Nathan Forrester
PFD Report
All Responded
Ref: 2023-0035Deceased
All 2 responses received
· Deadline: 28 Mar 2023
Coroner's Concerns (AI summary)
Prison officers lack training to safely remove and provide CPR to prisoners on top bunks. Nationally, nurses in detention settings may also have inadequate CPR training and insufficient emergency airway equipment.
View full coroner's concerns
6.
1. Deaths on top bunks (HMPPS) The first prison officer to arrive and find Mr Forrester unresponsive to voice, blue and cold, decided she was too small to be able to get him off his top bunk, even with a colleague, and left the cell. A second officer, having confirmed no pulse or response to pain, stated that there was no specific training on how to manage an arrest and CPR of a person on a top bunk. He tried unsuccessfully to bring him down. A third officer attending did not attempt to do so. After some delay, nurses brought him down to floor level when they arrived. The Head of Safer Custody has asked the local health service provider to advise how prison officers should be trained to manage assessment, removal and immediate CPR of a prisoner on a top bunk. The concern is that this training gap may exist in other establishments.
2. Training of nurses in CPR (NHS England)
Nurses attending the Code Blue had no training insertion of an IGel or oropharyngeal tubes, nor was an airway available in the emergency bags. Paramedics reported that resuscitation being provided by nurses was ineffective (too low and too fast) and that they had an inadequate handover. These deficiencies have been addressed locally and all nurses in Oxleas NHS Trust are trained annually to ILS level and airways are available. The concern is that this standard of training of nurses working in detention settings nationally may not be universal.
This REPORT IS BEING SENT TO:
1. , Director General Chief Executive HM Prison & Probation Service (HMPPS), 70 Petty France, London, SW1H 9AJ
2. , Lead Commissioner for Secure & Detained Estate, NHS England, Wellington House, 133-135 Waterloo Road, London, SE1 8UG
1. Deaths on top bunks (HMPPS) The first prison officer to arrive and find Mr Forrester unresponsive to voice, blue and cold, decided she was too small to be able to get him off his top bunk, even with a colleague, and left the cell. A second officer, having confirmed no pulse or response to pain, stated that there was no specific training on how to manage an arrest and CPR of a person on a top bunk. He tried unsuccessfully to bring him down. A third officer attending did not attempt to do so. After some delay, nurses brought him down to floor level when they arrived. The Head of Safer Custody has asked the local health service provider to advise how prison officers should be trained to manage assessment, removal and immediate CPR of a prisoner on a top bunk. The concern is that this training gap may exist in other establishments.
2. Training of nurses in CPR (NHS England)
Nurses attending the Code Blue had no training insertion of an IGel or oropharyngeal tubes, nor was an airway available in the emergency bags. Paramedics reported that resuscitation being provided by nurses was ineffective (too low and too fast) and that they had an inadequate handover. These deficiencies have been addressed locally and all nurses in Oxleas NHS Trust are trained annually to ILS level and airways are available. The concern is that this standard of training of nurses working in detention settings nationally may not be universal.
This REPORT IS BEING SENT TO:
1. , Director General Chief Executive HM Prison & Probation Service (HMPPS), 70 Petty France, London, SW1H 9AJ
2. , Lead Commissioner for Secure & Detained Estate, NHS England, Wellington House, 133-135 Waterloo Road, London, SE1 8UG
Responses
Noted
NHS England commissions healthcare in prisons and ensures equivalence of care. They state that shortcomings in training have been addressed locally and all nurses in Oxleas NHS Trust are trained annually to ILS level. All reports received are discussed by the Regulation 28 Working Group. (AI summary)
NHS England commissions healthcare in prisons and ensures equivalence of care. They state that shortcomings in training have been addressed locally and all nurses in Oxleas NHS Trust are trained annually to ILS level. All reports received are discussed by the Regulation 28 Working Group. (AI summary)
View full response
Dear Mr Harris
Re: Regulation 28 Report to Prevent Future Deaths – Nathan Forrester who died on 2 July 2019
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 30 January 2023 concerning the death of Nathan Forrester on 2 July 2019. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Mr Forrester’s family and loved ones. NHS England is keen to assure the family and the Coroner that the concerns raised about Mr Forrester’s care have been listened to and reflected upon.
