Source · Prevention of Future Deaths

Darren Wright

Ref: 2015-0035 Date: 2 Feb 2015 Coroner: Jacqueline Lake Area: Norfolk 3 responses identified · 3 indexed addressees View PDF

AI-generated concerns summaryThe staff nurse did not know the location for a Code Blue emergency, and prison officers who responded lacked recent CPR training due to resource limitations which created gaps in trained personnel.

Date 2 Feb 2015

56-day deadline 30 Mar 2015 est. estimated from the report date

Responses identified 3 of 3

State Custody related deaths

Coroner's concerns

AI summary

The staff nurse did not know the location for a Code Blue emergency, and prison officers who responded lacked recent CPR training due to resource limitations which created gaps in trained personnel.

View full coroner's concerns

_ (1) On receiving Code Blue notification the Staff Nurse did not know where to go and had to call on her radio to be found and then taken t0 the cell; (2) The Prison Officers attending Mr Wright had not had recent CPR training: It is understood that due to a lack of resources, CPR training has had to be allocated to certain members of staff only: This will result in gaps in CPR-trained Officers available and able to atlend emergencies_

Responses

3 respondents

Serco

Private Sector

Letter dated 11 Feb 2015 PDF

AI-classified response stance Noted

AI-generated response summary

• Serco stated it no longer provides services to HMP Norwich and therefore has no power to implement the recommendations at that location. • Serco stated it would use the recommendations to aid learning and effect continuous improvement as part of its Safer Custody commitment.

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Dear Madam , RE: REGULATION 28 REPORT TO PREVENT FUTURE DEATHS MR DARREN WRIGHT (DECEASED) refer to (he above regulalion 28 reporl which was sent to Ihe Chief Execulive of Serco Mr Rupert Soames. Mr Soames has requesled me lo respond to (he letter on his behalf:, Whilst at Ihe time of Mr Wright's unfortunate death Serco was the heallhcare provider at HMP Norwich, as from 1st April 2014 all responsibilily for delivery of healthcare services passed to Virgin Care. Accordingly, Serco no longer have any involvement in service delivery at HMP Norwich We note Ihe MATTERS OF CONCERN: (1) On receiving Code Blue notification the Staff Nurse did not know where lo go and had to call on her radio to be found and then taken to the cell: (2) The Prison Officers atlending Mr Wright had not had recent CPR training: It is understood that due to a lack of resources, CPR training has had to be allocated (0 certain members of staff only. This will result in gaps in CPR-trained Officers available and able to atlend emergencies_ As stated above, Serco does not provide any services to HMP Norwich (either custodial or heallhcare) Therefore, the company has no power to implement these recommendalions at HMP Norwich: However, we note that the Regulation 28 report has been sent to HMP Norwich and Virgin Care Limited and these parties do have power to implement the recommendalions_ As Serco was an Interested Party, Ihe recommendations made will be laken forward and used lo aid learning and to effect continuous improvement as part of Serco's Safer Custody commitment_ We hope that this assures YoU of Serco's commitment to ensure the health, safety and welfare of prisoners, and lo prevent fulure deaths_ Yours failhfully For Serco Limited Associate General Counsel C.C. HMP Norwich Virgln Care Limlted Serco Llmiled. A company reglslered In England and Wales No. 242246_ Reglstered Office: Serco touse, 16 Bartley Wood Buslness Park, Barley Way; Hook; Hampshire RG2Z 9UY, Uniled Kingdom: FEB 2015 We Plc,

Virgin Care Services Limited

Other

Letter dated 27 Mar 2015 PDF

AI-classified response stance Action Taken

AI-generated response summary

• The induction process for new and agency staff has been reviewed and revised to include shadowing time, with a checklist template to be introduced by 31 March 2015 and annual refresher training. • A joint protocol has been agreed with the Operations Governor, and put in place, for prison officers to direct nurses to medical emergencies during 'patrol state', to be ratified by 31 March 2015. • Virgin Care stated it was unable to respond to the concern regarding CPR training for prison officers as it was not within its remit.

