Nicola Lawrence
PFD Report
All Responded
Ref: 2018-0318
All 1 response received
· Deadline: 20 Apr 2019
Response Status
Responses
1 of 1
56-Day Deadline
20 Apr 2019
All responses received
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Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroner's Concerns
In the circumstances it is my statutory duty to report t0 you: (1) Some Prison staff had not received any cardiopulmonary resuscitation training_ Either as part of initial training or any refresher training: Evidence was received that good quality CPR within the first few minutes of those who stopped breathing or heart stopped was critical.
Responses
Response received
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Dear Mr Leach, Inquest into the death of Nicola Lawrence Thank You for your Regulation 28 Report of 23 October addressed to the Governor of HMP New Hall; following the conclusion of the inquest into the death of Nicola Lawrence. As Chief Executive Officer am responding on behalf of Her Majesty's Prison and Probation Service (HMPPS): know that you will share a copy of this response with Nicola's mother and would first like to express my sincere condolences for her loss. Every death in custody is a tragedy and the safety of those in our care is my absolute priority. am grateful t0 you for bringing to my attention your concem that some prison staff at HMP New Hall have not received cardiopulmonary resuscitation (CPR) training, either as part of initial training or as refresher training:
You may be aware that our approach is set out in PSI 29/2015 First Aid, which does not mandate first aid training for all staff, but requires Governors of public sector prisons to ensure that there are at all times sufficient suitably trained first aiders available. The appropriate number must be determined by conducting a first aid risk assessment, and first aiders must be trained to levels which are appropriate to the circumstances to either First Aid at Work (FAW) level or Emergency First Aid at Work (EFAW) level: The Governor at HMP New Hall has reviewed the bandlgrade and number of staff who need to be trained in first aid, and the number of such staff required on duty at times throughout the day: The prison currently has 40 staff trained in FAW and 48 in EFAW, and these numbers are considered to be sufficient to ensure that an appropriate response can be provided in any emergency situation that may arise at any time_ In April 2018. a notice was issued by the Govemor to all staff trained in first aid reminding them of the importance of responding promptly to an emergency Thank you again for bringing these matters of concem to my attention: hope that this response provides assurance that lessons have been leared from the circumstances of Nicola Lawrence's tragic death.
You may be aware that our approach is set out in PSI 29/2015 First Aid, which does not mandate first aid training for all staff, but requires Governors of public sector prisons to ensure that there are at all times sufficient suitably trained first aiders available. The appropriate number must be determined by conducting a first aid risk assessment, and first aiders must be trained to levels which are appropriate to the circumstances to either First Aid at Work (FAW) level or Emergency First Aid at Work (EFAW) level: The Governor at HMP New Hall has reviewed the bandlgrade and number of staff who need to be trained in first aid, and the number of such staff required on duty at times throughout the day: The prison currently has 40 staff trained in FAW and 48 in EFAW, and these numbers are considered to be sufficient to ensure that an appropriate response can be provided in any emergency situation that may arise at any time_ In April 2018. a notice was issued by the Govemor to all staff trained in first aid reminding them of the importance of responding promptly to an emergency Thank you again for bringing these matters of concem to my attention: hope that this response provides assurance that lessons have been leared from the circumstances of Nicola Lawrence's tragic death.
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you JANDIOR your organisation] have the power to take such action
Report Sections
Investigation and Inquest
On 28"h September 2016 commenced an Investigation into the death of Nicola Jayne Lawrence, aged 38 years. The Investigation concluded at the end of the Inquest on 17th May 2018. The conclusion of the Inquest was a Narrative. She died from 1(a) Methadone Toxicity 2 Multi Drug Administration.
Circumstances of the Death
At the time of her death the deceased was an Inmate at HMP New Hall. She arrived on the 9t September 2016. She was taking a considerable amount of medication including methadone_ She was seen by a number of Health Care staff: No consideration was given by them to the anti-respiratoryldepressant effects of the medication on her On the 246 September 2016 she was found unresponsive. Notwithstanding the efforts of Prison staff, Health Care staff and ambulance staff she died_
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.