Samuel Blair

Coroner's concerns

AI summary

Prison healthcare failed to adequately assess mental health, record vital information, or continue prescribed antidepressants. Delays in emergency response included slow 999 information, a nurse failing to acknowledge radio calls, and not immediately bringing a defibrillator.

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1. Although the assistant psychologist who triaged Mr Blair in prison on 2 July 2015 asked him about his alcohol dependency, she did not ask him about drug use, nor did she record asking him about his mood or any suicidal thoughts.

2. She later uploaded to the computer system the collateral history she had been sent as a Word document, but did not input any of it into the main body of the records, nor did the psychiatrist who made the note at the multi disciplinary team meeting in prison on 7 July 2015 at which Mr Blair was discussed.

3. There is no record from that meeting of any discussion or management plan for Mr Blair’s schizophrenia.

4. There is no record from that meeting or any other time, of any consideration of or management plan for Mr Blair’s depression. Most particularly, there is no record that it was ever recognised by the healthcare staff at HMP Pentonville that Mr Blair had been prescribed and had been compliant with the prescription of an anti depressant before his incarceration.

The assistant psychologist who obtained the history of a prescription of anti depressant medication did not refer Mr Blair to a prison GP for consideration of this.

Mr Blair was never offered any continuation of his citalopram prescription. The plan in the community had been to continue the prescription, but there is no record that this was ever considered by healthcare staff at HMP Pentonville.

5. After Mr Blair was found hanging, the officer in the prison control room did not give the prison gate location for the ambulance at the very outset of the 999 call to London Ambulance Service, but instead did so part way through the call.

The LAS controller did not ask at the very outset.

The ideal would be for the information to be given at the very beginning of any emergency call.

(I wrote to HMP Pentonville on 16 September 2016 in connection with the death of another prisoner about this issue. I appreciate that work on this matter is ongoing.)

6. The prison nurse on call for emergencies, call sign Hotel 7, who was called to attend Mr Blair after he had been found hanging, did not acknowledge the radio call for several minutes, despite numerous attempts by prison control.

When she finally did acknowledge the emergency, there was a delay of up to approximately 15 minutes before she was at Mr Blair’s side.

(I wrote to HMP Pentonville on 16 September 2016 in connection with the death of another prisoner about a different nurse, but also in the role of Hotel 7, who did not respond to an emergency alarm as soon as it was activated.)

7. The substance misuse nurse in the detoxification wing did respond immediately. He took his emergency bag with him to Mr Blair’s cell, but did not take the defibrillator stored in the same room as the bag. He later had to leave Mr Blair to retrieve the defibrillator, because it is stored in the nurses’ room and only nurses have the key.
8. That nurse (a mental health, rather than general nurse) began resuscitation. He gave evidence that he started chest compressions and continued these for two minutes until a custodial manager arrived, without any intention of ever stopping to re-check Mr Blair’s pulse.

He said that, whilst his basic life support certification was current at the time of Mr Blair’s death, his intermediate life support certification was not, and is still not; it is currently at least three years out of date.

9. That nurse gave a description of the code blue and code red system of describing an emergency, that was markedly different from the understanding given by the prison governor and the London Ambulance Service. I heard that the codes blue and red are even described on posters within the prison.

It therefore appears that a nurse within the prison healthcare team has the wrong understanding of basic prison healthcare emergency procedures.

Responses

3 respondents

London Ambulance Service NHS Trust NHS / Health Body

14 Jul 2016 PDF

Action Taken

The London Ambulance Service updated its Computerised Gazetteer to include multiple entrances to HMP Pentonville, and included specific reference to HMP Pentonville in refresher training for EOC staff, requiring confirmation of the gate to attend at the start of a call. They have also held meetings with senior prison staff to promote effective communication. (AI summary)

