Source · Prevention of Future Deaths

Ahmedreza Fathi

Ref: 2016-0173 Date: 5 May 2016 Coroner: Lydia Brown Area: Leicester City and Leicestershire South 2 responses identified · 2 indexed addressees View PDF

AI-generated concerns summaryHealthcare complex case planning lacked robustness and updates, with multi-disciplinary team meetings being informal and not providing ready access to all relevant risk assessment information. Services also failed to adequately investigate an earlier overdose event, which missed a safeguarding and learning opportunity.

Date 5 May 2016

56-day deadline 30 Jun 2016 est. estimated from the report date

Responses identified 2 of 2

Hospital Death (Clinical Procedures and medical management) related deaths State Custody related deaths Suicide (from 2015)

Coroner's concerns

AI summary

Healthcare complex case planning lacked robustness and updates, with multi-disciplinary team meetings being informal and not providing ready access to all relevant risk assessment information. Services also failed to adequately investigate an earlier overdose event, which missed a safeguarding and learning opportunity.

View full coroner's concerns

In the circumstances it is my statutory duty t0 report t0 you: Healthcare complex case planning was not robust or effective, and was not reviewed or updated in response t0 subsequent events Multi-disciplinary team meetings IF they took place, were not formalised and there was no ready access to all relevant information relating to risk assessment and case management through either System1 (the medical record storage and case management system) held by healthcare or the ACCT document held by the prison. The enhanced case management system referred to In PSI 64/11 was under-utilised for a prisoner of this complexity and further consideration should be given t0 its role in situations of this nature Mc Fathi was to hospital with (on the balance of probabilities) an earlier overdose some weeks before he lost his Neither the prison services nor healthcare considered the significance of this event; raised any hospital enquiries or completed an accidentlnear-miss incident report procedure and applied learning outcomes This was a missed opportunity to consider Mr Fathi s intentions his ability to access drugs in appropriately and t0 take appropriate safeguarding actions. Consideration should be given t0 adopting system that ensures invesligating such events on each occasion t0 ensure lessons can be learnt

Responses

2 respondents

HM Prison and Probation Service

Central Government

Letter dated 24 Jun 2016 PDF

AI-classified response stance Action Taken

AI-generated response summary

• HMP Gartree revised local contingency plans and re-issued instructions in May 2016 to ensure staff understanding of ambulance call procedures. • Local protocols now provide clear guidance for timely responses to medical emergencies. • Prison representatives met with EMAS in April 2016, with a joint emergency response protocol expected by 31 July 2016.

View full response

Dear Ms Brown Regulation 28 Report following the inquest into the death of Mr Ahmedreza Fathi on 13 May 2015 at HMP Gartree Thank you for your Regulation 28 report of 5 May addressed to the Governor of HMP Gartree and the East Midlands Ambulance Service NHS Trust, concerning the recent inquest into the death of Mr Ahmedreza Fathi. Your report has been passed to Equality, Rights and Decency (ERD) Group in NOMS, as we are responsible for sharing learning from deaths in custody. This response has been prepared in consultation with the Governor of HMP Gartree. In your report you repeat the concern that you, the Coroner and the PPO have raised following previous deaths in prisons in the Leicester area about delays by prison staff in calling for an ambulance. You point out that the East Midlands Ambulance Service NHS Trust (EMAS) had advised the court that discussion of a prison emergency response protocol would be welcomed and encourage the prison and EMAS to arrange a meeting to take this forward. You will be aware that PSI 03/2013 Medical Emergency Response Codes sets out the national instruction for calling a medical emergency over the establishment radio network in all prisons and NOMS-operated Immigration Removal Centres HMP Gartree has revised the local contingency plans and re-issued instructions in May 2016 to ensure that all staff understand that they must not delay calling an ambulance in all cases where there are serious concerns about the health of an offender. The local protocols now provide clear guidance to all staff to ensure timely, appropriate and effective responses to medical emergencies In addition HMP Gartree and other prisons in the Leicester area are collaborating with the EMAS to ensure effective Joint working and consistency of approach in all the prisons. Representatives of the prison met with EMAS in April 2016, and there is an expectation that a joint emergency response protocol will be in place by 31 July 2016 Thank you for bringing these matters of concern to our attention. I hope that this letter has been helpful in providing some national context and in giving you assurance that the concerns that you have raised have been, or are being, addressed locally at HMP Gartree and in the other prisons in the Leicester area.

