Kirk Duboise
PFD Report
All Responded
Ref: 2013-0329
No published response · Over 2 years old
Response Status
Responses
1
56-Day Deadline
31 Jan 2014
1 response received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroner’s Concerns
(1) The delay in summonsing an ambulance.
(2) That not all relevant forms were seen by those involved in the reception process one of whose duties at such time was to properly assess the risk of self harm of the new prisoner, particularly a prisoner who had not been in custody before.
(2) That not all relevant forms were seen by those involved in the reception process one of whose duties at such time was to properly assess the risk of self harm of the new prisoner, particularly a prisoner who had not been in custody before.
Responses
Response received
View full response
Dear Sir RE: The Inquest touchlng the death of Klrk Floyd Dubolse Deceased Response to Regulation 28 Prevent Future Death (PFD") Report Thank YoU for your Regulation 28 Prevent Future Death (PFD") Report dated 6lh December 2013 As you are aware Care UK has entered into an overarching contract with the County Durham Primary Care Trust ("the PCT") associate commissioners to provlde fuli range ol primary health and mental health services to the North East cluster of prisons which Includes HMP Durham: As YOU are aware mental health services are provided by Tees Esk and Wear Valleys NHS Foundatlon Trust ("TEW")- Thls response is on behalf of Care UK Clinical Services Limlted ("Care UK" ) who are the contracting party provldlng healthcare services within HMP Durham and the North East cluster of prisons Box 5 lists the Coroner s concems: Cere UK Clnkat Scmices Limiled Prnary Care Division Reglstered In England No 3482881 Registered Otlce. Haxker House. 5-8 Napier Court, Napier Road, Reading, Berkshire RGT BBW Dete the and
Matters of concern The delay in summoning an ambulance_ That not all relevant forms were seen by those involved in the reception process one of those duties at such time was to properly assess the risk of self hamm of the new prisoner; particularly a prisoner who had not been in custody before. At box 6 the report states that 'In the coroners opinion action shoul be taken' and that the coroner believes the personlorganisation has 'power t0 take such action' as follows: To ensure that all staff who may become Involved In an emergency situatlon know the appropriate prolocois to be follwed (both disciplina and healthcare staf) t0 ensure there Is no delay In an ambulance being summoned in an emergency situation. That training be given and where necessary repeated t0 ensure that all staff know that an ACCT can be opened at any time by any member ol staff wherever the circumstances S0 demand That those involved in the reception process and further in induction, have access t0 ail relevant documents s0 that they are best equipped to make &n Informed decision on the risks of the prisoner before then committing an act of self hamm or suicide. Response to the PFD Roport The delay In summoning an ambulance Prison Service Instruction (PSI 03/2013/Medical Emergency Response Codes) came Into effect after Mr Duboise's dealh: As a result & colour code system for the summoning of an ambulance has been Introduced. Thls has been disseminated t0 all staff: A Govemors notice to staff entitled 'Summoning medical assistance Hotel IAmbulance' was Issued and is dated 22m April 2013. Thls was also brought t0 the attention of staff by the head of heallhcare at a full staff brieling; the minutes of whlch are sent to all staff. 2, That training be glven and where neceesary repeated to ensure that all staff know that an ACCT can be opened at any time by any member of staft wherever the clrcumstances $0 demand Training bas been Implanted by NOMS On the 7th January 2014 healthcare were contacted in relation t0 further ACCT trainlng for nurses and the General Practitioners. Car UK Clinkol Sankys LIked - Prinary Care Dlvision. Repistered I Enaland No 348288 Rcobleied Ollikce: Hanicr Houso, 5-8 Napier Cour Napler Road, Roading Berkthlm RGt 8BW
Training sessions will commence on 24lh January 2014. Training will be mandatory for all healthcare staff That not all relevant forms were seen by those involved in the reception process one of those duties at such time was to properly a8se88 the rlek ot self harm of the new prlsoner, partlcularly a prisoner who had not been in custody before In addition to the steps taken by the prison service and following the re-location of the First Night Centre, a trolley which has also been located In reception t0 ensure that all of the relevant documentation is passed onto heallhcare In addition further refresher training Is regularly undertaken and particular focus is given regarding the Self Harm Warning Forms whlch Is considered as part of the Induction trainlng (or all new stalif . trust that you are reassured by the response and should you requlre any further clarification on these points, please do not hesitate t0 contact me