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Dear Ms Hassell RE: Regulation 28: Prevention of Future Deaths Report arising from the inquest into the death of Samuel Rodney Darren Blair Thank you for your Regulation 28 Report to Prevent Future Deaths, dated 19 May 2016, bringing to my attention the matters of concern arising from the death of Mr Samuel Rodney Darren Blair on August 2015 not 2 August 2016 as stated in the title and paragraphs 5.5 and 6 of your Report: "After Mr Blair was found hanging, the officer in the prison control room did not give the prison gate location for the ambulance at the very outset of the 999 call to London Ambulance Service, but instead did so part way through the call. The LAS controller did not ask at the very outset

The ideal would be for the information to be given at the very beginning of any emergency call wrote to HMP Pentonville on 16 September 2016 in connection with the death of another prisoner about this issue. appreciate that work on this matter is 0n - going )" The letter to HMP Pentonville on 16 September 2015, relating to Mr H was also addressed to me_ In my reply of 13 November 2015 confirmed the actions taken by the London Ambulance Service NHS Trust (LAS) after the death of Mr H to ensure that the LAS attend the correct prison gate when called to HMP Pentonville: Shortly before the inquest into the death of Mr H changes were made to the LAS's Computerised Gazetteer; used in the Emergency Operations Control (EOC); t0 record that there was more than one vehicular entrance to HMP Pentonville, namely the Roman Gate and North Wall Gate. The postal address of both entrances, were added t0 the Gazetteer Following the inquest into the death of Mr H it was requested that HMP Pentonville staff were prompted and reminded to say at the beginning of a 999 call which entrance LAS staff were to use. Unfortunately these actions occurred after the call to Mr Blair on 02 August 2015. have been assured bi the LAS's Deputy Director of Operations (Control Services)] that in early May 2016, when the refresher training for 2016/17 for staff in EOC began, a session was included that made specific reference to HMP Pentonville and of the requirement that when a call from HMP Pentonville was received, at the start ofthe call the emergency medical dispatcher was to seek confirmation of the gate the LAS should attend: This training is in process and due to be completed in November 2016. On 26 May 2016 our Senior Quality Assurance Manager, Control Services, and other LAS senior managers, met senior prison staff to discuss matters of mutual interest for the LAS ad HMP Pentonville to promote effectivve communication and working: am advised that these meetings will continue. Our Medical Director, has confirmed that the Regulation 28 Report from the inquest into death Of WI Blair will be shared with the National Ambulance Service Medical Directors Group to facilitate wider learning by UK Ambulance Services; Way joint

hope that this reply is helpful to you and to Mr Blair's family in explaining all that we have done to address your matters of concern We offer our sincere condolences to Mr Blair's family:

Care Uk Private Sector

25 Jul 2016 PDF

Action Planned

Care UK refers to the response provided by BEH-MHT for some concerns, and states they will collaborate with them to ensure their action plan is implemented. They have implemented a training plan to ensure most healthcare staff will be ILS trained by December 2016, with yearly refresher trainings. (AI summary)

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Dear Coroner ME Hassell, Regulation 28: Prevention of Future Deaths report; Samuel Rodney Darren Blair (died
02.08.2015) We hereby respond to your Rule 28 report issued to Care UK following the inquest into the death of Mr Rodney Blair. Care UK would like to express its condolences to Mr Blair's family and friends_ Care UK is the main provider of healthcare services at HMP Pentonville_ There is a sub- contracting arrangement in place with Barnet; Enfield and Haringey Mental Health Trust (BEH- MHT) in respect of mental health services. Our response addresses the matters of concern which relate to our staff and services It should be read in conjunction with the separate response provided by the BEH-MHT. The actions below form part of the overall action plan across healthcare between both providers_ Matter of Concern
1. Although the assistant psychologist who triaged Mr Blair in prison on 2 July 2015 asked him about his alcohol dependency, she did not ask him about drug use, nor did she record asking him about his mood or any suicidal thoughts: Response: We refer to the response provided by BEH-MHT and we will collaborate with them to ensure that the action plan outlined in their response is implemented and that all healthcare staff are aware of the plan: Matters of Concern 2, 3 & 4. Response: We refer you to the response provided by BEH-MHT as these concerns are relating to their services rather than the services of Care UK. Matter of concern 5. Response: This concern is matter for the prison and accordingly, we will leave it for them to respond Matter of Concern 6. The prison nurse on call for emergencies; call sign Hotel 7, who was called to attend Mr Blair after he had been found hanging did not acknowledge the radio call for several minutes, despite numerous attempts by prison control. When she finally did acknowledge the

