Source · Prevention of Future Deaths

Keith Murphy

Ref: 2015-0120 Date: 25 Mar 2015 Coroner: Simon Wickens Area: Surrey Responses identified: 1 / 2 View PDF

Prison staff lack basic first aid, CPR, and defibrillator training, and healthcare provision is unavailable outside limited hours, leaving prisoners vulnerable to medical emergencies.

Date 25 Mar 2015

56-day deadline 20 May 2015 est.

Responses identified 1 of 2

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

Coroner's concerns

AI summary

Prison staff lack basic first aid, CPR, and defibrillator training, and healthcare provision is unavailable outside limited hours, leaving prisoners vulnerable to medical emergencies.

View full coroner's concerns

During the course of the inquest the evidence revealed a number matters that gave rise to a concern that circumstances creating a risk of other deaths will continue to exist in the future unless action is taken.

1. Action is required to ensure that Prison Officers and Staff with direct access to prisoners have basic first aid training, CPR training and familiarisation with the use of a defibrillator.

2. Action is required to ensure someone from Healthcare is available beyond the current arrangement of 7am – 6.30pm to provide an RT4534

Responses

1 respondent

HM Prison and Probation Service Central Government

6 May 2015 PDF

Action Taken

NOMS states that first aid training is being implemented at HMP Coldingley, with custodial managers trained and monthly closedown sessions used for wider staff training. They also state that a recent Health Needs Assessment confirmed existing healthcare arrangements meet the needs of the prison population. (AI summary)

View full response

Dear Mr Wickens RE: the death of Mr Keith Murphy on 18 July 2013 at HMP Coldingley Thank you for your Regulation 28 Report dated 25 March addressed to Michael Spurr; Chief Executive Officer of the National Offender Management Service (NOMS) , and Simon Stevens, Chief Executive of NHS England, following the inquest into the death of Keith Murphy at HMP Coldingley on 18 July 2013 Your letter has been passed to Equality Rights and Decency Group in NOMS to respond, as we have responsibility for policy on suicide prevention and self-harm reduction and for sharing learning from deaths in custody: am responding on behalf of both NOMS and NHS England as the two matters that you have raised are of shared concern: will address each in turn; First Aid training for prison staff PSI 0112014 First Aid describes the process for ensuring effective provision of first aid that enables NOMS to discharge its of care to its employees, to prisoners and to visitors to our premises_ Governors are required to ensure that at all times such a number of suitably trained first aiders as is sufficient and appropriate for the circumstances at their prison is available. A First Aid riskslneeds assessment is undertaken by the local Health and Safety Advisor to determine the appropriate numbers. Governors must ensure that first aiders are trained to levels which are appropriate for the circumstances and hold a valid certificate of competence in either First Aid at Work (FAW) Or Emergency First Aid at Work (EFAW): This policy is being implemented at HMP Coldingley: In order to ensure that a trained member of staff is always available, all Custodiai Managers (CMs) are trained. At present;, all but two of the CMs at the prison have been trained, and those two members of staff will be provided with training as soon as they return to HMP Coldingley also uses monthly closedown of the prisoner regime to provide opportunities for training for the wider staff group and this includes instruction on CPR and on the use of defibrillators Qut_of _hour's healthcare provision At HMP Coldingley there is access to on-site healthcare practitioners from 7.30am -
6.30pm Monday to Friday and 8.30am
5.30pm at weekends When prisoners require access to healthcare advice outside of these hours the local GP out of hours service, provided by Care UK, is used. This service offers telephone advice or a visit to the prison to assess the duty . being duty.

needs of the prisoner as appropriate. This arrangement is considered to be equivalent to what is available in the community. Where prisoners are perceived to require access to emergency and lifesaving care the local Ambulance Trust (South East Coast Ambulance NHS Trust) is called for an emergency response_ The size (531) and nature of the population at the prison, which is composed of prisoners who have been assessed by staff in other prisons as suitable to be accommodated at HMP Coldingley, is not believed to require the provision of on-site healthcare staffing of hours A recent Health Needs Assessment, commissioned through the NHS England South East Health and Justice commissioning team, confirms that the existing healthcare arrangements meet the needs of the prisoner population at the establishment hope that this response provides reassurance that the concerns that you have raised have been considered, and that; where appropriate, action has been taken to address them.

Report sections

Investigation and inquest

The inquest into Keith John Murphy’s death was opened on the 23rd July 2013 was resumed with a jury on 9th of March 2015. The Jury returned their conclusion on the 13th March 2015.

The jury found the cause of death was: 1a – Ischaemic Heart Disease 1b – Coronary Artery Atheroma/ SPICE (Synthetic Cannabinoid) Toxicity

The Jury returned box 3 as:

On Thursday 18th July 2013, Keith John Murphy was pronounced dead by paramedic staff at 20.37hrs at Shaftsbury Road, Bisely. Mr. Murphy’s death was caused by Ischemic Heart Disease and Coronary Artery Atheroma. He had a history of both smoking and also drug use in later life. Mr. Murphy displayed uncharacteristic behaviors such as aggression, abnormal movements, dehydration and profuse sweating. He also admitted to using ‘Spice’. The ingestion of a synthetic cannabinoid had a more than minimal contribution to Mr. Murphy’s death.

RT4534 And their conclusion was; Natural Causes hastened by the use of synthetic cannabinoid.

Circumstances of the death

On the 18th July 2013, Keith John Murphy was noted by other prisoners and staff to be physically ill and to be acting in such a manner that appeared to indicate he might have taken some form of drug. He later admitted to another prisoner and a member of staff he had taken SPICE. As a consequence of him refusing to take medical advice to attend hospital, he was locked in his cell. Later Mr Murphy was found on the cell floor and an ambulance was called. Prison Officers attempted to assist Mr Murphy until the paramedics arrived. There was some confusion over whether the defibrillator was working or not. Such was the extent of the Ischemic Heart Disease that any assistance in the circumstances would have been unlikely to have saved Mr Murphy.

The inquest further heard that between the hours of 7am and 6.30pm prisoners had access to on site Healthcare staff and Prison Staff had the benefit of their guidance when dealing with prisoners. After this period reliance is placed upon either Thamesdoc or an Ambulance being called with the associated time delay in their arriving at the prison. The Court further heard that in a prison of over 500 inmates, from 6.30pm to 7am one person would be available who was first aid trained.

Copies sent to

Simon WickensDATED this 25th day of March 2015

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Shared signals

Report details

Reference: 2015-0120
Date of report: 25 March 2015
Coroner: Simon Wickens
Coroner area: Surrey

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: 20 May 2015 (estimated).

Sent to

National Offender Management Service

NHS England

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.