East Midlands Ambulance Service NHS Trust

NHS Trust

Indexed date: 25 Jul 2016 PDF

AI-classified response stance Action Planned

AI-generated response summary

• The Trust stated that its management of Coronial processes is under review. • An initial meeting with HMP Gartree has been scheduled to address access issues, ambulance activation protocols, and partnership working principles. • The Trust has formed a senior regional group to address issues relating to secure environments and has provided Secondary Emergency Notification of Dispatch (SEND) cards for staff.

View full response

~~GR~~~~~ East Midlands Ambulance Service '' "~ _, %,$r~ Emergency Care ~ Urgent Care (1Ne Care Trust Headquarters 1 Horizon Place Mellors Way Nottingham Business Park Nottingham NG8 6PY Telephone: 0115 884 5000 Fax: 0115 884 5001 Website: www.emas.nhs.uk Our ref: 25 July 2016 Mrs Lydia Brown HM Assistant Coroner. Leicester City and Leicestershire South The Coroner's Court Town Hall Town Hall Square Leicester LE1 9BG I~Z~Tii11
• . ~ Re: Report to Prevent Future Deaths: Ahmedreza Fathi (DECEASED) Thank you for your Regulation 28 Report to Prevent Future Deaths, dated 11 May 2016, bringing to my attention HM Coroner's concerns arising from the Inquest into the death of Ahmedreza Fathi. I would like to re-emphasise our apologies for the failure to respond to the original Regulation 28 Report. An initial investigation has not found evidence of receipt of this report, however our management of Coronial processes is under review to ensure stronger and more robust handling of all cases to avoid such events in the future. would like to reassure you that within the East Midlands Ambulance Service (EMAS) all matters related to patient safety are taken extremely seriously. In particular, any matters arising from Coroner's Inquests from which lessons can be learnt, and this includes any Prevention of Future Deaths notices, are discussed within the Coroners Working Group. The Coroners Working Group, having considered all the relevant issues of concern relating to the particular Inquest at hand, will then develop an appropriate action plan with specified timelines for each action, together with identified individuals to deliver the actions specified. This process has been applied to the Prevention of Future Deaths notice (PFD notice) pertaining to the Inquest into the death of Ahmedreza Fathi.

d~, _- 4a, ~ ~ Y. r =~ ~~, East Midlands Ambulance Service ~ ~` ~;_:- ~~::~'~ ~lHs Trust Emergency Care ~ Urgent Care (1Ne Care The MATTERS OF CONCERN are as follows:
• On previous occasions following deaths in prison locally in Leicester, the Coroner and the PPO have raised concerns regarding delays in requesting 999 emergency assistance. On the night of 12 May 2015 there was a delay in summonsing an ambulance, in breach of PSI 03/13 and the prisons own internal policy. The then serving Head of Safety advised the Court that she "dealt with this problem a lot". There appeared to be a perception from gatehouse staff that calls had to be delayed until further information could be obtained from those officers at the scene.
• EMAS advised the court that 3 protocols already exist between other stakeholders and discussions to consider aprison/emergency response protocol would be welcomed and could be accommodated. I therefore encourage both the prison and EMAS to arrange a meeting to take this matter forward. set out below the actions EMAS has taken and our response to HM Coroner's concerns as detailed in the PFD notice. To address the specific issues identified in relation to Gartree Prison, alongside informing wider regional secure units, an initial meeting has been scheduled for Wednesday 3 August 2016. This meeting will be attended by the (Deputy Medical Director), (Consultant Paramedic Lead) from EMAS, and the Head of Operations .and Senior Operations Team from HMP Gartree. This meeting will aim to set an agenda to address access issues, ambulance activation protocols and partnership working principles. It is planned that this will be the first of a number of meetings and workshops to address the identified issues and available opportunities. EMAS has been proactively working with secure environment teams to develop working practices to create safe and efficient care delivery. This has been led by local management teams based upon locally identified needs. A key example of this working is the provision of SEND cards (Secondary Emergency Notification of Dispatch) for all secure environments for staff issue. These cards identify the core information required by the AMPDS triage system to appropriately triage patients and act as an aide memoire for front line police and public safety officials. In order to provide suitable oversight, leadership and empowerment to change, EMAS has now formed a senior regional group to address issues relating to secure environments such as prisons and secure mental health units etc. This centralised approach will enable a consistent and informed approach to this complex area of healthcare provision. This group has membership of senior team members from the Operations Directorate, Medical Directorate, Emergency Planning and Resilience Directorate and Emergency Operations Centre.