care emergency, there was delay of up to approximately 15 minutes before she was at Mr Blair's side. Response: We set out below a timeframe which we have compiled from the written evidence and with reference to the evidence heard at the inquest hearing and which suggests that the time taken was less than 15 minutes. In his witness statement of 2 August 2015 states thatuhearrived at Mr Blair's cell at
7.35pm. He states that officer was on the landing and officer) and nurse were in the cell. He states that he assisted in giving breaths and compressions with them swapping roles He states that he "again" makes a call to Hotel who he estimates arrives after 10 minutes and attaches the defibrillator: He states that the first paramedic arrives at 7.SOpm_ PCO is the first officer to arrive at Mr Blair's cell. In his PPO evidence , he states that he discovers Mr Blair at 7.30 pm. PCO Istates that he shouted at the top of his voice because he did not have a radio and that PCO rrived in around "minute or two" PCO does not call a level 1 (code blue) because he did not have a radio_ PCO states that she hears PCO Icalling her name and asking her to go to Mr Blair's cell: She asks him why and he asks her to rush down: According to her account; by the time that she arrives, PCO has entered the cell and cut the ligature. PCO asks PCO tto raise level incident which she states that she does. PCO tthen states that officers rush down She mentions PCO and who she savs radios to request an ambulance. PCO says that she then calls to nurse PCO says that responds and states that he has to go and get the bag which he does before going to Mr Blair s cell: Once he arrives, PCO Soli's account is that Mr Blair is moved to the landing In PCO Haslam's PPO statement; he says that after arriving, going into the cell and talking to PCO about whether Mr Blair had a pulse, he runs upstairs and explains to Xavier what has happened: In his PPO interview, states that around 7.30 p.m:, he hears his name called and that he responds by asking What the matter is. He is asked to "come down" to Mr Blair's cell and the tone causes him to go upstairs to his bag and oxygen before going back downstairs to the cell: assesses Mr Blair, checks for pulse , eases him to the floor andstairts compressions_ He then asks the officers to call another member of healthcare staff. states that he does compressions for 2 Or 3 minutes before an officer asks about mask and that had_been doing compressions and using the mask for around minutes before Hotel 7 arrived. states that he then goes to get the defibrillator. He states that then attach the defibrillator for instructions "several times" (and it advises to continue compressions). He estimates that the paramedics arrives 10 or 15 minutes later In oral evidence at the inquest hearing, Istated that it took him about 2 minutes to arrive at Mr Blair's cell after hearing his name being called and collecting the emergency bag: In oral evidence, PCO stated that it was at 7.34pm that PCO made a call to the prison control room to call for assistance regarding an imminent threat to Ile_ However , we know that PCO Idid not have a radio and so he could not have made such a call: PCO stated_that he attempted to contact Hotel 7 and that it took her 3-4 minutes to respond PCO was aware that there had been another incident at the prison where prisoner had set to their cell and PCO was aware that there was already another nurse in attendance at Mr Blair's cell: PCO states that the first paramedic arrived at the prison within 6 or 7 minutes at 7.46pm:. being get they they fire

