Source · Prevention of Future Deaths

Anthony Brian Flynn

Ref: 2013-0297 Date: 14 Nov 2013 Coroner: Jennifer Leeming Area: Manchester West Responses identified: 1 / 2 View PDF

Seriously ill prisoners were inhumanely shackled during medical examinations, clinician concerns were ignored, and there was inadequate training for prison officers regarding hospital escorts and clinicians' powers over restraints.

Date 14 Nov 2013
56-day deadline 14 Feb 2014 est.
Responses identified 1 of 2
State Custody related deaths

Coroner's concerns

AI summary
Seriously ill prisoners were inhumanely shackled during medical examinations, clinician concerns were ignored, and there was inadequate training for prison officers regarding hospital escorts and clinicians' powers over restraints.
View full coroner's concerns
(1) Anthony Brian Flynn was admitted to HMP Forest Bank on 24th July 2012. He was at the time of that admission suffering from diagnosed testicular cancer.

(2) From time to time during Mr Flynn’s imprisonment he was escorted to clinical appointments at various hospitals. He also spent time as an in-patient. On these occasions he was accompanied by prison officers and was handcuffed and chained.

(3) On the 10th September 2012, a Consultant Clinical Oncologist at the Royal Preston Hospital who was treating Mr Flynn, wrote to HMP Forest Bank expressing concerns. She said “I was extremely concerned that there was an absolute lack of compassion demonstrated to what was a very sick man who was extremely distressed in the clinic. Unfortunately I felt that there was no really empathy in terms of the huge amount he had already received treatment for the significant side effects he has had and certainly conducting my examination of the abdomen and pelvis including the genitalia in a sensitive manner was extremely difficult.” Evidence given at the Inquest confirmed that Mr Flynn had been chained and handcuffed during the examination to which the Doctor refers. (4) letter was received at HMP Forest Bank, but it was never acknowledged. No reply was sent, nor were the matters of concern described in the letter, especially that the Doctor had found it ‘extremely difficult’ to conduct the examination of Mr Flynn, ever investigated.

(5) Further evidence given at the Inquest revealed that: a) When a prisoner is being escorted to hospital or other appointments escorting officers can, if they consider it appropriate, telephone the prison and seek permission to remove or lengthen the prisoner’s restraints. b) Clinicians have the power to request that the action described in a) be taken, but most clinicians are unaware that they can do this.

(6) The evidence concluded that there was a need to consider the following: a) The training of prison officers in relation to escorting prisoners, particularly during hospital visits. b) Procedures for making clinicians, particularly hospital clinicians, aware of their powers in relation to prisoners attending for treatment.

Responses

1 respondent
Sodexo Private Sector
2 Jan 2014 PDF
Action Planned

Sodexo is planning Safer Custody, Cell Sharing Risk Assessment (CSRA) and Escort & Bedwatch awareness days and a training programme for prison officers who conduct escorts, particularly during hospital visits. They have also re-issued an Operational Instruction regarding prisoner correspondence. (AI summary)

View full response
Dear Ms J Leeming Re: Regulation 28 correspondence Mr Anthony Flynn In response to your report dated 14 November 2013 sent under paragraph 7, Schedule 5, of Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 and as a result of the inquest into the death by natural causes of Mr Anthony Flynn at HMP Forest Bank; have reviewed the training of prison officers in relation to escorting prisoners_ particularly hospital visits and the procedures for making clinicians, particularly hospital clinicians , aware of their powers in relation to prisoners attending for treatment within HMP Forest Bank set out below the action which has been taken by the prison and future plans which we are endeavouring to implement in the Year. A Safer Custody, Cell Sharing Risk Assessment (CSRA) and Escort & Bedwatch awareness days have been planned to take place on 23rd and January
2014. Our aim is to speak to all staff (including non operational staff). Part of the sessions will include an examination of the Escort & Bedwatch paperwork and the conduct expected of staff. Speakers will include;_ Safer Custody Manager; Safer Custody Senior Officer _ Operations Manager and Quality Assurance and Risk Co-ordinator: Following the event; a small questionnaire will be completed by each member of staff to ensure gained sufficient knowledge in each area. In addition, a programme of- training for prison officers who conduct escorts (particularly during hospital visits) is implemented: This will include a guide to good practice and will reinforce behaviour we expect of officers whilst performing bedwatch duties The officers will be made aware that failure to adhere to such standards may result in disciplinary action_ STOP HIUNGER INVESTORS IN PEOPLE Asdoo nlalt SCCETVED : ; the during New 22na . 24th they have being the

Sodexo Justice services enclose a copy of the escortlbedwatch booklet which has been prepared to give to staff to remind them of their duties whilst out on escort and to ensure staff are conversant within the arrangements for the removal of restraints where there is an immediate risk to the health of the prisoner or to facilitate essential treatment. The booklet is also going to be used for training purposes and staff will be asked to sign to say that have received the training and understand what is expected of them A Prison Manager will visit the hospital at least once in each 24 hours. During the visit; there will be an assessment of the current security arrangements to ensure that remain as previously assessed and where possible take into account the views of medical staff, subject to their availability. Finally, was concemed to learn thatl letter did not receive the attention that it should have: Accepting entirely that the letter should have been acknowledged and dealt with, an Operational Instruction has been re-issued to remind and reinforce to staff that all correspondence received regarding prisoner should be sent to the Performance Delivery Unit which will examine record and liaise with the relevant department to ensure that a coordinated response is provided within a maximum of 20 working days. enclose copy of the Operational Instruction which was recently re issued am grateful to you for the matters you have raised and trust you find my response tolbe appropriate and helpful. Yours sincere Director STOP HUNGER Agecroft Road Pendlebury Salford M27 8FB INVESTORS Tel: +01619257000 Ext 2303 IN PEOPLE Sodexo Limited No 842846 England Registered Ofnce One Southampton Row London WCIB SHA

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Report sections

Investigation and inquest
On 1st October 2012 I commenced an investigation into the death of Anthony Brian Flynn, aged 41 years. The investigation concluded at the end of the inquest on 31st October 2013. The conclusion of the inquest was that Anthony Brian Flynn had died of metastatic testicular carcinoma, and that this was a natural cause of death.
Circumstances of the death
In or about 2010 at the Royal Preston Hospital Anthony Brian Flynn was diagnosed to be suffering from testicular cancer. On the 24th July 2012 he was remanded into custody and taken to Forest Bank Prison, Salford, where he remained until his death on the 28th September 2012.
Copies sent to
Director of HMP Forest Bank Mr Jeremy Hunt MP, Secretary of State for Health

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Report details

Reference
2013-0297
Date of report
14 November 2013
Coroner
Jennifer Leeming
Coroner area
Manchester West

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: 14 Feb 2014 (estimated).

Sent to

Department of Health and Social Care
HMP Forest Bank

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