Source · Prevention of Future Deaths

Sharon Butcher

Ref: 2015-0129 Date: 31 Mar 2015 Coroner: Andrew Tweddle Area: County Durham & Darlington 1 response identified · 2 indexed addressees View PDF

AI-generated concerns summaryThe coroner noted a 10-minute delay in calling an ambulance after an emergency code, with the local protocol not followed. Similar issues with medical emergency responses, including incorrect codes and control room delays, have occurred at other prisons.

Date 31 Mar 2015

56-day deadline 26 May 2015 est. estimated from the report date

Responses identified 1 of 2

State Custody related deaths

Coroner's concerns

AI summary

The coroner noted a 10-minute delay in calling an ambulance after an emergency code, with the local protocol not followed. Similar issues with medical emergency responses, including incorrect codes and control room delays, have occurred at other prisons.

View full coroner's concerns

_ The PPO report highlights an issue relating to the delay in calling for an ambulance as soon as an emergency medical code was broadcast. There was a 10 minute delay and the prisons local protocol for summoning an ambulance was not followed. There have been a series of similar failings in dealing with medical emergencies at HMP Frankland and HMP Durham with either staff using wrong or inappropriate codes, or there delays in the control room and this recurring issue of lack of clarity in response to a medical emergency could well lead to a fatality in the future.

Responses

1 respondent

HM Prison and Probation Service

Central Government

Letter dated 22 May 2015 PDF

AI-classified response stance Action Taken

AI-generated response summary

• HMP Frankland revised local contingency plans and re-issued instructions to staff regarding calling an ambulance. • An additional learning bulletin was issued nationally by ERDG in April 2015. • HMP Frankland is working with the North East Prisons cluster and the North East Ambulance Service to ensure consistency.

View full response

Dear Coroner; RE: the death of Sharon Butcher on 25 August 2014 whilst In HMP Frankland Thank YOu for your ketter dated 31 March addressed to the Govemor of HMP Frankland and the National Offender Management Service conceming the Inquest into the death of Ms. Sharon Butcher: Your letter has been passed to Equality Rights &d Decency (ERD) Group in the National Offender ement Service (NOMS) to respond, a8 we have policy responsibllity for sulckde prevention and selcham management and for sharing keaming from deaths In custody: am als0 responding on behali HMP Frankland: In your report,_YOU expressed your concem about the delay in for an ambulance when the emergency medical code was broadcast You may be aware of PSI 03/2013 Medical Emergency Response Codes which sets the national instructions for calling & medical emergency over the establishment radio network in all prisons and NpMS operated Immigration Removal Centers. HMP Frankland revised their local contingency plans and re-issued instructions follwing death of MMs: Sharon Butcher t0 ensure that all staff understand, that must not delay in calling an ambulance irall cases where there are serous concems about the health ofan offender; The local protocols now provide clear guldance to all staff to ensure timely, appropriate and efiective response to medical emergencles and thereby maximise the likelihood of a positive outcome for the patient: The protocol defines the nature of the medical emergency with the use of a two level code (code Red and Code Blue) system that differentiates between blood and other injuries, such as breathing difficulties, unconscious casualties as specified by PSI 03/2013. In April 2015 an additional learing bullketin was issued nationally by ERDG (please see attached): In addition HMP Frankland are also working with the North East Prisons cluster and the North East Ambulance Service to ensure joint working and conslstency of approach across all establishments. hope that you find this response helpful and reassuring:

Report sections

Investigation and inquest

On 26ih August 2014 commenced an investigation into the death of Sharon Louise Suki Butcher: The investigation concluded at the end of the inquest on 31st March 2015. The conclusion of the inquest was Natural Causes with a cause of death given as Ia) Ischaemic Heart Disease, Ib) Coronary artery Atheroma, 2) Diabetes Mellitus and Cirrhosis of the Liver.

Circumstances of the death

The deceased died of natural causes.

Action should be taken

In my opinion action should be taken to prevent future deaths and believe you your organisation have the power to take such action:

Similar PFD reports

Shared signals

Report details

Reference: 2015-0129
Date of report: 31 March 2015
Coroner: Andrew Tweddle
Coroner area: County Durham & Darlington

Responses identified

Responses identified 1 of 2

1 response not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 26 May 2015 (estimated from the report date).

Sent to

HMP Frankland

National Offender Management Service

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk.

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