Matters of concern The delay in summoning an ambulance_ That not all relevant forms were seen by those involved in the reception process one of those duties at such time was to properly assess the risk of self hamm of the new prisoner; particularly a prisoner who had not been in custody before. At box 6 the report states that 'In the coroners opinion action shoul be taken' and that the coroner believes the personlorganisation has 'power t0 take such action' as follows: To ensure that all staff who may become Involved In an emergency situatlon know the appropriate prolocois to be follwed (both disciplina and healthcare staf) t0 ensure there Is no delay In an ambulance being summoned in an emergency situation. That training be given and where necessary repeated t0 ensure that all staff know that an ACCT can be opened at any time by any member ol staff wherever the circumstances S0 demand That those involved in the reception process and further in induction, have access t0 ail relevant documents s0 that they are best equipped to make &n Informed decision on the risks of the prisoner before then committing an act of self hamm or suicide. Response to the PFD Roport The delay In summoning an ambulance Prison Service Instruction (PSI 03/2013/Medical Emergency Response Codes) came Into effect after Mr Duboise's dealh: As a result & colour code system for the summoning of an ambulance has been Introduced. Thls has been disseminated t0 all staff: A Govemors notice to staff entitled 'Summoning medical assistance Hotel IAmbulance' was Issued and is dated 22m April 2013. Thls was also brought t0 the attention of staff by the head of heallhcare at a full staff brieling; the minutes of whlch are sent to all staff. 2, That training be glven and where neceesary repeated to ensure that all staff know that an ACCT can be opened at any time by any member of staft wherever the clrcumstances $0 demand Training bas been Implanted by NOMS On the 7th January 2014 healthcare were contacted in relation t0 further ACCT trainlng for nurses and the General Practitioners. Car UK Clinkol Sankys LIked - Prinary Care Dlvision. Repistered I Enaland No 348288 Rcobleied Ollikce: Hanicr Houso, 5-8 Napier Cour Napler Road, Roading Berkthlm RGt 8BW
Training sessions will commence on 24lh January 2014. Training will be mandatory for all healthcare staff That not all relevant forms were seen by those involved in the reception process one of those duties at such time was to properly a8se88 the rlek ot self harm of the new prlsoner, partlcularly a prisoner who had not been in custody before In addition to the steps taken by the prison service and following the re-location of the First Night Centre, a trolley which has also been located In reception t0 ensure that all of the relevant documentation is passed onto heallhcare In addition further refresher training Is regularly undertaken and particular focus is given regarding the Self Harm Warning Forms whlch Is considered as part of the Induction trainlng (or all new stalif . trust that you are reassured by the response and should you requlre any further clarification on these points, please do not hesitate t0 contact me
Action Should Be Taken
1. To ensure that all staff who may become involved in an emergency situation know the appropriate protocols to be followed (both discipline and health care staff) to ensure that there is no delay in an ambulance being summonsed in an emergency situation.
2. That training be given and where necessary repeated to ensure that all staff know that an ACCT can be opened at any time by any member of staff wherever they believe the circumstances so demand.
3.That those involved in the reception process and further in induction, have access to all relevant documents so that they are best equipped to make an informed decision on the risks of the prisoner before them committing an act of self harm and/or suicide.
2. That training be given and where necessary repeated to ensure that all staff know that an ACCT can be opened at any time by any member of staff wherever they believe the circumstances so demand.
3.That those involved in the reception process and further in induction, have access to all relevant documents so that they are best equipped to make an informed decision on the risks of the prisoner before them committing an act of self harm and/or suicide.
Report Sections
Investigation and Inquest
On 3rd December 2013 I commenced an investigation into the death of Kirk Duboise. The investigation concluded at the end of the inquest on 5th December 2013. The conclusion of the inquest was Mr Duboise was found dead in his cell at HMP Durham on 13/2/13 and a narrative conclusion was returned “The deceased intentionally took his own life. The deceased was not correctly assessed at HMP Durham. An ACCT should have been opened at reception by prison staff.”
Circumstances of the Death
The deceased arrived at HMP Durham when there was with him a prisoner escort report form highlighting self harm issues and also a suicide/self harm warning form again highlighting self harm issues. The deceased had clear self harm marks on his arms. Prison and health care staff at reception did not see both of these documents and did not open an ACCT. Mr Duboise committed suicide in his cell approximately 8 hours after arriving at HMP Durham. No other member of staff opened at ACCT in the intervening period. The Jury concluded that an ACCT ought to have been opened at reception by prison staff. Notwithstanding training which states that an ACCT can be opened by any member of staff at any time the practice of at least one senior officer at reception was that he would not open an ACCT unless at reception the incoming prisoner was subject to constant watch observations. This practice was confirmed by an experienced mental health nurse who saw the deceased as part of the reception process. Evidence was given that the reception process has, since the deceased’s death in February 2013, been changed.
A prison governor confirmed that the correct code words had not been used when the deceased was found hanging in his cell which resulted in in their being a delay before an ambulance was summonsed.
A prison governor confirmed that the correct code words had not been used when the deceased was found hanging in his cell which resulted in in their being a delay before an ambulance was summonsed.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.