Source · Article 2 investigation
PL — HMP Stocken
Life-Threatening Incident
Incident 29 July 2019
5 learning points
Investigator Barbara Stow
The report of the independent investigation conducted by Barbara Stow into the life-threatening incident involving ‘PL’ at HMP Stocken on 29 July 2019 is published here. Also published are the responses to the investigation from those responsible for commissioning and providing custodial and healthcare services at the prison. ‘PL’ was discovered lying unresponsive on the floor of his cell at HMP Stocken on 29 July 2019. Staff administered first aid before paramedics arrived and ‘PL’ was taken to hospital. ‘PL’ sustained long-term injuries that may have affected his ability to live independently.
Original evidence
Key findings
AI-generated summary
The investigation was unable to determine the exact cause of PL's life-threatening brain injury, concluding it was a physical injury but unable to confirm if it was an assault or a fall, and found no link to previous injuries. While no specific shortcomings in PL's direct care were identified, the report highlighted issues such as officers feeling disengaged from the violence reduction process (CSIP) and increased volatility in the prison due to a large influx of new prisoners.
Learning points
Learning point · source text
We recommend that the healthcare provider at HMP Stocken reviews the local practice on risk assessment for medication in possession to ensure that risk assessments are conducted as required.
Learning point · source text
We recommend that the prison takes note of the problems that occurred in this case and ensures that where the police are investigating an incident in the prison, clear arrangements are made for a single point of contact in the prison and for another staff member to deputise if they are absent.
Learning point · source text
We recommend that PPG review their protocols for supplying data for the investigation of a suspected crime where the alleged victim has no capacity to give or withhold consent. Any request to disclose information to the police should be recorded, with a note of the reasons for the decision to disclose or to refuse disclosure.
Learning point · source text
We recommend that the Governor of Stocken (locally) and HMPPS (nationally) review the present arrangements for communications with the ambulance services to examine whether current policy and practice appropriately reflects the ambulance services’ system of allocating priorities.
HMPPS Response
A national review of the process for communication with Operational Security March 2025
Group and Safety
amulance services will be conducted in conjunction with Group, HMPPS
healthcare partners and the Association of Ambulance Chief Executives.
The Head of Operations and Head of Healthcare will Head of Operations, August 2024
discuss this recommendation. The Head of Healthcare HMP Stocken,
will then contact the ambulance service about their HMPPS and Head of
system of allocating priorities and review current Healthcare, PPG
processes and policies to ensure they are up to date and
appropriate.
Group and Safety
amulance services will be conducted in conjunction with Group, HMPPS
healthcare partners and the Association of Ambulance Chief Executives.
The Head of Operations and Head of Healthcare will Head of Operations, August 2024
discuss this recommendation. The Head of Healthcare HMP Stocken,
will then contact the ambulance service about their HMPPS and Head of
system of allocating priorities and review current Healthcare, PPG
processes and policies to ensure they are up to date and
appropriate.
Learning point · source text
We invite the Governor to examine whether the 12 minutes from arrival at the prison to attending a patient on K wing is unavoidable or whether the process of accessing the wings in emergencies can be made more efficient.
HMPPS Response
HMP Stocken is aware that it can take a significant Head of Operations, August 2024
amount of time to get to certain wings of the prison. The HMP Stocken,
prison has previously completed a number of walk HMPPS
throughs in order to identify ways in which access to the
wings can be made more efficient in an emergency, but
there are limitations as to what can be done due to the
layout of the prison.
HMP Stocken will issue a reminder to all staff that on any
occasion where the emergency services are called, the
Orderly Officer will ask all available staff to support the
unlocking of vehicle gates en route to the wings to
ensure emergency vehicles arrive in a timely manner.
amount of time to get to certain wings of the prison. The HMP Stocken,
prison has previously completed a number of walk HMPPS
throughs in order to identify ways in which access to the
wings can be made more efficient in an emergency, but
there are limitations as to what can be done due to the
layout of the prison.
HMP Stocken will issue a reminder to all staff that on any
occasion where the emergency services are called, the
Orderly Officer will ask all available staff to support the
unlocking of vehicle gates en route to the wings to
ensure emergency vehicles arrive in a timely manner.
Case details
| Establishment | HMP Stocken |
| Responsible body | HMP Stocken |
| Incident date | 29 July 2019 |
| Incident type | Life-Threatening Incident |
| Investigator | Barbara Stow |
| Learning points | 5 |
Documents
Learning point themes
healthcare (1)
communication (2)
policy (1)
safety (1)