NHS England is the responsible organisation for the commissioning of healthcare into prisons, which is devolved to regional teams. Commissioning healthcare in prisons is done on a principle of equivalence, which has been defined by the Royal College of General Practitioners (RCGP and broadly states the aim is to ensure people detained in prisons in England, are offered provision of and access to appropriate services and treatment, considered to be at least consistent in range and quality, with that available in the wider community.
I have considered the concerns raised in your report and I will respond to each of them in turn below.
1. Deaths on top bunks (HMPPS)
Responsibility for training of prison officers in respect of the management of a prisoner on a top bunk lies with HMPPS and I understand that they will respond to this concern directly.
2. Training of nurses in CPR (NHS England)
NHS England is the responsible organisation for the commissioning of healthcare in prisons, which is done on a principle of equivalence as defined by the Royal College of General Practitioners (RCGP) Royal College of General Practitioners (RCGP). This definition, agreed by the Prison Healthcare Partnership Board, broadly states the aim is to ensure people detained in prisons in England are afforded provision of, and access to appropriate services and treatment, which is at least consistent in range and quality, with that available in the wider community.
National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG
29 March 2023
The Service Specification, ‘primary care service, medical and nursing for prisons in England,’ published in March 2020, includes a section on unplanned and emergency. This outlines the requirements for the healthcare provider to develop and implement protocols, specific to each prison, for responding to and managing emergencies including training for staff in CPR. Immediate Life Support (ILS) training provides healthcare professionals with the skills needed to respond in an emergency.
The Service Specification also details exclusion criteria of injuries or illnesses that require medical or emergency intervention, beyond the scope and practice of primary care nursing and general medical practice.
This reflects the Resuscitation Council UK ‘Quality Standards: Primary care | Resuscitation Council UK’ which state:
“training must be in place to ensure clinical staff can undertake CPR. Training and facilities must ensure that, when cardiorespiratory arrest occurs, as a minimum all clinical staff can:
• Recognise cardiopulmonary arrest (ABCDE approach)
• Summon help.
• Start CPR and defibrillation (manual and/or AED) and simple airway manoeuvres) with a minimum of delay, whenever possible within minutes of collapse.”
The Resuscitation Council UK also outlines that Advanced Life Support (ALS), which includes the use of supraglottic airway devices such as an IGel, is appropriate for healthcare professionals who would undertake ALS as part of their clinical duties.
This includes doctors, paramedics and nurses working in acute care areas such as Emergency Departments, Coronary Care Units, Intensive Care Units, High Dependency Units, operating theatres, acute medical admissions units or, on resuscitation/medical emergency Critical Care outreach Teams.
This level of life support involves some specialist clinical procedures which, to be clinically effective and cause no harm, must be performed as a regular part of clinical duties.
Healthcare professionals working in prisons (primary care), do not fall within the specified categories for ALS and therefore these procedures, if conducted, may lead to staff working outside of their registered professional clinical competencies. I understand shortcomings in training have been addressed locally and all nurses in Oxleas NHS Trust are trained annually to ILS level. I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors and other clinical and quality colleagues from across the regions. This ensures key learnings and insights around events, such as the sad death of Mr Forrester, are shared across the NHS at both a national and regional level and helps
us to pay close attention to any emerging trends that may require further review and action. Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.
Re: Regulation 28 Report to Prevent Future Deaths – Nathan Forrester who died on 2 July 2019
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 30 January 2023 concerning the death of Nathan Forrester on 2 July 2019. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Mr Forrester’s family and loved ones. NHS England is keen to assure the family and the Coroner that the concerns raised about Mr Forrester’s care have been listened to and reflected upon.
