Source · Prevention of Future Deaths

Wayne Cornlouer

Ref: 2016-0356 Date: 12 Oct 2016 Coroner: Brendan Allen Area: Dorset 1 response identified · 1 indexed addressee View PDF

AI-generated concerns summaryThe coroner noted that Night Orders now include a medical emergency coding system (code red/code blue) but raised concerns about whether all staff are aware of this change.

Date 12 Oct 2016

56-day deadline 23 Apr 2017 est. estimated from the Judiciary.uk publication date

Responses identified 1 of 1

State Custody related deaths Suicide (from 2015)

Coroner's concerns

AI summary

The coroner noted that Night Orders now include a medical emergency coding system (code red/code blue) but raised concerns about whether all staff are aware of this change.

View full coroner's concerns

understand that coding system for a medical emergency, code redlcode blue, was not part of the Night Orders at the time of Mr Cornlouer's death. However, the Night Orders have since been amended to include this emergency coding: My concern is as to whether or not all staff are aware of the change in the Night Orders_ The Coroner'$ Court; Town Hall, Bourne Avenue; Bournemouth; Dorset, BHZ 6DY Tel 01202 310049 Fax 01202 780423 24"h the

Responses

1 respondent

HM Prison and Probation Service

Central Government

Letter dated 15 Dec 2016 PDF

AI-classified response stance Action Taken

AI-generated response summary

• The Notice to Staff regarding emergency codes and ambulance requests was re-issued on 28 September 2016, and the local emergency code protocol was distributed and displayed. • Existing staff will receive personal briefings, and the induction programme for new staff is being updated to include guidance on the local emergency protocol. • A joint exercise with the South Western Ambulance Service is planned to ensure staff understanding of the local protocol.

View full response

Dear Mr Allen Thank you for your Regulation 28 Report to Prevent a Future Deaths, addressed to the Governor; James Lucas, concerning the recent inquest into the death of Wayne Cornlouer at HMP Portland on 24 October 2014 Your Report been passed to the casework team in the Safer Custody and Public Protection Group (SCPPG) in the National Offender Management Service (NOMS) , as we have responsibility for policy on suicide prevention and self-harm management and for sharing learning from deaths in custody. This letter is shared with you following consultation with colleagues at Portland, and am grateful to you for allowing us a short extension to finalise this response note your concern that all staff at Portland need to be aware of the local Night Order which has been amended to include reference to the emergency codes and the requirement to call an ambulance promptly when staff use such a code_ can confirm that the relevant Notice to Staff was re-issued on 28 September 2016. This reminds all staff that an emergency code, either Red or must be called when there are serious concerns about the health of a prisoner; and that on receiving either emergency code the staff are required t request an ambulance The Notice to Staff also confirms the nature of the injuries that should prompt the use of each of the emergency codes, and the further information that it is helpful to pass on to assist the local Ambulance Service. In addition, the local emergency code protocol has been distributed to all areas of the establishment and is displayed in prominent areas for easy reference, including the communications room_ In addition to a copy of the emergency code protocol and the Notice to Staff, all existing staff will receive a personal briefing from their head of function. The induction programme for all new staff is being updated to include guidance on the local emergency protocol Finally, the prison and the South Western Ambulance Service are intending to undertake a joint exercise in the near future t reassure both organisations that staff understand the local protocol and will follow required procedures in real emergency hope this letter reassures you that Governor of Portland has taken steps to ensure that all operational staff are familiar with the local emergency code protocol: has the very Blue, gate the

Report sections

Investigation and inquest

On 12th November 2014 commenced an investigation into the death of Wayne Wesley Cornlouer. The investigation and inquest concluded on 23r September 2016. The conclusion of the Inquest was that Mr Cornlouer committed suicide. The jury also concluded that an ACCT should have been opened following an incident on 14th October , but that this did not more than minimally contribute to the death.

Circumstances of the death

Wayne Cornlouer was found hanging in his cell on Collingwood Wing at approximately 5.50 am on October 2014. The officer that discovered Mr Cornlouer called for "Immediate assistance on Collingwood" The evidence suggests that his colleagues arrived at the scene within 5 minutes. It was only at this point that a call was put through to the control room to call for an ambulance_

Action should be taken

In my opinion action should be taken to prevent future deaths and believe you The Governor HMP Portland of 104 Grove Road; Portland, Dorset; DTS 1DL have the power to take such action.

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Shared signals

Report details

Reference: 2016-0356
Date of report: 12 October 2016
Coroner: Brendan Allen
Coroner area: Dorset

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: 23 Apr 2017 (estimated from the Judiciary.uk publication date).

Sent to

HMP Portland

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk.

Contains public sector information licensed under the Open Government Licence v3.0.