Dear Ms Hassall

Thank you for your Regulation 28 report dated 16 September and addressed to the Governor of HMP Pentonville concerning the recent inquest into the death of Adil Habib who died on 31 October 2014. Your report has been passed to the Equality, Rights and Decency Group (ERDG) in the National Offender Management Service (NOMS), as we have responsibility for the policy on suicide prevention and self-harm management and for sharing learning from deaths in custody.

In your letter you raise concern that the national training for search and restraint does not cover those situations where a prisoner is at risk of choking after attempting to conceal an item during control and restraint procedures. You will be aware that the Chief Executive of NOMS accepted the Prisons and Probation Ombudsman’s recommendation that clear guidance and training be given on the safe use of force, including pain compliance techniques, when resistant prisoners have items in their mouths, which might compromise their breathing. In the response, NOMS confirmed that a DVD was being produced to aid staff training in the safe use of force, in conjunction with current medical advice, and that NOMS would consider the best way to include specific guidance within the DVD on what action should be taken where items are concealed in a resistant prisoner’s mouth.

I can confirm that the DVD has been completed and that the accompanying training material has been prepared and is out for consultation with key stakeholders. I can also confirm that the DVD includes medical advice related to the use of control and restraint and covers:

 Principles of safe restraint  Medical complications of restraint  Mechanics of breathing  Restraint asphyxia  Medical conditions and risk factors  Medical emergencies

The DVD will be sent to all prison Governors by Christmas along with a Notice to Governors advising them of the content and that it should be made available for all operational staff to view. The content will be reinforced in due course when all operation staff receive updated control and restraint training from the National Control & Restraint Instructors. It is expected that the roll out of training will commence in January 2016. All Prison Officer Entry Level Trainees (POELTs) will receive training relating to the contents of this DVD from in December.

I hope you find the contents of this letter have been helpful in providing some assurance that the concerns that you have raised have been, or are being, addressed by NOMS.

Dear Ms Hassell,

Regulation 28; Prevention of Future Deaths Report arising from the inquest into the death of Adil Habib

Thank you for your Regulation 28 Report to prevent future deaths, dated 16th September 2015, bringing to my attention the matters of concern:

When a prison officer at HMP Pentonville rang 999 to ask that paramedics attend the prison, the caller did not immediately offer the location of the prison gate that London Ambulance Service should attend. Whilst there is of course an issue for the prison in terms of offering the information, it would be helpful for LAS call handlers to be provided with a drop down menu showing the alternative gates when they input the prison details. I understand the LAS computer system has been augmented in this respect since Mr Habib’s death for HMP Pentonville, but not for the other London prisons. Perhaps that would be a useful exercise?

Before responding to the matter of concern I would like to apologise to Mr Habib’s family for not being able to reach Mr Habib earlier than we did and to offer my condolences.

The evidence submitted to the Court during the inquest outlined the actions the London Ambulance Service NHS Trust (LAS) had taken since the death of Mr Habib to ensure that we attend the correct prison gate at HMP Pentonville. At the time of the 999 call to attend Mr. Habib, the Gazetteer in the Emergency Operations Centre (EOC) only held the main postal address in Caledonian Road for HMP Pentonville and the prison officer making the 999 call did not volunteer that a different prison gate was to be used. After being advised that a second gate was operated in Roman Way the address was added to the Gazetteer with accurate GPS information so that when selected, ambulance staff would be guided to the address by satellite navigation.

Following the inquest HMP Pentonville’s Head of Residence, has confirmed to the LAS’s Senior Quality Assurance Manager, , that HMP Pentonville will continue to operate two prison gates. We requested that staff at HMP Pentonville are prompted to give the address of the prison gate ambulance staff are to attend at the beginning of the emergency call to the LAS.

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With the assistance of the National Offender Management Service (NOMS) we have obtained a list of postal addresses for all prisons and young offender institutions in the UK and have been assured that the Local Safer Custody Leads have been asked to contact their respective local Ambulance Service Trusts to advise if there are additional or temporary gates to be used, either on a temporary or longer term basis, to those held by NOMS. We have made contact with the Safer Custody Lead for Greater London and established that aside from HMP Pentonville the thirteen prison and young offender institutions operate with a single vehicle access gate.

To share the learning about the call to attend Mr Habib with EOC staff, the November Control Services Team Talk disseminated on 6 November 2015, see copy enclosed, asked staff to confirm the address to attend when taking a call from any prison or young offender institution. Further, as is our practice, a copy of this reply will be shared with the Association of Ambulance Chief Executives and the National Ambulance Service Medical Directors to share our learning with other ambulance services.

I hope that this reply is helpful to you and to Mr Habib’s family in explaining what we have done to address your matters of concern.