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.

Key findings

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

5 extracted
Learning Point 1 PPG healthcare

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 2 HMPPS communication

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 3 PPG policy

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 4 HMPPS communication Accepted

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.

Learning Point 5 HMPPS safety Accepted

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.

Case details

Establishment HMP Stocken
Responsible body HMP Stocken
Incident date29 July 2019
Incident typeLife-Threatening Incident
Investigator Barbara Stow
Learning points5

Documents

Learning point themes

healthcare (1) communication (2) policy (1) safety (1)