Source · Prevention of Future Deaths

Davin Short

Ref: 2015-0245 Date: 29 Jun 2015 Coroner: David Osborne Area: Norfolk Responses identified: 2 / 1 View PDF

The prison's lack of an electronic cell bell recording system and unclear guidance on radio use for healthcare staff create risks of medical emergencies being overlooked or delayed, endangering prisoners.

Date 29 Jun 2015
56-day deadline 24 Aug 2015 est.
Responses identified 2 of 1
State Custody related deaths

Coroner's concerns

AI summary
The prison's lack of an electronic cell bell recording system and unclear guidance on radio use for healthcare staff create risks of medical emergencies being overlooked or delayed, endangering prisoners.
View full coroner's concerns
leg sadly my

_ (1) During the course of the hearing heard evidence that the prison did not have electronic system for recording cell bells and it was left to the discretion of individual officers whether to record a cell bell call in the Record: am therefore concerned that without guidance as t0 Ihe making of a record of a cell bell call of medical nature an important matter may be overlooked with risk to life (2) also heard evidence that although there were now adequate radios for all three heallhcare staff it was not made clear that if a single member of heallhcare were on he or she must have a radio. am therefore concerned lhat without a specific guidance, there is a risk that a single member of healthcare may not have a radio causing delay in responding to an emergency call and possible risk to life.

Responses

2 respondents
HMP Weyland Prison / Probation
4 Aug 2015 PDF
Action Taken

HMP Wayland published a Governor's Order clarifying the recording of medical issues occurring overnight and amended the Local Security Strategy to support this. They also introduced a new radio system with more radios for healthcare staff. (AI summary)

View full response
Dear SirIMadam, My name is and I am the Head of Safer Prisons and Equalities at HMP Wayland. Within my role_ am responsible for undertaken actions as a result of a death in custody and am best placed to respond to the Regulation 28 letter regarding the death of Mr Davin Short at HMP Wayland. also attended and gave evidence at the enquiry: In relation to the concerns raised regarding the recording of medical issues that may occur during the night have ensured that the attached Governors Order was published to clarify this and have amended the Local Security Strategy to support this_ In relation to the issue of radios to Healthcare staff, since the death of Mr Short, a new radio system has been introduced with a greater number of radios. All Healthcare staff are issued radios upon arrival as a matter of course and as such_ the circumstances discussed as part of the inquiry will not re-occur
HM Prison and Probation Service Prison / Probation
14 Sep 2015 PDF
Action Taken

HMP Wayland has issued a Governor's Order instructing staff to record medical issues during the night in the wing observation book and amended the Local Security Strategy to reflect this procedure. A new radio system has been introduced at HMP Wayland and all healthcare staff are now routinely issued with radios. (AI summary)

View full response
Dear Mr Osborne, Regulation 28 report concerning the inquest into the death of Davin Short on 4 October 2011 at HMP Wayland Thank you for your report addressed to Matthew Spooner, Head of Safer Custody and Equality at HMP Wayland, dated 29 June 2015, concerning the inquest into the death of Mr_Davin Short; understand that you have already received response from This was sent because he was not aware that it is our policy for Ihe Equalty, Rlghts and Decency Group to respond to all such reports addressed to the National Offender Management Service (NOMS) , as we have responsibility for sharing learning from all deaihs in prison cusiody in England and Wales would to bring to your attention some information that was not included in his response, and am grateful for the additional iime that you have permitted to do so, The two concerns that you raise in your repoit are as follows: (1) ihe course 0f the hearing heard evidence that 'the prison did not have electronic system for recording, cell bells and it was left to Ihe discretion of indjvidual officers whether to record a ceii bell call in ihe Wing Record. am thereiore'concerned that witnout guidance 2s t0 the making Qf a record 0f a cell bell call of medical nature an important matter may be overlooked with risk to life (2) also heard evidence ihat altnough there were now adequate radios for all three healthcare stalf it was not made clear tat if a single member of healthcare were on duty he or she must have a radio am therefore concerned that without a specific guidance. there is a risk that a Single member of healthcare may riot have a radio causing delay in responding to an emergency call and possible risk to life_ As you know, each at HMP Wayland has a cell call system, but, unlike in some prisons of more recent construction, calls are not recorded electronically, and it is not therefore possible to conduct an analysis of the number of calls or the time taken to answer them: There are currently no plans to introduce system that permits electronic recording of calls, as this would be prohibitively expensive. like me During wing

In response to your first concern, Ihe attached Governor's Order was issued at HMP Wayland or 30 June 2015. It instructs staff to record medical issues Ihat occur during the night in the wing observalion book to ensure that are brought to the attention of relevant staff the next day. The Local Security Strategy has been amended to reflect this procedure_ In response to your second concern, as You were informed at the inquest; a new radio system with an additional number of radios has been introduced at HMP Wayland since Mr Short's death: AIl healthcare staff are now roulinely issued with radios upon arrival at Ihe prison and this enables (hem to respond t0 emergency calls without delay: hope this provides assurance that your concerns been addressed, Yours sinceely NOMS Equallly, Rights and Decency Group they have

Report sections

Investigation and inquest
On 6 October 2011 an Inquest into the death of DAVIN PAUL SHORT aged 46 years was opened: The Inquest concluded at the end of the inquest on 25 June 2015. The conclusion of the inquest was that Davin Short died from natural causes with the medical cause of death being 1a Acute Lobar Pneumonia_
Circumstances of the death
Mr Short had been diagnosed and treated for & chest infection on 21 September 2011. At a review appointment on 28 September 2011 it was considered that his infection had resolved. Expert evidence from confirmed that Mr Short received appropriate treatment and that his presentalion on 28 September 2011 was of a resolved pneumonia: Mr Short rang his cell bell at 03.00 on 4 October 2011 and was spoken to by an officer when he complained of pain. He appeared to take advice and get some rest: He was discovered unresponsive in his cell at about 08.15 hours n October 2011, CPR was commenced but he was pronounced deceased by altending ambulance service at 08.43. In the opinion of the pathologist Mr Short was deceased when discovered,
Action should be taken
In my opinion action should be taken to prevent future deaths and believe your organisation has the power to take such action:

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Report details

Reference
2015-0245
Date of report
29 June 2015
Coroner
David Osborne
Coroner area
Norfolk

Responses identified

Responses identified 2 of 1
All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 24 Aug 2015 (estimated).

Sent to

HMP Wayland

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