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Dear Sirs Inquest touching the death of Darren Wright We are providing this letter In response to (he Coroners report issued pursuant to Regulation 28 of the Coroner's (Investigations) Regulalions 2013 dated 2 February 2015. At the conclusion of the inquest;, the Coroner raised two concerns, one of which is directed to the healthcare deparlment, which is currently provided by Virgin Care Services Limited ("Virgin Care") We have set out below the steps Virgin Care has taken to address the concerns raised by the Coroner, At the outset which the Coroner may already be aware of, at the time of Mr Wright's death, on 3 November 2013, Virgin Care was not lhe provider of heallhcare services at HMP Norwich: The provider at the time was SERCO. The Coroner's conclusions have been of considerable assistance in informing our review of the training and guidelines which are currently in place. We now address the specific concern directed at heallhcare which the Coroner has required Virgin Care's response lo in his Rule 28 report: (1) On receiving Code Blue Notification the Staff Nurse did not know where to go and had to call on her radio to be found and then taken to the cell Mr Wright was transferred to HMP Norwich on 4 September 2013 Mr Wright was found dead in his cell on 3 November 2013. This was Mr Wright's first time in prison at HMP Norwich and no active risks were identified, although he was described as 'nervous and anxious'_ The cause of death was hanging and the coroner heard (hat (he contributory factor was due to inconsislencies with and access to information across different departments within the prison system_ As stated previously, this incident occurred before April 2014, and therefore pre-dates Virgin Care's management of the healthcare service at HMP Norwich_ The provider at the time of the incident was SERCO_ We have instigated Iwo specific measures as a result of our review but It Is worth setting out a short summary of the background on these matters. Virgin Care w: wvA.vilgjine; Wt.Ik 1R:qissl;tc (d oilice : Virqin (awe; #.v6 $; "nlon Icm4s,4, 1? Isislock *(QU;Ia;_ (flalar #c;I!
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virgincx It NHS] The specific issue in this matter was that the staff nurse did not know how to get to the cell: To address this, it is important to understand the building issues within HMP Nowich_ HMP Norwich is split into two sites and the layout is not similar in a number of locations due lo the differing ages of the building: As a result, the celi numbering Is not straightforward and it can be confusing to know which cell numbers can be found where, and (he sequence being followed in specific part of the building_ This is of particular note as healthcare services are provided in the FIG wing and does not usually require our nurses to attend to prisoners in their cells and hence their knowledge of fhe numbering of cells is limited_ In terms of training, all new nurses working in HMP Norwich are required to undergo a two week 'shadow' period where are fully inducted to all areas of (he prison. During this time, emergency response kits are highlighted to staff, This amended process for shadowing of new staff was already in place on April 2014 when Virgin Care's contract to provide the service came into force_ Unfortunately, whilst we did consider introducing maps of the prison to assist our staff in localing cell numbers, this is not permitted by the prison governor for security reasons in prisons During normal operational hours, prison officers would direct nurses to the medical emergency but this can be more challenging during 'patrol state' (when prisoners are locked in Iheir cells) as the number of prison staff on duty is reduced. In response to the concerns raised, we have undertaken (he following: The induction process has been reviewed and revised lo include 'shadowing' time for all new starters and agency staff: To further evidence this, local induction process and checklist template is being developed and introduced to record an individual's completion of this process_ This will therefore increase (he knowledge of our staff in terms of the layout of cells when are required to attend an emergency. This will be followed up with refresher training on an annual basis_ A review of the response procedure the Head of Healthcare at HMP Norwich has met with the Operations Governor within the prison and agreed where a medical emergency arises when the prison is in patrol state, prison officer will wait for lhe nurse in the entrance corridor and direct the nurse to the medical emergency: This has already been into place and a joint protocol will be ratified by both ourselves and HMP Norwich by 31 March 2015_ This will ensure that our nurses can be directed to the correct cell (o attend to medical emergencies As a result of (hese measures, Virgin Care is confident that it has in place robust process for ensuring that staff members have completed Ihe appropriate training when they commence work at HMP Norwich and that they complete the induction process: Virgin Care is also confident Ihat the agreed process with the Prison Operations Governor will ensure that nurses are appropriately directed in a medical emergency: For completeness, we enclose Ihe following documents: Local Induction Process and Checklist template (to be in place by 31s March 2015); Guidance for Resuscilation joint protocol with HM Prison Service (to be in by 31st March
2015): Vlrgln Care w: !wvavirgjiru Ic.€).Uk K/c"jisledel ollic e: Virgyin (A) Iimxin:: "lelo )} Iknss:, 7.12 |:ais,l;k Seuate cfhchc:c WcIn#. Kyjis;lctcul in nc;la1c] #816/ Wakss: Numdp%6 01/25(85/ / Date: 27/03/2015 v1.0 they Ihey put place

virginex Ic; NHS] We also note the second concern raised by (he Coroner as follows: (2) The Prison Officers attending Mr Wright had not had recent CPR training: It is understood that due to lack of resource, CPR training has to be allocated to certain members of staff only. This result in gaps in CPR-trained Officers available and able to attend emergencies Unfortunately, this is a concern that Virgin Care is unable to respond to as it is not within our remit: In conclusion, Virgin Care has welcomed the constructive comments which have been made by the Coroner in his Rule 28 report: The contents of (he report have been considered carefully, and Virgin Care has instiluted changes to its procedures to ensure robust processes are now in place to address the concerns raised by the Coroner Should the Coroner have any queries once she has had an opportunity to consider this letter and (he attached documentalion, she should not hesitate to contact us. Yours failhfylly Karen Mllen General Counsel and Company Secretary For and on behalf of Virgin Care Services Limited Enc. Vlrgin Care w: wavw.virgyinlcIc}ct}lk Ft ejislc Itzei (4ic:o: Virgjin 3y soolcm) lotee 7.% uvisWn k Squsle:, (u4len) #cii! . 1x-nislo.tc} in Fmab-u:i um;lMonlxr 073*i/8( [ Dale: 27/03/2015v1.0 will (if

