Luke Pearce
PFD Report
1 of 3 responses identified
Ref: 2024-0270
Coroner's Concerns (AI summary)
Staff lack timely training and guidance on appropriate cell entry during medical emergencies and correct use of Code Blue/Red communications, risking delayed or improper responses.
View full coroner's concerns
That relevant training and guidance to equip staff to understand when and how to enter a cell in a medical emergency, and the appropriate use of Code Blue and Code Red communications in a medical emergency, is not being delivered in a timely manner to appropriate staff.
Responses
Action Taken
A new national video on medical emergency procedures, including entering cells and using emergency codes, was launched in January 2024 and made available to all HMPPS staff. The Governor of HMP/YOI Swinfen Hall has been showing the video to existing staff as part of Safety Critical training with the goal of completion by March 2025. (AI summary)
A new national video on medical emergency procedures, including entering cells and using emergency codes, was launched in January 2024 and made available to all HMPPS staff. The Governor of HMP/YOI Swinfen Hall has been showing the video to existing staff as part of Safety Critical training with the goal of completion by March 2025. (AI summary)
View full response
Dear Ms Dixon,
Thank you for your Regulation 28 report of 16 May 2024, addressed to the Ministry of Justice, His Majesty’s Prison and Probation Service (HMPPS), and the Governor of HMP/YOI Swinfen Hall. I am responding on behalf of HMPPS as Director General of Operations.
I know that you will share a copy of this response with Mr Pearce’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.
You have expressed concerns concerning the timeliness of training and guidance provided to staff with regards to medical emergency procedures, including the entering of cells and the appropriate use of medical emergency codes.
During the inquest, evidence was heard concerning the new national video that was launched in January 2024. The video includes a demonstration on how staff should respond to an emergency situation, which includes instructions on when to enter a cell in an emergency and the appropriate use of Code Blue and Code Red communications. This video has been made available to all HMPPS staff, including Officer Support Grades (OSGs) and staff completing night duties who may need to respond to a medical emergency. Since January 2024, the video has been delivered to all new officers via foundation training and has been shared locally with Governing Governors.
I have received assurance from the Governor of HMP/YOI Swinfen Hall that the emergency response training video is being shown to all existing members of staff as part of their Safety Critical training, with the view for this to be achieved by March 2025. Going forward, HMP/YOI Swinfen Hall will also ensure that the video is shown annually to all staff.
Additionally, Custodial Managers have been instructed to brief all staff at the beginning of night duty about the use of Code Blue and Code Red and entering cells in a medical emergency, which will be subject to quality assurance checks by both the Safety and Security departments. As part
of HMP/YOI Swinfen Hall’s local training programme, staff will be trained to understand when it is appropriate and necessary to enter a cell during patrol state and guidance on emergency response procedures will be issued to staff every 6 months.
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 16 May 2024, addressed to the Ministry of Justice, His Majesty’s Prison and Probation Service (HMPPS), and the Governor of HMP/YOI Swinfen Hall. I am responding on behalf of HMPPS as Director General of Operations.
I know that you will share a copy of this response with Mr Pearce’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.
You have expressed concerns concerning the timeliness of training and guidance provided to staff with regards to medical emergency procedures, including the entering of cells and the appropriate use of medical emergency codes.
During the inquest, evidence was heard concerning the new national video that was launched in January 2024. The video includes a demonstration on how staff should respond to an emergency situation, which includes instructions on when to enter a cell in an emergency and the appropriate use of Code Blue and Code Red communications. This video has been made available to all HMPPS staff, including Officer Support Grades (OSGs) and staff completing night duties who may need to respond to a medical emergency. Since January 2024, the video has been delivered to all new officers via foundation training and has been shared locally with Governing Governors.
I have received assurance from the Governor of HMP/YOI Swinfen Hall that the emergency response training video is being shown to all existing members of staff as part of their Safety Critical training, with the view for this to be achieved by March 2025. Going forward, HMP/YOI Swinfen Hall will also ensure that the video is shown annually to all staff.
Additionally, Custodial Managers have been instructed to brief all staff at the beginning of night duty about the use of Code Blue and Code Red and entering cells in a medical emergency, which will be subject to quality assurance checks by both the Safety and Security departments. As part
of HMP/YOI Swinfen Hall’s local training programme, staff will be trained to understand when it is appropriate and necessary to enter a cell during patrol state and guidance on emergency response procedures will be issued to staff every 6 months.
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.
Sent To
- HM Prison and Probation Service
- Ministry of Justice
Responses Identified
Responses identified
1 of 3
56-Day Deadline
11 Jul 2024
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 12 April 2023 I commenced an investigation into the death of Luke Mikael PEARCE aged
21. The investigation concluded at the end of the inquest on 16 May 2024. The conclusion of the inquest was that: suicide.
21. The investigation concluded at the end of the inquest on 16 May 2024. The conclusion of the inquest was that: suicide.
Circumstances of the Death
Mr Luke Pearce was found hanging in his cell on 6 April 2023, at HMP/YOI Swinfen Hall. He was 21 years old. Mr Pearce had given no indication to staff that he was at risk of suicide or self harm in the months leading up to his death.
Shortly after 5.30am on 6 April 2023, during a routine check,
The officer called to Mr Pearce but got no response. He looked through the crack of the door and saw Mr Pearce with a ligature around his neck. The officer radioed for urgent assistance but did not use the appropriate coded wording of “Code Blue”.
An Operation Support Grade attended and briefly entered Mr Pearce’s cell before coming out again. When another officer attended, the first officer and OSG told her that she should not enter the cell as it was a crime scene. She contacted a custodial manager for permission to go in and then cut the ligature and lowered Mr Pearce to the floor. The officer and OSG waited outside and did not assist.
At 5.40am, more staff arrived and the control room staff called an ambulance. Staff started CPR at 05.42am. Ambulance paramedics arrived at 5.59am and took over CPR. At 6.30am, they pronounced that Mr Pearce had died.
There was a delay in staff entering the cell, removing the ligature and starting CPR. This did not contribute towards Mr Pearce’s death.
Shortly after 5.30am on 6 April 2023, during a routine check,
The officer called to Mr Pearce but got no response. He looked through the crack of the door and saw Mr Pearce with a ligature around his neck. The officer radioed for urgent assistance but did not use the appropriate coded wording of “Code Blue”.
An Operation Support Grade attended and briefly entered Mr Pearce’s cell before coming out again. When another officer attended, the first officer and OSG told her that she should not enter the cell as it was a crime scene. She contacted a custodial manager for permission to go in and then cut the ligature and lowered Mr Pearce to the floor. The officer and OSG waited outside and did not assist.
At 5.40am, more staff arrived and the control room staff called an ambulance. Staff started CPR at 05.42am. Ambulance paramedics arrived at 5.59am and took over CPR. At 6.30am, they pronounced that Mr Pearce had died.
There was a delay in staff entering the cell, removing the ligature and starting CPR. This did not contribute towards Mr Pearce’s death.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.