since the cluster of deaths in 2017/2018, and while the prison has been subject to Urgent Notification procedures.

I heard evidence from a medical expert that post-cardiac arrest, every minute which elapses without appropriate CPR and defibrillator use reduces the patient’s chances of survival. Timely life support is critical, and staff must be clear on when to call a medical emergency code, and when to enter the cell, subject to their dynamic risk assessment.
4. (TPP-UK) Amendment of Medical Records without clear evidence of such amendment on the face of the SystmOne patient summary

The vast majority of primary care health services across the community and secure settings, such as prisons, utilise an electronic patient health record known as SystmOne.

I heard evidence that the system automatically records the date, time, and user, shown along the left-hand side of each entry in the printed patient summary, as below.

I was assured by health staff that any retrospective entry or amendment to a previous entry in the patient record would be flagged by a new date and time stamp towards the right-hand side of the entry, as below.

However, in this case, I discovered from scrutinising an audit record, that an entry made in Alex’s patient record at 06.46 hours on 10 March 2020, had been amended by way of the deletion of some words, and the addition of others, at 09.30 hours on the same date, without any such time stamp being generated on the right-hand side of the entry. This made it look as if the entire text visible in the record would have been visible from around 06.46 hours that date.

The Head of Healthcare was unable to explain how the health professional who made the entry had been able to amend her previous entry, without it being obvious on the face of the record, after it became apparent Alex was critically unwell

This potentially raises serious safety issues about the integrity of the patient record, and at the very least, if the record is not as robust as first thought by its users, this ought to be made clear. I shall share this report with TPP-UK, the creators of SystmOne, to see if they can explain the safety features in place to ensure amended records are clearly marked as such, especially as in this case, the witness was not forthcoming about her amendment of Alex’s patient record. Accurate record keeping is integral to learning from incidents and seeking to prevent future deaths.

Responses

3 respondents

TPP LTD Other

22 Dec 2022 PDF

Noted

TPP explains how the SystmOne electronic patient record system tracks amendments to consultations, stating that users are informed when an amendment has been made, by whom, and when, and that the audit trail is readily accessible. (AI summary)

View full response

Dear Miss Bower Thank you for your letter addressed to , the CEO of TPP who supply the SystmOne electronic patient record. I am the Clinical Director, Data Protection Officer and lead the Clinical Safety team for TPP. I am replying to section 5 (4) in your regulation 28 report. From the extract you included it appears that you have been presented with a printout taken from SystmOne. This is a routine function in the system that delivers a copy of the medical record into the Microsoft Word application. As such it is not to be used as a representation of the audit trail, and especially not for forensic investigation. The main reason for this is that the word document is editable - that is, entries can be reworked before saving and I or onward transmission and is therefore not to be considered secure. As is usual in IT systems the audit trail is held within SystmOne and is readily accessible to the user. With the Word printout out you shown to the left, the entry is not flagged as amended (as you describe), since, for clinical purposes, the record is transmitted as it exists in the amended state. I will demonstrate how the audit trail is shown within SystmOne below. The following screen shots are taken from SystmOne using fictitious data.
1. The ability to amend a consultation note (once saved to the database) has a specific user access right controlled by the unit administrator so ensuring that only authorised users can amend records:

Figure 1 user access rights
2. Figure 2 shows two separate consultations recorded in SystmOne that demonstrate the following:
a. The first shows how a consultation that has been entered and then back dated demonstrated by the clock icon with the arrow, to the far right. Hovering over the icon shows the details of the back dated event (figure 4).
b. The second consultation was recorded, saved to the database and then amended. This is indicated by the green pen on paper icon to the far right. Hovering over this icon shows who amended the consultation and when (figure 5).
c. Figure 3 also shows a final consultation recorded with the date and time stamp of when the user made the amendment - but is blank as the entry was placed in the amended consultation, but showing that an action took place. Figure 3 consultation after amendment Figure 4 back dated too/tip Figure 5 amended tool tip

3. When an amendment has been made the details of the amendment are available to users of SystmOne by right clicking over the consultation and using the dialogue below (figure 6). This is also how the user amends a consultation 'Amend Notes'. Figure 6 amend options
4. Figure 7 shows what is shown to the user when they select 'View Amendment' - the screen shows how the entry appeared before the amendment was made. Figure 7 details of amendment I hope that this clearly demonstrates that SystmOne has a complete and robust audit trail, and how a user of the system is readily informed if an amendment has been made, by whom and when. I would be happy to talk through the functionality as it is obviously important that you have confidence in our system, and that the public record is correct. It would appear that the SystmOne users you have been speaking to are not fully aware of the functionality that has been in the system for 20 years.

