Care UK
Private Sector
Action Taken
Care UK has re-briefed control room staff, created a crib sheet for ambulance calls, launched a publicity campaign on emergency response codes, and improved intranet information and signage. The National Medical Director clarified GPs' responsibilities regarding verifying death, and guidance/training is being developed to support decision-making in unexpected collapse or death cases. (AI summary)
View full response
Dear Mr Hassell, RE: Prevention of Future Deaths - Mr William Davies (died 16.06.14) On 5 November 2014 Coroner ME Hassell issued a Regulation 28 :Prevention of Future Deaths Report to Care UK. This letter is in response to the aforementioned PFD report (a copy of which we have enclosed for your reference) and we will deal with each point highlighted in turn:
1. Requesting an ambulance after a level one emergency has been declared We understand from our prison colleagues that on 3rd December 2014, the Head of Safer Prisons, Head of Operations 2 (gates and the control room) and the Deputy Governor met with the local London Ambulance Service (LAS), Emergency Planning & Resilience Officer and Station Officer to discuss how make the process clearer regarding the calling of an ambulance. We are told that the following actions are being taken forward:
• Control Room staff have been re-briefed about their requirement to call an ambulance when a level 1 emergency is called (See Appendix 1 - Calling of an Ambulance).
• Information specifically required by the LAS has been made into a crib sheet so control room staff are aware of what questions the LAS could ask before attending to the emergency. It is anticipated that this will speed up the phone call process. The details of this can be found at Appendix 1, page 2.
• A publicity campaign (based on PSI 2013/03 Emergency Response Codes) has taken place reminding staff of who can call a medical emergency, who calls the ambulance, the use of the correct medical emergency codes, and what information they should be communicating with the control room (See Appendix 3 - Emergency Healthcare Response). This document was jointly developed with prison service colleagues prior to us taking over healthcare services in HMP Pentonville and our Health in Justice team are reviewing this as part of a wider piece of work around emergency care, including training of staff and standardisation of the emergency bags. The publicity campaign has reached out to all staff working within Pentonville; operational, non-operational and healthcare. The leaflet has been published to staff via
the intranet, publicised at the main gate entrance and a small copy will be attached to all operational staffs' payslips for December 2014. The leaflet and information has been added in induction for new non-operational and healthcare staff.
• Better signage has been ordered to help emergency services identify Roman Way Gate (January 2015).
2. GPs understanding of their responsibilities and permission to verify the fact of death The Care UK National Medical Director for Health in Justice has spoken with the lead GP to clarify her role regarding decision to cease CPR and declare life extinct. The Head of Healthcare has additionally briefed all General Practitioners working at HMP Pentonville about their responsibility and legal right to declare life extinct following their examination in an emergency situation. All doctors are given orientation and induction prior to working at HMP Pentonville; this has been reinforced with the existing team and any locum providers. This is also included in all GP inductions. Decisions to cease CPR or to not commence CPR can be difficult in emergency situations so in addition to the above actions, our National Medical Director and National Lead Nurse a·re currently working with our networks of lead GPs and lead nurses to develop guidance and additional training to help support good decision making in cases of unexpected collapse or death. In the case of expected deaths and palliative care situations we have well established protocols for DNAR (do not actively resuscitate) forms to be used in our prisons elsewhere and are in the process of sharing this practice as part of a wider project on improving end of life care across our prisons. We trust this answers all of your concerns raised in the Prevention of Future Deaths Regulation 28 Report. Should you require any further clarification please do not hesitate to get in touch with us.
1. Requesting an ambulance after a level one emergency has been declared We understand from our prison colleagues that on 3rd December 2014, the Head of Safer Prisons, Head of Operations 2 (gates and the control room) and the Deputy Governor met with the local London Ambulance Service (LAS), Emergency Planning & Resilience Officer and Station Officer to discuss how make the process clearer regarding the calling of an ambulance. We are told that the following actions are being taken forward:
• Control Room staff have been re-briefed about their requirement to call an ambulance when a level 1 emergency is called (See Appendix 1 - Calling of an Ambulance).
• Information specifically required by the LAS has been made into a crib sheet so control room staff are aware of what questions the LAS could ask before attending to the emergency. It is anticipated that this will speed up the phone call process. The details of this can be found at Appendix 1, page 2.
• A publicity campaign (based on PSI 2013/03 Emergency Response Codes) has taken place reminding staff of who can call a medical emergency, who calls the ambulance, the use of the correct medical emergency codes, and what information they should be communicating with the control room (See Appendix 3 - Emergency Healthcare Response). This document was jointly developed with prison service colleagues prior to us taking over healthcare services in HMP Pentonville and our Health in Justice team are reviewing this as part of a wider piece of work around emergency care, including training of staff and standardisation of the emergency bags. The publicity campaign has reached out to all staff working within Pentonville; operational, non-operational and healthcare. The leaflet has been published to staff via
the intranet, publicised at the main gate entrance and a small copy will be attached to all operational staffs' payslips for December 2014. The leaflet and information has been added in induction for new non-operational and healthcare staff.
• Better signage has been ordered to help emergency services identify Roman Way Gate (January 2015).
2. GPs understanding of their responsibilities and permission to verify the fact of death The Care UK National Medical Director for Health in Justice has spoken with the lead GP to clarify her role regarding decision to cease CPR and declare life extinct. The Head of Healthcare has additionally briefed all General Practitioners working at HMP Pentonville about their responsibility and legal right to declare life extinct following their examination in an emergency situation. All doctors are given orientation and induction prior to working at HMP Pentonville; this has been reinforced with the existing team and any locum providers. This is also included in all GP inductions. Decisions to cease CPR or to not commence CPR can be difficult in emergency situations so in addition to the above actions, our National Medical Director and National Lead Nurse a·re currently working with our networks of lead GPs and lead nurses to develop guidance and additional training to help support good decision making in cases of unexpected collapse or death. In the case of expected deaths and palliative care situations we have well established protocols for DNAR (do not actively resuscitate) forms to be used in our prisons elsewhere and are in the process of sharing this practice as part of a wider project on improving end of life care across our prisons. We trust this answers all of your concerns raised in the Prevention of Future Deaths Regulation 28 Report. Should you require any further clarification please do not hesitate to get in touch with us.