Ministry of Justice

Central Government

Letter dated 27 Mar 2015 PDF

AI-classified response stance Noted

AI-generated response summary

• The Ministry of Justice stated that HMP Norwich operates within existing first aid regulations, with a risk assessment in place and appropriate staff trained. • It confirmed that a 24-hour healthcare team with professional nursing staff is available to attend serious incidents quickly. • It stated that there is no requirement to provide defibrillator training, and it is not considered reasonably practicable to train all Prison Service staff.

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Dear Madam, RE Mr Darren Wight Regulation 28 report to prevent future deaths refer to the above regulation 28 report which was sent to me regarding the matter of concern surrounding CPR training: The Health and Safety (First- Aid) Regulations' 1981, require employers to: Ensure there is adequate and appropriate equipment and facilities to provide first-aid to employees who become injured or ill at work; Ensure that there are a sufficient number of "suitable persons able to administer first-aid if employees become injured or ill at work This is the current legislation in which NOMS and the wider Prison Service operate in, and at the time of Mr. Wright's unfortunate death Those in charge of NOMS premises are required to carry out a risk assessment of the first aid needs for their prison HMPNOI Norwich has such an assessment in place which takes into account: The number of staff; The number of prisoners; Workplace hazards and risks; The size and distribution of the workforce; Risks posed by additional activities carried out on site such as workshops etc;

TL Annex 16.5 The shift patterns operating in the establishment including night state and weekends; The risk of suicide or self-harm by prisoners. Such an assessment was in place in 2013. The regulalions give general guidance on the number of first aiders that may be required in workplaces_ HMPIOI Norwich operates within the existing advice which is one first aid at work trained per 50 staff In addition to this, all our permanent night staff are trained to ensure adequate cover on nights and weekends_ At this present time there is no requirement in the First Aid Regulations or Guidance to provide AEDS in the workplace, therefore we do not provide defibrillator training to staff. It simply isn't reasonably practicable to train all of our Prison Service staff and keep them in date_ would also like to point out that Norwich Prison has significant Healthcare team, providing 24 hour healthcare cover within the Prison_ This uS in position that professional nursing staff are able to attend any serious incident very quickly at any time of the day or night: would be grateful if you would consider our current position and advise me further_ fully appreciate how you are and the huge challenges of role and the difficult situations you are asked to make decisions on. am therefore very grateful that you have been able to find the time to visit the prison in the near future_ You will be very welcome guest and we will be very interested to hear your thoughts and observations following a look around; hope that this assures you of HMPIYOl Norwich's commitment to ensure the health, safety and welfare of prisoners in our care and to prevent future deaths_ On this and any other matter please do not hesitate t0 contact me Respectfully Governor very puts very busy your very yours

Report sections

Investigation and inquest

On 11 November 2013 commenced an investigation into the death f DARREN WRIGHT, AGE 35 YEARS_ The investigation concluded at the end of the inquest on 21 January 2015. The conclusion of the inquest was medical cause of death: 1a) Hanging conclusion: Mr Wright hanged himself_ Contributory Factors: Inconsistencies with the sharing of and access to information across different departments within the Prison system. CIRCUMSTANCES OF THE DEATH: Mr Wright was admitted to HMP Norwich on 4 September 2013 following an assault against a family member. It was his first time in prison. He was described by all members of staff and prisoners as "quiet" and "anxious" . During October 2 staff members raised concerns regarding his demeanour and he was assessed by mental health staff: He was not deemed at risk of self harm No ACCT document was opened. He was found dead in his cell on 3 November 2013. Evidence was given Ihat self harm risk assessments tools have been revisedlput in place_ have been in place to ensure communication between different staff is recorded so that other members of staff have access Further training has been instigated regarding when opening an ACCT is appropriate and to ensure all members of staff are aware of procedures Way and Rege and Steps put

Action should be taken

In my opinion action should be taken to prevent future deaths and believe your organisation has (he power to take such action

Similar PFD reports

Shared signals

Report details

Reference: 2015-0035
Date of report: 2 February 2015
Coroner: Jacqueline Lake
Coroner area: Norfolk

Responses identified

Responses identified 3 of 3

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 30 Mar 2015 (estimated from the report date).

Sent to

HMP Norwich

Serco

Virgin Care Limited

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk.

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