Anthony Smith
PFD Report
All Responded
Ref: 2023-0187
All 1 response received
· Deadline: 3 Aug 2023
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Response Status
Responses
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56-Day Deadline
3 Aug 2023
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
(1) An officer attempting resuscitation carried out mouth to mouth resuscitation without the safeguard of mouth protection which was not available in the prison at the time. Mr Smith was a regular drug user who on occasions injected drugs. Performing mouth to mouth resuscitation carried with it the risk of transmission of blood born viruses with possible fatal consequences.
(2) The lack of available protection not only carried with it a risk to those who performed resuscitation but potentially also to the person suffering a cardiac arrest in that without protection the would-be resuscitator might decline to provide rescue breaths (3) Consideration should be given to informing prison governors of the need to secure a readily accessible supply of protection masks. PSI 29 of 2015 on the subject of First Aid is currently under review and might be a vehicle for providing appropriate direction.
(2) The lack of available protection not only carried with it a risk to those who performed resuscitation but potentially also to the person suffering a cardiac arrest in that without protection the would-be resuscitator might decline to provide rescue breaths (3) Consideration should be given to informing prison governors of the need to secure a readily accessible supply of protection masks. PSI 29 of 2015 on the subject of First Aid is currently under review and might be a vehicle for providing appropriate direction.
Responses
HMP Preston has already purchased and placed face shields in first aid boxes and issued a notice to staff regarding their use during CPR. The First Aid Policy Framework is also under review to include instructions on face shield use and their required presence in all prison first aid kits.
AI summary
View full response
Dear Mr Rheinberg,
Thank you for your Regulation 28 report of 7 June 2023 following the inquest into the death of Anthony Smith at HMP Preston on 16 May 2022.
I know that you will share a copy of this response with Mr Smith’s family, and I would first 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.
Your concerns relate to the availability and use of protective face masks for staff when performing CPR.
As you are aware, the First Aid Policy Framework is currently under review and is due to be re- issued by August 2023. The revised policy document will include instructions on the use of face shields including the requirement for all first aid kits in prisons to contain resuscitation face shields and for these to be monitored and replenished when required. The policy also emphasises the training requirements for Emergency First Aid and First Aid at Work, including the importance of using the face masks correctly and of these being available at all times.
At HMP Preston, face shields have been purchased and added to the existing first aid boxes on all residential units and will be monitored by the Health and Safety Team. A Notice to Staff was also issued in June 2023 to advise staff of the location of the face shields and the importance of using these when administering CPR.
Thank you again for bringing your concerns to my attention. I trust that this response provides assurance that action is being taken to address this matter.
Thank you for your Regulation 28 report of 7 June 2023 following the inquest into the death of Anthony Smith at HMP Preston on 16 May 2022.
I know that you will share a copy of this response with Mr Smith’s family, and I would first 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.
Your concerns relate to the availability and use of protective face masks for staff when performing CPR.
As you are aware, the First Aid Policy Framework is currently under review and is due to be re- issued by August 2023. The revised policy document will include instructions on the use of face shields including the requirement for all first aid kits in prisons to contain resuscitation face shields and for these to be monitored and replenished when required. The policy also emphasises the training requirements for Emergency First Aid and First Aid at Work, including the importance of using the face masks correctly and of these being available at all times.
At HMP Preston, face shields have been purchased and added to the existing first aid boxes on all residential units and will be monitored by the Health and Safety Team. A Notice to Staff was also issued in June 2023 to advise staff of the location of the face shields and the importance of using these when administering CPR.
Thank you again for bringing your concerns to my attention. I trust that this response provides assurance that action is being taken to address this matter.
Report Sections
Investigation and Inquest
An investigation into the death of Anthony George Smith aged 34 was commenced on 16th May 2022. The investigation concluded at the end of the inquest on 7th June 2023. The conclusion of the inquest was that Mr Smith died as a result of self-suspension but his intention in doing so could not be determined
Circumstances of the Death
Mr Smith at the time of his death at HMP Preston was suffering an acute relapse in respect of his schizophrenia. He was delusional, hallucinating and hearing voices. On 4th May 2022 he was found hanging in his cell. He was cut down and officers commenced cardio-pulmonary resuscitation
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.