Care At the time, Hotel was attending another incident and treating another patient on a different wing: Upon acknowledging the call from PCO in her PPO interview, Hotel states that she went via A wing to collect the emergency response bags and that it took her five minutes to arrive at Mr Blair's cell: According to LAS records, the call for an ambulance connected at 7.40 p.m: and paramedic G199 was with Mr Blair at 7.5Opm. When he arrived, there was a nurse and an officer carrying out CPR another nurse (presumably Hotel 7) was maintaining an airway and the defibrillator was attached. Although in her statement Hotel 7 states that she received a code blue at approximately 7.3Opm according to the written and oral evidence, this time is inaccurate In summary, PCO larrives at Mr Blair's cell at 7.30 p.m_ This time appears to be consistent across the PPO interviews_ The LAS records show that the first paramedic arrives in the cell at
7.50 p.m The window is therefore one of 20 minutes: Having arrived at the cell at 7.30 p.m, PCO finds Mr Blair hanging He enters the cell and cuts the ligature although the evidence indicates that he does not enter the cell until a colleague arrives. Upon discovering Mr Blair; he shouts for help but does not say why and he does not have his radio to issue the relevant level 1/code blue call; PCO arrives within a few minutes and PCO tells her what has happened and asks her to radio the alert. It is not clear whether this is the code blue that Hotel hears but this call must have been made several minutes after 3Opm. According to PCO the earliest this call was made is 7.34 p.m_ By 7.SOpm only 16 minutes later , when the paramedics arrivve atuthe cell, Hotel has already arrived, is maintaining an airway and the defibrillator is attached: statement is that he collects the defibrillator after Hotel 7 arrives It therefore appears that the time it took Hotel 7 to arrive at the cell was less than 15 minutes. If it was Mr instructions to the control room that resulted inthe code blue (and the 999 call as per PCO account) , then he arrived at the cell after) who states that he arrived at 7.35 p.m. If the code blue call went out at around the same time as the 999 call (7.40 p.m:) then Hotel must have arrived in less than 10 minutes_ In any event; any on the part of Hotel 7 was as a result of her being located in a different wing and treating another patient following another incident: It would therefore have been entirely correct to ensure that her patient was clinically stable before leaving to attend another incident where a clinician was already in attendance_ Matter of Concern
7. The substance misuse nurse in the detoxification wing did respond immediately. He took the emergency bag with him to Mr Blair's cell, but did not take the defibrillator stored in the same room as the He later had to leave Mr Blair to retrieve the defibrillator; because it is stored in the nurses' room and only nurses have the Response & Actions: As can be seen from PPO interviews and as was heard during the inquest hearing, the nurse was called for assistance but not informed by the officers as to what the nature of the emergency was He was also not aware of any code blue call at the time_ He therefore collected the emergency bag: After attending Mr Blair's cell and identifying the nature of the emergency, he went back to the nurses room to collect the defibrillator. Hotel 7 had already arrived at this point and was assisting Mr Blair when the nurse left Mr Blair's cell to collect the defibrillator: However to ensure that there is no misunderstanding of emergency procedures in the future, we have implemented the actions outlined in the table below for all healthcare staff delay bag: key: the

Care Matter of Concern 8. The nurse (a mental health nurse rather than general nurse) began resuscitation. He gave evidence that he started chest compressions and continued these for two minutes until a custodial manager arrived, without the intention of ever stopping to re-check Mr Blair's pulse. He said that, whilst his basic life support certification was current at the time of Mr Blair's death, his intermediate life support certification was not; and is still not. It is currently at least three years out of date. Response & Actions: Care UK Cardiopulmonary (CPR) Resuscitation Policy in the Training section (section 7) states: 'As a minimum all staff within Care UK should be provided with Basic life Support (BLS) training on induction This should be maintained by participating in regular practice sessions within the workplace and by mandatory annual updates in BLS' . 'The resuscitation team members will immediately mobilise to the location and perform BLS, ILS or ALS according to their ability' 'AlI Healthcare staff are expected to recognise cardiac arrest, call for help and initiate BLS' The nurse concerned was trained in Basic Life Support (BLS) but not Intermediate Life Support (ILS): As such, staff trained to BLS level are not expected to check pulse as per the Resuscitation Council UK 2015 guidelines. The nurse was therefore acting within the scope of his practice and competence_ However, as detailed in the table below; we have implemented training plan to ensure that; by December 2016, most healthcare staff will be ILS trained and that refresher trainings will occur yearly. Matter of Concern 9. That nurse gave a description of the code blue and code red system of describing an emergency that was markedly different from the understanding given by the prison governor and the London Ambulance Service. heard that the codes blue and red are even described on posters within the prison. It therefore appears that nurse within the prison healthcare team has the wrong understanding of basic prison healthcare emergency procedures