Clinical Director TPP TPP House Leeds LS18 SPX

HM Prison and Probation Service Central Government

13 Feb 2023 PDF

Action Taken

HMPPS has implemented a training program on medical emergency procedures for staff, including the use of emergency codes and cell entry protocols. A joint training event with healthcare staff was also held to improve care for acutely unwell prisoners, and weekly safety intervention meetings were introduced. (AI summary)

View full response

Dear Miss Bower

Thank you for your Regulation 28 report of 20 December 2022, addressed to the Governor of HMP Nottingham following the inquest into the death of Alexander Michael Braund on 10 March 2020. I am responding as the Director General of Operations for HMPPS. I understand that NHS England is responding separately.

I am aware that you will share a copy of this response with the family of Mr Braund, and I would 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.

I will first address the matter of concern that you raised solely for HMPPS, which is that there continues to be a misunderstanding across discipline staff at HMP Nottingham as to what constitutes a code blue or code red situation, and in what circumstances a cell can be entered by a prison officer for the purpose of preserving life.

A number of new measures including a robust training programme have been implemented to address these concerns. An annual training plan for staff has been introduced, and this includes training on the role of staff during a medical emergency, including the specific issues of the correct use of the emergency codes and the expectations about when staff should enter a cell during a patrol state. Staff received this training in May and September 2022 and it will be repeated at least twice yearly. An additional measure introduced in February 2022 is for all staff who join HMP Nottingham, irrespective of their grade or department, to be given a pocket size card that clearly explains the codes and what to do in an emergency.

A process is now in place to review all incidents included in the daily briefing sheet, and where it is found that the process was not followed, the member of staff concerned is identified and their behaviour is addressed, through targeted training or guidance and/or through the performance management system. Senior Management Team members conduct monthly night visits and use these to check staff understanding of their responsibilities and to reiterate the importance of the medical emergency response procedures.

The matter of concern raised for both HMPPS and Healthcare concerned the absence of a safe joint system of care (between discipline and healthcare staff) for supporting and managing acutely unwell patients who remain in the prison setting, rather than being transferred to a dedicated healthcare facility. I can confirm that the Head of Healthcare and the Governor of HMP Nottingham arranged a joint training event for all staff on 25 January 2023, designed to encourage a collaborative approach between prison and healthcare staff to achieve joined up planning of care for prisoners with acute illnesses. The Head of Safer Custody now chairs a weekly Safety Intervention Meeting at which prisoners who are acutely unwell or at risk of harm are identified and discussed, with prison and healthcare staff agreeing the care and support to be put in place in each case.

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

Nottingham Healthcare NHS Foundation Trust NHS / Health Body

PDF

Action Taken

The Trust has implemented compliance audit plans for NEWS2, is undertaking joint training with the prison service on several topics, and holds daily handover meetings to discuss prisoner clinical issues. (AI summary)

View full response

Dear Miss. Bower,

Please find below the organisational response to the recently received Preventing Future Deaths Report, following the unfortunate death of Mr. Braund. In responding, we have worked closely in conjunction with HMP Nottingham. We offer our condolences to Mr. Braund’s family, and we hope this response and the subsequent improvement plan goes someway to reassuring you and Mr. Braund’s family that we take this very seriously and will improve our services to prevent such reoccurrences. Matters of concern raised in the report:

1.(HEALTHCARE) Lack of safe system, supported by training, guidance, and compliance auditing, for the provision of physical healthcare assessment and monitoring by NEWS2 for acutely unwell patients in a secure setting.

“Staff were not consistently assessing acutely unwell patients using the NEWS2 system, despite the scoring system having been adopted across the NHS over the past decade and having been adopted by this Trust many years prior.

The inconsistent application of NEWS2 by staff, an inconsistent awareness of NEWS2 across the staff body, and an absence of clear and robust training supported by guidance, ensuring staff were aware of the expectations of their employer with regards to the use of NEWS2 in monitoring acutely unwell patients.

