Stephen Coster
PFD Report
All Responded
Ref: 2024-0146
All 1 response received
· Deadline: 15 May 2024
Sent To
Response Status
Responses
1 of 1
56-Day Deadline
15 May 2024
All responses 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
a. Evidence was heard relating to poor and inadequate record keeping by prison staff.
b. A failure by healthcare staff to carry out adequate observations and to properly assess Stephen Coster's condition as well as a failure to escalate his case.
c. Healthcare staff failed to provide the prison staff with an adequate care plan so that Stephen Coster could be monitored effectively. Evidence was heard that there was no protocol or policy in place regarding communication between Healthcare staff and Prison staff for the monitoring of sick prisoners on the wing at night.
d. There was inadequate understanding amongst prison staff about when to call Code Blue.
e. There was a breakdown in communication between healthcare staff and prison staff regarding transferring a sick prisoner to hospital as an emergency. Further, there was inadequate information included on the paperwork prepared by healthcare staff about Stephen Coster's condition resulting in delay in arranging for his urgent escort and transfer to hospital.
f. An inadequate understanding amongst prison staff about the local policy to transfer emergency cases to hospital with a retrospective risk assessment.
g. Inadequate leadership by prison staff leading to a breakdown in communication amongst junior prison staff which caused the delay in transferring Stephen from the prison to hospital. Having heard evidence from Practice Plus Group about the improvements in its service delivery which have been implemented and which are being monitored, I have decided not to send a copy of this PFD report to PPG on the understanding that action is being taken to prevent future deaths such as Stephen Coster's.
b. A failure by healthcare staff to carry out adequate observations and to properly assess Stephen Coster's condition as well as a failure to escalate his case.
c. Healthcare staff failed to provide the prison staff with an adequate care plan so that Stephen Coster could be monitored effectively. Evidence was heard that there was no protocol or policy in place regarding communication between Healthcare staff and Prison staff for the monitoring of sick prisoners on the wing at night.
d. There was inadequate understanding amongst prison staff about when to call Code Blue.
e. There was a breakdown in communication between healthcare staff and prison staff regarding transferring a sick prisoner to hospital as an emergency. Further, there was inadequate information included on the paperwork prepared by healthcare staff about Stephen Coster's condition resulting in delay in arranging for his urgent escort and transfer to hospital.
f. An inadequate understanding amongst prison staff about the local policy to transfer emergency cases to hospital with a retrospective risk assessment.
g. Inadequate leadership by prison staff leading to a breakdown in communication amongst junior prison staff which caused the delay in transferring Stephen from the prison to hospital. Having heard evidence from Practice Plus Group about the improvements in its service delivery which have been implemented and which are being monitored, I have decided not to send a copy of this PFD report to PPG on the understanding that action is being taken to prevent future deaths such as Stephen Coster's.
Responses
Response received
View full response
Dear Ms Redman
Thank you for your Regulation 28 report of 4 January 2024 addressed to the Minister of State for Prisons, Parole and Probation following the inquest into the death of Stephen Coster at HMP Lewes on 5 May 2022. I am responding on behalf of HMPPS as Director General of Operations.
I know that you will share a copy of this response with the family of Mr Coster, and I would like to express my condolences for their loss. Every death in custody is a tragedy and the safety of those in our care is my absolute priority.
Following evidence heard at the inquest you raised concerns directed to both HMPPS and Practice Plus Group (PPG). I am responding to those relating to HMPPS.
Following the Fact-Finding report on 16 May 2022 HMP Lewes undertook a review of record-keeping practices which identified a generally very good approach by staff. Issues identified, such as the need for staff to record smaller interactions, have been addressed, with staff being reminded of the need to record all relevant information.
The prison has also conducted a further review, together with healthcare, to consider how best to manage the care and monitoring of unwell prisoners. An agreed system is now in place which clarifies that prison staff are responsible for welfare checks and medical staff are responsible for clinical observations. Healthcare staff inform prison staff of the need for checks on a particular prisoner and what level of check is required. Where healthcare feel it is clinically appropriate, a move to the inpatient unit at the prison will be facilitated so that healthcare staff are present to undertake all observations.
The prison continues to brief staff regularly regarding the appropriate use of Code Red and Code Blue, and the importance of using them to ensure the emergency services are called immediately. Shortly after Mr Costers death, a Notice to Staff was sent out to raise awareness and remind staff of their responsibilities. This was followed up by reminders in the Safety Newsletter later in the year and the Safety Nudge the following year. A number of training events have also taken place, delivered by the Safety Team, on the emergency
codes. Every person was also issued with a business card-sized pocket guide as a handy reminder, which all new staff now receive as part of their training.
Following the death of Mr Coster and the PPO’s recommendations, the Deputy Governor and Head of Safety conducted a review into the circumstances of the prison escort to hospital. Their findings identified a need for improved communication with and greater clarity from healthcare staff to ensure that urgency of the matter is made clear to prison staff. This has been shared with healthcare.