„V iil ~4~a~~~ East Midlands Ambulance Service ~~ .'m ~.z~,~~ `~'-~:'~~~ tVNs Trust Emergency Care ~ Urgent Care (We Care hope that you agree that EMAS have taken initial steps to ensure that the provision of high quality emergency care for secure environments working alongside partner agencies. I can assure you that we are taking the actions identified with a view to ensuring that similar tragic events can be avoided wherever possible in the future and that lessons are learnt. Please do not hesitate to contact me should you require any additional information, or any clarification, in connection with the above.

Report sections

Investigation and inquest

On 15 May 2015 commenced an investigation into the death of Ahmedreza Fathi The Inquest concluded on 12" April 2016.The Juries conclusion was Suicide on May 13th 2015, Gallow Field Road, Market Harborough; Leicestershire. The circumstances that the deceased came by his death were combination of plastic asphyxia and multi drug toxicity, which we believe t0 be a deliberate act of suicide. From the evidence presented we are of the opinion that the main two contributing factors to Mr Fathi's actions the constant physical pain he was experiencing; and the Iack of trust (he developed after acute episodes of anxiety and paranoia) for his support network With the evidence presented we have heard that there was a fragmented incohesive approach to the care and support Mr Fathi received which lacked strategic lead On night of 12th May 2015 there were clear changes in Mr Fathi's usual pattern of behaviour that should have been managed more appropriately-Il is evident that there was breakdown in effective communication which led t0 information provided and inadequate decisions being made. Questions t0 Jury: Q1) Do you agree the cause of death to be Ia. Combination of plastic asphyxia and multi drug toxicity? A) Yes.
02) Following his admission t0 Leicester Royal Infirmary on 26th March 2015, was Mr Fathl appropriately risk assessed with access t0 all relevant information; after his return t0 HMP Gartree A) No; 03) Did the care plan approach used by the healthcare teams include sufficient detail t0 ensure all aspects 0f his safe-keeping available t0 and understood by all relevant staff with direct contact with Mr Fathi ? A) No. 04) Did the prison; primary secondary healthcare services work togelher and share appropriate information, and review this regularly, to keep Mr Fathi as safe as can reasonably be expected within secure prison environment? A) No: 05) On the evening of 12 2015 were the changed observation levels appropriale at all times? A) No; 06) If your answer t0 question 5 is "no" do you think that different, more appropriate, observations may have resulted in an alternative outcome on this night? A) Yes Cause of death Combination of plastic bag asphyxia and multi drug toxicity and and bag are the partial being pag were and May

Circumstances of the death

Mr Fathi was a serving prisoner on a life sentence at HMP Gartree He was on an ACCT document for many months and under the ongoing care of the physical and mental heallh teams, as well as receiving physical heallh care outside the prison He had made several attempts to harm himself in the past; including 4 significant episodes during 2015 when he required emergency treatment out of hospital and had threatened t0 take his own Iife on many occasions On 12" May he made comment t0 a fellow In-male Ihat he intended t0 take his own Iife that night; and his observation levels were increased, but not to an appropriate level according to the jury $ findings of fact He was discovered in his cell during Ihe night; his head and chest inside a large plastic bag in a collapsed state and resuscitation efforts were unsuccessful Toxicology revealed high levels of drugs, both prescribed and non-prescribed, that he should not have had in his possession

Action should be taken

In my opinion action should be taken to prevent future dealhs and | believe you have the power t0 take such action;

Similar PFD reports

Shared signals

Report details

Reference: 2016-0173
Date of report: 5 May 2016
Coroner: Lydia Brown
Coroner area: Leicester City and Leicestershire South

Responses identified

Responses identified 2 of 2

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 30 Jun 2016 (estimated from the report date).

Sent to

Leicestershire Partnership NHS Trust

Northamptonshire Healthcare NHS Foundation Trust

East Midlands Ambulance Service NHS Trust

HMP Gartree

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk.

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