Prison CPR guidance

The coroner noted concerns that prison officers in facilities without 24-hour healthcare are not trained to assess rigor mortis, a condition included in CPR guidance, which risks missed opportunities for resuscitation.

Nursing staff exhibited insufficient understanding to accurately diagnose hypostasis and rigor mortis, which management agreed needed better coverage in life support training. Additionally, definitions within the CPR guidance document for prisons were found to be confusing.

Concerns were raised regarding the insufficient number of first aiders available at Springhill site, particularly at night, and potential delays in healthcare staff moving between prison sites. There is also a lack of clear guidance for staff on when to commence CPR.

Establish a basic life support (BLS) training programme for prison operational staff with the aim of training all prison staff in cardiopulmonary resuscitation (CPR) and the use of automated external defibrillator (AED) devices. Provision of compression-only CPR could be a first step towards this goal. The location of AEDs should also be easily identifiable and accessible to staff...

The Governor will wish to consider Highpoint’s local safer custody policy to ensure it reflects Resuscitation Council (UK) guidelines regarding the futility of CPR when there is clear evidence of rigor mortis.

Care home staff did not perform CPR when the deceased collapsed, and there was no process or procedure in place to ensure resuscitation during an emergency.

The coroner identified concerns regarding the improper preparation of food, inadequate feeding practices by carers, and staff's failure to provide appropriate choking first aid. There were also significant issues with nursing staff not recognising cardiac arrest or performing effective CPR, indicating a need for frequent training.

The Governor and the Head of Healthcare should ensure that staff are given clear guidance about the circumstances in which resuscitation is inappropriate in line with European Resuscitation Council Guidelines.

Staff should be given clear guidance about the circumstances in which resuscitation is inappropriate in line with the Resuscitation Council Guidelines.

The Director and Head of Healthcare should ensure that all staff are given clear guidance about and understand the circumstances in which resuscitation is inappropriate in line with European Resuscitation Council guidelines.

The Governor and Head of Healthcare should ensure that staff are given clear guidance about the circumstances in which resuscitation is inappropriate in accordance with European Resuscitation Council Guidelines.

Concerns were raised about the quality and documentation of care at Westmorland Court, including unreliable resident notes, a nurse's actions during resuscitation, and the absence of a defibrillator.

The Governor should ensure that all staff are given clear guidance about and understand the circumstances in which resuscitation is inappropriate in line with European Resuscitation Council guidelines.

We recommend that HMPPS and NHSE/I consider specific guidance for the process of ligature cut down to ensure optimum management of the unconscious patient. This will include clarification of whether emergency bags should contain a soft cervical collar as a standard item.

The Head of Healthcare should ensure that staff, including agency staff, understand when not to perform cardiopulmonary resuscitation in accordance with European Resuscitation Council Guidelines.

The Governor should ensure that all staff are aware of the location of defibrillators and that they understand how to access and use them during a medical emergency.