Newly implemented compliance audit plans for NEWS2 are not safe or robust because the audit is limited to monitoring the emergency review template on SystmOne, which staff are routinely failing to utilise, instead preferring to add free text entries to the running record, which cannot be audited with ease. If the Trust is incapable of monitoring compliance with the initiative, there will be repeated missed opportunities to provide support and guidance to Directorates, wards or individual staff who are deviating from expected practice with regards to NEWS2.”

Response

Subsequent to receiving the Regulation 28 Report on 21st December 2022, all Trust employees of Offender Health were emailed in regard to the findings and in particular the outcome of NEWS2 failures. Private and Confidential

Miss. Bower HM Area Coroner for Nottingham and Nottinghamshire Nottinghamshire Coroner’s Office The Council House Old Market Square Nottingham NG1 2DT

Date: 14 February 2023

The Resource, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA

In the first instance employees were requested to ensure they had completed the online training by 31st December 2022. To date, as of 13th February 2023, across the Offender Health Directorate we have achieved 86% in relation to staff who have completed the training. This is for those staff currently working and not absent.

Following this, the Heads of Healthcare have weekly communication to all employees to ensure they have undertaken the training, with audits in place to monitor compliance. To support this process of monitoring training, Heads of Healthcare are provided with weekly updates on their teams’ compliance and a requirement to provide an exception report to the Divisional Management Team (DMT) for non- compliance. This will alert the DMT to any hot spot areas and identify where to dedicate further support to allow training. Nottinghamshire Healthcare NHS Foundation Trust Learning and Development Department are working closely with the Offender Health DMT to ensure essential training on NEWS2, and physical healthcare meets the requirements to teach staff how to use NEWS2 in practice.

In addition, the Clinical Lead for Physical Healthcare has provided a training tool regarding NEWS2 and SEPSIS. This has been circulated to all sites for the clinical matrons to deliver this training during CPD sessions.

A cleansing of the training database is being undertaken by the ESR Team (Workforce database) to ensure those that have left the Offender Health Directorate are removed and those absent are not forgotten on their return. This process will have been completed by the end of March 2023 across all Offender Health sites.

It has been recognised that the NEWS2 Emergency Template located in SystmOne was not easily accessible. Therefore, the emergency template is now located on the Clinical Tree where staff have easy access (Appendix 1). To support Trust employees, a NEWS2 Flashcard and paper templates have been reviewed and distributed across all sites and will be available in all emergency response bags as an aide memoire and working documents (Appendix 2). This is to support ease of access and act as a reminder during emergency situations across the sites, communicating clear expectations and requirements for patient safety. The NEWS2 observation template is also clearly visible on the Clinical Tree and should link to the observations template within SystmOne.

It is recognised that training alone is not sufficient to assess individuals’ learning and understanding of the toolkit and responses required for unwell patients. The Trust essential training will assess employees’ understanding of the News2 toolkit. In addition, Clinical Leads will be attending all sites on a rolling basis to assess competency of staff using NEWS2 and provide further support/ training where required. We are currently working with the wider Trust to look at how this can be delivered regularly to the all the teams across Offender Health.

Heads of Healthcare and Clinical Matrons undertake regular audits on SystmOne as part of monitoring staff compliance to the training with NEWS2. We have engaged with the Trustwide resuscitation trainers to explore using live simulations on sites to ensure that emergency responses are fully tested with our Prison colleagues. These will be scheduled throughout the next twelve months on all sites.

The Resource, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA

The Trust offer a robust induction programme to all new starters. Alongside this the Directorate has introduced a two-day programme specifically for Offender Health. This will be signed off by line managers within the initial three months of new employee start dates and will seek to identify any further training. A record of this will be kept on their personnel file on completion (Appendix 3). The Clinical Leads for Offender Health, alongside the Head of Nursing are currently undertaking a training gap analysis exercise with a view to identifying the critical training needs for all healthcare staff and develop a robust training programme for Offender Health on a rolling 12 monthly basis. This has been planned on Prison lockdown days and we have identified critical topics that need to be addressed including but not exhaustive, emergency response to NEWS2, Mental Capacity Record Keeping and Assessment, Care in Custody and Team work, Suicide and Self Harm training (Appendix
4). The wider Trust is committed to providing bespoke training to support staff in Offender Health to ensure they have the correct skills required to work in the environment.