HM Prison and Probation Service Central Government

15 Aug 2016 PDF

Action Taken

NOMS states that the local risk assessment at Pentonville is up to date, and there is a sufficient number of staff trained in first aid. Prison control room staff have been briefed to provide the prison gate location at the beginning of calls to the London Ambulance Service. (AI summary)

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Dear Ms Hassell Thank you for your Regulation 28 Reports to Prevent Future Deaths addressed to Michael Spurr, Chief Executive Officer at the National Offender Management Service (NOMS) , and tol the Governor of HMP Pentonville, concerning the recent inquest into ihe death of Samuel Rodney Blair at HMP Pentonville on 2 August 2015. am very grateful to you for agreeing an extension to the statutory deadline so that we could finalise our response to your reports. This response is sent on behalf of NOMS and HMP Pentonville, and has been formulated following consultation with the London Ambulance Service NHS Trust. am aware that Care UK will reply separately concerning the matters of concern in your report that were addressed to them: The report that you addressed to NOMS expresses concern that the staff who discovered Mr Blair had not received cardiopulmonary resuscitation (CPR) training: It correctly states that the NOMS position is that such training is not mandatory for all prison staff. However;, it is not correct to characterise this as 'resource-led' decision. NOMS is committed to ensuring that that a sufficient number of suitably trained first aiders is always available in prisons to enable First Aid to be given to employees, prisoners and visitors. Prison Service Instruction 29/2015 First Aid, issued on 16 November 2015, requires every establishment to carry out a First Aid risk assessment to identify the number of trained first aiders required to provide cover throughout the day: Trained first aiders must hold an up to date, valid certificate of competence in either First Aid at Work (FAW) or Emergency First Aid at Work (EFAW), and the number of staff trained is dependent on a number of factors which are considered during the risk assessment process_ Colleagues at Pentonville have confirmed that their local risk assessment is up to date, and that; in accordance with it, there is a sufficient number of staff trained in first aid, including all night staff and all managers who undertake the role of Orderly Officer. As yoy know; the healthcare provider at Pentonville provides 24 hour cover_ so the prison's Own arrangements are supplemented by the presence of trained healthcare staff at all times: The separate report addressed to the Governor raises concern about the fact that the prison's control room did not immediately provide the London Ambulance Service (LAS) with the gate location when they requested the attendance of an ambulance. can confirm that since Mr Blair's death, colleagues at Pentonville have met the LAS to discuss this issue and it has been agreed that the prison gate location will be

provided at the beginning of the call. Prison control room staff have been made aware of this requirement through verbal briefings. This report also brings to the attention of the Governor the inadequate response of a nurse to the emergency call from the control room: As you point out in your report; the local protocol on action to be taken in response to emergency response codes is well publicised throughout the prison: The prison will continue to work with the healthcare provider to ensure that all staff are aware of the steps that are required to take when responding to an emergency call. am grateful to you for raising these concerns with NOMS and the Governor, and hope that this response provides assurance that appropriate action is being taken to prevent future deaths_

Report sections

Investigation and inquest

On 6 August 2015 I commenced an investigation into the death of Rodney Blair, aged 40 years. The investigation concluded at the end of the inquest earlier today.

The jury made a narrative determination, which I attach, concluding that death came about by way of suicide, with several contributing factors. The medical cause of death was: 1a suspension by ligature.

Circumstances of the death

Rodney Blair was remanded in custody at HM Prison Pentonville on 30 June 2015. He had a history of paranoid schizophrenia, alcohol dependency, multiple drug use and depression. At no time did any member of staff at HMP Pentonville suspect that Mr Blair had thoughts of taking his life.

On Sunday, 2 August 2015, he was found hanging in his cell.

Copies sent to

National Offender Management Service (NOMS)Rodney Blair’s mum & stepdadassistant clinical psychologist, mental health nurse

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