Custodial Managers have the authority to dispatch an emergency escort without the relevant risk assessment where the life of a prisoner is in danger. The Local Operating Procedure for Hospital Escorts and Bedwatches refers to escorts being dispatched without the relevant risk assessment where there is an ‘emergency.’ The policy on emergency escorts as a whole is being actively reviewed.
Following a review into incident management the Assistant Orderly Officer now attends each Code Blue/Red to personally oversee, provide direction, and ensure standards are kept, ensuring effective leadership during the management of the incident.
Thank you again for bringing your concerns to my attention. I trust that this response provides assurance that action is being taken to address the matters that you have raised.
Thank you for your Regulation 28 report of 4 January 2024 addressed to the Minister of State for Prisons, Parole and Probation following the inquest into the death of Stephen Coster at HMP Lewes on 5 May 2022. I am responding on behalf of HMPPS as Director General of Operations.
I know that you will share a copy of this response with the family of Mr Coster, and I would like to express my condolences for their loss. Every death in custody is a tragedy and the safety of those in our care is my absolute priority.
Following evidence heard at the inquest you raised concerns directed to both HMPPS and Practice Plus Group (PPG). I am responding to those relating to HMPPS.
Following the Fact-Finding report on 16 May 2022 HMP Lewes undertook a review of record-keeping practices which identified a generally very good approach by staff. Issues identified, such as the need for staff to record smaller interactions, have been addressed, with staff being reminded of the need to record all relevant information.
The prison has also conducted a further review, together with healthcare, to consider how best to manage the care and monitoring of unwell prisoners. An agreed system is now in place which clarifies that prison staff are responsible for welfare checks and medical staff are responsible for clinical observations. Healthcare staff inform prison staff of the need for checks on a particular prisoner and what level of check is required. Where healthcare feel it is clinically appropriate, a move to the inpatient unit at the prison will be facilitated so that healthcare staff are present to undertake all observations.
The prison continues to brief staff regularly regarding the appropriate use of Code Red and Code Blue, and the importance of using them to ensure the emergency services are called immediately. Shortly after Mr Costers death, a Notice to Staff was sent out to raise awareness and remind staff of their responsibilities. This was followed up by reminders in the Safety Newsletter later in the year and the Safety Nudge the following year. A number of training events have also taken place, delivered by the Safety Team, on the emergency
codes. Every person was also issued with a business card-sized pocket guide as a handy reminder, which all new staff now receive as part of their training.
Following the death of Mr Coster and the PPO’s recommendations, the Deputy Governor and Head of Safety conducted a review into the circumstances of the prison escort to hospital. Their findings identified a need for improved communication with and greater clarity from healthcare staff to ensure that urgency of the matter is made clear to prison staff. This has been shared with healthcare.
Custodial Managers have the authority to dispatch an emergency escort without the relevant risk assessment where the life of a prisoner is in danger. The Local Operating Procedure for Hospital Escorts and Bedwatches refers to escorts being dispatched without the relevant risk assessment where there is an ‘emergency.’ The policy on emergency escorts as a whole is being actively reviewed.
Following a review into incident management the Assistant Orderly Officer now attends each Code Blue/Red to personally oversee, provide direction, and ensure standards are kept, ensuring effective leadership during the management of the incident.
Thank you again for bringing your concerns to my attention. I trust that this response provides assurance that action is being taken to address the matters that you have raised.
Report Sections
Investigation and Inquest
On 13 May 2022 I commenced an investigation into the death of Stephen COSTER aged 43. The investigation concluded at the end of the inquest on 04 December 2023. The conclusion of the inquest was that: Stephen was detained at HMP Lewes on 26.4.2022 on remand. Stephen was found in his cell on the floor naked between 5am-5.30am on the morning 3rd May 2022. Prison officers called for health care to attend Stephen’s cell. Medical staff attended, very limited examination was made. At this time no treatment was given. Stephen was left in his cell in the same condition. Health care staff advised Prison staff to undertake observations. It was recorded Stephen was under the influence. At approximately 8.30am, Stephen was checked in his cell. His condition had deteriorated. Prison staff asked for healthcare to attend. Healthcare staff deemed it necessary for an ambulance to be called. Following assessment ambulance staff advised Stephen should immediately be taken to hospital. There is evidence that delays to paperwork resulted in the ambulance being unable to leave the prison grounds. The Paramedic clearly stated that Stephen should be taken to hospital immediately with life threatening conditions. Paperwork was eventually completed. The ambulance was able to leave prison at 10.29am, Stephen arrived at hospital at 10.45am. Stephen was taken to resuscitation, and received treatment at the hospital.
Circumstances of the Death
Stephen Coster died as a result of 1a Meningo encephalitis owing to Streptococcus pneumoniae at Royal Sussex County Hospital, Brighton. The jury found that delay by the prison staff and healthcare staff in enabling the correct treatment to be given to Stephen Coster in HMP Lewes more than negligibly, minimally and trivially contributed to his death.
Copies Sent To
Practice Plus Group
South East Coast Ambulance Service NHS Foundation Trust
Independent Advisory Panel on Deaths in Custody
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.