The Trust has developed a comprehensive Quality Improvement Plan for Offender Heath that identifies areas of learning and development requirements and is committed to ensuring these areas are improved for our patients to ensure better outcomes (Appendix 5).

2) (HEALTHCARE AND HMP) The absence of a safe joint system of care (between discipline and healthcare staff) for supporting and managing acutely unwell patients who remain in the prison setting, rather than being transferred to a dedicated healthcare facility.

Response

The strategic and operational relationship between Nottinghamshire Healthcare NHS Foundation Trust and HMP Nottingham is well embedded at both strategic and operational levels. This is evidenced strategically with the Head of Healthcare being a contributory member of the HMP Nottingham senior management team (SMT).

Staff receive a daily briefing sheet to highlight any issues and concerns overnight and for the next 24 hours. There is always a healthcare representative at the daily morning operational meeting. The daily briefing sheet is circulated to all Prison and Healthcare staff to provide a dynamic operational briefing daily.

In addition, the Head of Healthcare and Governor will meet regularly to discuss strategic and operational issues. This is generally monthly, although has been much more frequent and issue driven in recent months.

Locally, we have formal quarterly meetings that are held by way of a Local Delivery Board (LDB) meeting, which is a tripartite meeting with the Nottinghamshire Healthcare NHS Foundation Trust, The Prison and NHS England Health and Justice Commissioners. This forum includes Head of Healthcare and Clinical Matrons alongside Senior Management from the Prison and senior commissioners and formalises our joint priorities, operational management, service delivery, procedures and identifies any operational or strategic issues and concerns that could impact on service delivery across healthcare and the prison, with the aim of these being jointly resolved. In recent months this has focused on staffing recruitment and retention, self-harm and suicide responses, emergency response procedures,

The Resource, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA

including at night, enabling issues, assessments, contingency planning during recent strike actions and lessons learned following serious incidents.

In support of this meeting the Head of Drug Strategy integrates operationally with healthcare managers weekly to address and provide assurance on key performance and delivery areas.

The Senior Commissioning Manager (Health & Justice NHS England – East Midlands) also holds a quarterly Contract Review Meeting with Nottinghamshire Healthcare NHS Foundation Trust with representation by the Governor at HMP Nottingham. This meeting focuses on performance, quality and contractual compliance. This is further supported with regular monthly contact with the Health and Justice Senior Commissioners, Heads of Healthcare and Divisional Management team for Offender Health

More recently HMP Nottingham have established a monthly Death in Custody meeting which is attended by a Healthcare representative. This meeting focuses on our responsibilities to address repeat PPO recommendations after a death in custody. This meeting provides a strategic overview of our progress in addressing issues in support of preventing further deaths. This meeting reviews the DIC database and actions across the prison related to improving actions and gaining assurance against repeat recommendations. In addition to this Offender Health hold their own internal weekly Death in Custody meeting which provides an opportunity to share learning from recent inquests and reflect on how these are embedded into practice alongside opportunities to discuss and learn immediate lessons from serious incidents and opportunities for reflective debriefs. Any themes from this will also be taken to the joint monthly Death in Custody meeting facilitated but the prison

A weekly Safety Intervention Meeting (SIM) is held and chaired by the Head of Safety for HMP Nottingham, Healthcare representation is in attendance at this meeting. This forum offers opportunity to identify those prisoners who are acutely unwell, may be at high risk of suicide and/or self-harm alongside prisoners who may be vulnerable and offer a structured forum to discuss joint management strategies required including care planning and interventions to support the individual prisoner/s. This demonstrates our continued collaborative working between healthcare colleagues and the prison.

Reduction of self-harm and suicide is a critical daily consideration addressed in the daily morning meeting. This is facilitated by the Prison and attended daily by healthcare. This process enables both the prison and healthcare to identify any concerns with specific prisoners that may have arisen overnight or the previous day and opportunity to discuss and agree the interventions and support needed to keep the prisoner safe which may include instigation of additional support mechanisms including use of ACCT (Assessment, Care in Custody and Teamwork). ACCT is a function which requires multi-agency involvement between the prison and healthcare in the management of individuals who present as a high risk to themselves. This process requires collaborative working and the devising of individualised care maps or plans to support prisoners in crisis to manage the risks they are presenting to themselves.

