Source · Prevention of Future Deaths

Robert Ellery

Ref: 2021-0390 Date: 19 Nov 2021 Coroner: David Regan Area: South Wales Central Responses identified: 1 / 1 View PDF

The prison control room delayed relaying critical information to the ambulance service, and a lack of direct communication between emergency operators and prison first responders hindered resuscitation efforts.

Date 19 Nov 2021

56-day deadline 14 Jan 2022 est.

Responses identified 1 of 1

State Custody related deaths Wales prevention of future deaths reports (2019 onwards)

Coroner's concerns

AI summary

View full coroner's concerns

(1) The prison control room was not able to provide the Welsh Ambulance Service with any specific information as to the reason why an ambulance was required for 19 minutes after Mr Ellery was found in his cell. This delayed the ability of the ambulance service to despatch a response. While this was not, on the evidence heard by the jury, causative of Mr Ellery’s death, it gives rise to a concern that a risk that other deaths will occur.

(2) There was no method of communication to allow the Ambulance Service call centre staff to communicate directly with the nurse and officers who were providing basic life support to Mr Ellery. This delayed the relaying of specific information with respect to Mr Ellery’s condition by the prison to the Welsh Ambulance Service. It also impeded the ability of the ambulance service operator to provide guidance to those attempting to resuscitate Mr Ellery. This may affect the use of a defibrillator. In circumstances where not all prison staff are trained in the provision of CPR, it might also prevent the ambulance service operator providing instruction to first responders, or reduce the effectiveness of the same.

Responses

1 respondent

HMP Cardiff Prison / Probation

19 Nov 2021 PDF

Action Taken

HMP Cardiff has devised a Local Operating Protocol and will pilot a mobile phone carried by officers to enable direct communication with the Welsh Ambulance Service. (AI summary)

View full response

Dear Mr Regan.

Thank you for your Regulation 28 Report dated the 19th November 2021 addressed to HMP Cardiff, following the inquest into the death of Mr Robert Ellery at the prison on 31 st October 2016. I am responding on behalf of Her Majesty’s Prison Cardiff.

I know that you will send a copy of this response to the family of Mr Ellery 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 concern surrounding the communication between staff at the side of the patient and the ambulance service.

At a local level, in recognition of the concerns raised by yourself, a Local Operating Protocol has been devised. HMP Cardiff will pilot the use of a mobile phone carried by the Orderly Officer and Night Orderly Officer to enable direct communication with the Welsh Ambulance Service. This will ensure updates from the scene can be provided or to allow the Ambulance Service call centre staff to communicate directly with the nurse and officer providing basic life support to a patient. Our Local Operating Protocol sets out the following operational objectives:

• To assist communication between the Ambulance Service call centre and the staff providing basic life support to a patient.
• To allow the Ambulance Service operator to provide guidance to those attempting to resuscitate the patient. Including the use of a defibrillator.
• To communicate updates from the scene direct to the Ambulance Service call centre and not via a third party.
• To offer assistance and guidance to both healthcare and prison staff at the scene who would be unable to leave the patient to communicate direct with the Ambulance call centre (especially at night). Thank you again for bringing your concerns to my attention, and I hope that this response provides assurance that action is being taken.

Report sections

Investigation and inquest

A Coronial investigation was commenced on 8th November 2016 into the death of Robert Ellery. The Investigation concluded at the end of an inquest which I conducted with a jury on 8th – 18th November 2021. The conclusion of the jury was that Mr Ellery died as the result of in circumstances where his intentions could not be ascertained. The medical cause of death was

Circumstances of the death

These were recorded as :- “Robert Ellery was found in his cell on 31st October 2016. Robert had recently self harmed, An ACCT was not opened, zopiclone was prescribed but not administered to him. In addition, there was 19 minutes between the first 999 call and the ambulance service being informed that Mr Ellery had been found . It cannot be concluded that such issues caused or contributed to Robert's death.”

Action should be taken

In my opinion action should be taken to improve communication between staff at the side of the patient and the ambulance service to prevent future deaths and I believe you and your organisation have the power to take such action.

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Shared signals

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Report details

Reference: 2021-0390
Date of report: 19 November 2021
Coroner: David Regan
Coroner area: South Wales Central

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: 14 Jan 2022 (estimated).

Sent to

HM Prison Cardiff

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.