Source · Prevention of Future Deaths
Andrew Crane
Ref: 2018-0158
Date: 22 May 2018
Coroner: Philip Barlow
Area: Northamptonshire
Responses identified: 0 / 1
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Unclear guidance for prison officers on initiating emergency calls for chest pain, and failure to update ambulance services with critical changes in patient condition, compromised emergency response.
Date
22 May 2018
56-day deadline
17 Jul 2018
Responses identified
0 of 1
Coroner's concerns
Unclear guidance for prison officers on initiating emergency calls for chest pain, and failure to update ambulance services with critical changes in patient condition, compromised emergency response.
View full coroner's concerns
Although both the prison and ambulance service have made amendments to their systems to address other matters of concern which arose during the inquest, the following matters remain:
(1) Mr Crane had complained of chest pain shortly before his cardiac arrest. The prison officer did not consider that he was unwell and so asked the healthcare nurse to attend. According to PSI 3/2013 and the prison’s emergency response policy, a complaint of chest pain should result in a Code Blue call. There was a lack of clarity amongst witnesses as to what, if any, discretion should be given in these circumstances to a prison officer who thinks that a complaint of chest pain does not require a Code Blue response.
(2) A Code Blue was called when Mr Crane collapsed, and at this stage an ambulance was called. After this call, it became clear that Mr Crane was not breathing and CPR was commenced, but this further information was not passed to the ambulance service. This information would have changed the priority of the ambulance response.
(1) Mr Crane had complained of chest pain shortly before his cardiac arrest. The prison officer did not consider that he was unwell and so asked the healthcare nurse to attend. According to PSI 3/2013 and the prison’s emergency response policy, a complaint of chest pain should result in a Code Blue call. There was a lack of clarity amongst witnesses as to what, if any, discretion should be given in these circumstances to a prison officer who thinks that a complaint of chest pain does not require a Code Blue response.
(2) A Code Blue was called when Mr Crane collapsed, and at this stage an ambulance was called. After this call, it became clear that Mr Crane was not breathing and CPR was commenced, but this further information was not passed to the ambulance service. This information would have changed the priority of the ambulance response.
Report sections
Investigation and inquest
On 18 November 2016 an investigation was commenced into the death of Andrew Crane, age 53. The investigation concluded at the end of the inquest on 25 April 2018. The conclusion of the inquest was that Mr Crane died of natural causes. The medical cause of death was 1a) Acute myocardial insufficiency 1b) Coronary artery atherosclerosis 2) Long term smoking habit.
Circumstances of the death
Mr Crane suffered a cardiac arrest in his cell on 16 November 2016 and he died despite efforts at resuscitation. The following non-causative failures were recorded in the conclusion: Mr Crane had previously been noted to have high blood pressure and high blood sugar, but there was a failure by the prison healthcare system to follow up and monitor these results; there was a failure by the ambulance service to ensure that an ambulance was dispatched promptly.
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Report details
- Reference
- 2018-0158
- Date of report
- 22 May 2018
- Coroner
- Philip Barlow
- Coroner area
- Northamptonshire
Responses identified
Responses identified
0 of 1
1 response not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 17 Jul 2018.
Sent to
- HMP Ryehill