NHS England is the responsible organisation for the commissioning of healthcare into prisons, which is devolved to regional teams. Commissioning healthcare in prisons is done on a principle of equivalence, which has been defined by the Royal College of General Practitioners (RCGP and broadly states the aim is to ensure people detained in prisons in England, are offered provision of and access to appropriate services and treatment, considered to be at least consistent in range and quality, with that available in the wider community.
I have considered the concerns raised in your report and I will respond to each of them in turn below.
1. Deaths on top bunks (HMPPS)
Responsibility for training of prison officers in respect of the management of a prisoner on a top bunk lies with HMPPS and I understand that they will respond to this concern directly.
2. Training of nurses in CPR (NHS England)
NHS England is the responsible organisation for the commissioning of healthcare in prisons, which is done on a principle of equivalence as defined by the Royal College of General Practitioners (RCGP) Royal College of General Practitioners (RCGP). This definition, agreed by the Prison Healthcare Partnership Board, broadly states the aim is to ensure people detained in prisons in England are afforded provision of, and access to appropriate services and treatment, which is at least consistent in range and quality, with that available in the wider community.
National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG
29 March 2023
The Service Specification, ‘primary care service, medical and nursing for prisons in England,’ published in March 2020, includes a section on unplanned and emergency. This outlines the requirements for the healthcare provider to develop and implement protocols, specific to each prison, for responding to and managing emergencies including training for staff in CPR. Immediate Life Support (ILS) training provides healthcare professionals with the skills needed to respond in an emergency.
The Service Specification also details exclusion criteria of injuries or illnesses that require medical or emergency intervention, beyond the scope and practice of primary care nursing and general medical practice.
This reflects the Resuscitation Council UK ‘Quality Standards: Primary care | Resuscitation Council UK’ which state:
“training must be in place to ensure clinical staff can undertake CPR. Training and facilities must ensure that, when cardiorespiratory arrest occurs, as a minimum all clinical staff can:
• Recognise cardiopulmonary arrest (ABCDE approach)
• Summon help.
• Start CPR and defibrillation (manual and/or AED) and simple airway manoeuvres) with a minimum of delay, whenever possible within minutes of collapse.”
The Resuscitation Council UK also outlines that Advanced Life Support (ALS), which includes the use of supraglottic airway devices such as an IGel, is appropriate for healthcare professionals who would undertake ALS as part of their clinical duties.
This includes doctors, paramedics and nurses working in acute care areas such as Emergency Departments, Coronary Care Units, Intensive Care Units, High Dependency Units, operating theatres, acute medical admissions units or, on resuscitation/medical emergency Critical Care outreach Teams.
This level of life support involves some specialist clinical procedures which, to be clinically effective and cause no harm, must be performed as a regular part of clinical duties.
Healthcare professionals working in prisons (primary care), do not fall within the specified categories for ALS and therefore these procedures, if conducted, may lead to staff working outside of their registered professional clinical competencies. I understand shortcomings in training have been addressed locally and all nurses in Oxleas NHS Trust are trained annually to ILS level. I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors and other clinical and quality colleagues from across the regions. This ensures key learnings and insights around events, such as the sad death of Mr Forrester, are shared across the NHS at both a national and regional level and helps
us to pay close attention to any emerging trends that may require further review and action. Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.
Action Taken
All new prison officers receive first aid training covering moving individuals for CPR, and manual handling training has been updated to a digital format. eLearning is available to all staff. (AI summary)
All new prison officers receive first aid training covering moving individuals for CPR, and manual handling training has been updated to a digital format. eLearning is available to all staff. (AI summary)
View full response
Dear Mr Harris,
Thank you for your Regulation 28 report of 30 January 2023 addressed to , Director General Chief Executive of His Majesty’s Prison and Probation Service (HMPPS). I am responding as Director General of Operations for HMPPS. I am grateful to you for granting an extension for this response.