Healthcare also holds a daily handover meeting at lunchtime with all healthcare staff. Any prisoner, clinical issues or concerns raised at this meeting are then shared with the prison for discussion and follow up, if required.

The Head of Healthcare and the Prison Governor are working in partnership to devise a joint training programme for all staff, ensuring the learning from the Regulation 28 Notice has been prioritised.

The Resource, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA

Joint training opportunities will focus on repeat PPO recommendations, ACCT training, segregation protocols, emergency response protocols including code blue/code red, out of hours emergency response processes, violence reduction strategies. There is also a plan to undertake scenario-based training exercises for the whole site to monitor and evaluate staff understanding of processes and learning from training, as stated above.

The joint protocol for the urgent assessment process for the deteriorating patient is to be updated and re-circulated to all prison and healthcare staff. This includes the PSO 1300 emergency response and the management of code red and code blue. Joint training is to be provided to Prison staff to ensure they are familiar with the process and are confident in its use.

We hope the information contained within this response provides reassurance that the Trust has been considering these recommendations seriously and has taken action to improve the quality and safety of care being delivered to men in custody. We are committed to improving our healthcare in these environments and will continue to work through the actions described to ensure these improvements are made and maintained moving forward.

Report sections

Investigation and inquest

On 06 April 2020, I commenced an investigation into the death of Alexander Michael BRAUND, aged 25. The investigation concluded at the end of an inquest, conducted before a Jury, on 30 November 2022.

Alex was a remand prisoner at HMP Nottingham, when he became acutely unwell on 6 March 2020, with symptoms of a productive cough (brown sputum) and feeling generally unwell.

He deteriorated such that by the 8 March 2020 he was coughing, vomiting, wheezing, wasn’t eating and had a headache.

Alex and/or his cell mate pressed the emergency buzzer inside their cell at 22.22 hours on 9 March 2020 because Alex had deteriorated further. He had a burning sensation in his chest and difficulty breathing. The nurse attended but did not perform a complete NEWS2 assessment, take a sputum sample, nor listen to his chest. A plan was made to refer Alex to the prison GP the next day.

There was no agreed plan between healthcare and discipline staff as to whether or how frequently Alex ought to be checked in his cell, what constituted a deterioration of his condition, and what to do in such circumstances.

At 05.35 hours on 10 March 2020 the emergency cell bell was activated again. Alex’s cell mate explained to the PCO that he was increasingly concerned about Alex’s condition and that he wanted to see healthcare. Sometime later the nurse attended the wing but did not see Alex. She told the PCO nothing more could be done at this time of night.

Alex was noted to be collapsed on the floor of his cell at 06.55 hours, and his cell mate raised the alarm by pressing the emergency cell bell for the third time. The PCO in charge of the wing failed to clearly establish whether Alex was breathing. There was a delay in entering his cell for the provision of basic life support, and there was a delay in calling a code blue, which in turn delayed the dispatch of an ambulance. These delays probably more than minimally contributed to Alex’s death. Alex was declared deceased at 11.44 hours on 10 March 2020 in the Intensive Care Unit at Queens Medical Centre, Nottingham, following the withdrawal of life support. He had been suffering from an atypical pneumonitis that was not detected.

The continuous failures to provide adequate healthcare to Alex probably more than minimally contributed to his death.

Circumstances of the death

The conclusion of the Jury was that Alex died on 10 March 2020 as a result of a hypoxic-ischaemic brain injury, caused by cardiac arrest with prolonged downtime, caused by an atypical pneumonitis, to which neglect had probably contributed.

Copies sent to

Care Quality CommissionIndependent Monitoring Board, HMP Nottingham

Similar PFD reports

Shared signals

Related inquiry recommendations

Report details

Reference: 2022-0407Deceased
Date of report: 20 December 2022
Coroner: Laurinder Bower
Coroner area: Nottingham City and Nottinghamshire

Responses identified

Responses identified 3 of 1

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 1 Mar 2023 (estimated).

Sent to

HMP Nottingham, Forensic Services Nottinghamshire Healthcare NHS Foundation Trust and TTP-UK

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.