I know that you will share a copy of this response with the family of Mr Forrester, 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 a concern that prison officers may need further training on responding to emergency situations where they need to move a prisoner in order to complete an assessment and to commence cardiopulmonary resuscitation (CPR) immediately. Thank you for bringing your concern to my attention.
I can confirm that all new prison officers receive first aid training as part of their initial prison officer training. The training covers the requirement to move individuals to a hard, flat surface before commencing CPR, and as such staff are aware that anyone found unresponsive on a top bunk bed would need to be brought to the floor prior to commencing CPR. The Learning and Development team, responsible for the management and delivery of training for HMPPS staff, also provide training in manual handling and movement of prisoners to ensure that our staff are well equipped with the skills to move a prisoner in order to enable CPR and emergency first aid to commence.
Manual handling training has recently been updated to a digital format and all new prison officers complete this during their initial training induction. In addition, there is eLearning available to all staff on MyLearning which is the digital learning platform used by HMPPS.
Thank you again for bringing your concern to my attention. I trust that this response provides assurance that the training provided to officers is sufficient.
Thank you for your Regulation 28 report of 30 January 2023 addressed to , Director General Chief Executive of His Majesty’s Prison and Probation Service (HMPPS). I am responding as Director General of Operations for HMPPS. I am grateful to you for granting an extension for this response.
I know that you will share a copy of this response with the family of Mr Forrester, 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 a concern that prison officers may need further training on responding to emergency situations where they need to move a prisoner in order to complete an assessment and to commence cardiopulmonary resuscitation (CPR) immediately. Thank you for bringing your concern to my attention.
I can confirm that all new prison officers receive first aid training as part of their initial prison officer training. The training covers the requirement to move individuals to a hard, flat surface before commencing CPR, and as such staff are aware that anyone found unresponsive on a top bunk bed would need to be brought to the floor prior to commencing CPR. The Learning and Development team, responsible for the management and delivery of training for HMPPS staff, also provide training in manual handling and movement of prisoners to ensure that our staff are well equipped with the skills to move a prisoner in order to enable CPR and emergency first aid to commence.
Manual handling training has recently been updated to a digital format and all new prison officers complete this during their initial training induction. In addition, there is eLearning available to all staff on MyLearning which is the digital learning platform used by HMPPS.
Thank you again for bringing your concern to my attention. I trust that this response provides assurance that the training provided to officers is sufficient.
Sent To
Response Status
Linked responses
2 of 1
56-Day Deadline
28 Mar 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
Report Sections
Investigation and Inquest
On 2nd July 2019 death of Mr Nathan Forrester ( was reported to the coroner by HMP Thameside. A forensic autopsy was conducted and on 3rd September 2019, an inquest was opened. The listing was delayed by the pandemic. An inquest was part heard and jury dismissed in January 2022 and a fresh inquest heard from 9th until 19th January 2023, before a jury. The medical cause of death was 1a Acute toxic effects of Heroin, Cocaine and Methadone and the jury concluded he died of a drug related death.
Circumstances of the Death
He was well known as drug dependent with a history of concealing drugs. He had been released from prison on licence and was recalled and detained again, under the influence of drugs. The intoxication wore off. He was later found dead in his shared cell, having consumed illicit drugs there, after his cell mate alerted officers. Although emergency measures were instigated, at inquest it was determined that he had been beyond resuscitation, when found by officers. A substantial number of actions were taken both by the prison service and local provider of health care to the prison, to prevent future deaths, including installation of a scanner to detect drugs hidden in orifices, training in CPR and increases in night nurse staffing.
Action Should Be Taken
The case is brought to the attention of both national organizations responsible for commissioning or provision of CPR training, to enable them to assess whether the dangerous circumstances of this death could be present in other detention facilities and if so to consider the steps that need to be taken to reduce the risks of deaths from such circumstances.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.