Lewis Johnson
PFD Report
Partially Responded
Ref: 2022-0397
Coroner's Concerns (AI summary)
HMP Wealstun lacks night-time healthcare staff, and prison officers are inadequately trained in CPR and defibrillator use for self-harm incidents, compounded by a missing policy directive for immediate resuscitation.
View full coroner's concerns
(1) HMP Wealstun does not have nurses or other healthcare staff in the prison during the night.
(2) The incidence of self-harm incidents amongst prisoners (both in 2019 and today) make such emergencies foreseeable.
(3) In the absence of healthcare staff being immediately available, the night patrol staff should be trained to respond effectively to ligature or other self-harm incidents.
(4) The OSG officer who encountered the situation involving Mr Johnson around 04:45 hours had not been trained to carry out CPR.
(5) The officer acting as attended the cell but did not think about CPR, believing Mr Johnson to be already dead (notwithstanding that none of the discipline officers present had anv medical qualifications to certifv death). He had undertaken defibrillator training "many years ago".
(6) The four prison officers present in the cell did not discuss the need for CPR. The possibility of using a defibrillator was not mentioned. Mr Johnson was left in the cell in a seated position without the wisdom of placing him in the recovery position being considered.
(7) The medical evidence available at the Inquest indicated "Effective CPR more than doubles the chance of someone surviving a cardiac arrest". Furthermore, the Resuscitation Council UK advises "provide chest compressions as soon as possible after cardiac arrest is confirmed".
(8) The value of all night patrol staff (particularly in a prison without 24 hour healthcare provision) being trained to provide effective CPR and use a defibrillator competently was recognised at the inquest, along with the wisdom of this being refreshed annually.
(9) The inquest noted that there is currently no express direction in PSI 03/2013 or other instruction to carry out CPR pending the arrival of paramedics or other qualified medical professional, when a prisoner is found in an unresponsive condition following a ligature incident.
(2) The incidence of self-harm incidents amongst prisoners (both in 2019 and today) make such emergencies foreseeable.
(3) In the absence of healthcare staff being immediately available, the night patrol staff should be trained to respond effectively to ligature or other self-harm incidents.
(4) The OSG officer who encountered the situation involving Mr Johnson around 04:45 hours had not been trained to carry out CPR.
(5) The officer acting as attended the cell but did not think about CPR, believing Mr Johnson to be already dead (notwithstanding that none of the discipline officers present had anv medical qualifications to certifv death). He had undertaken defibrillator training "many years ago".
(6) The four prison officers present in the cell did not discuss the need for CPR. The possibility of using a defibrillator was not mentioned. Mr Johnson was left in the cell in a seated position without the wisdom of placing him in the recovery position being considered.
(7) The medical evidence available at the Inquest indicated "Effective CPR more than doubles the chance of someone surviving a cardiac arrest". Furthermore, the Resuscitation Council UK advises "provide chest compressions as soon as possible after cardiac arrest is confirmed".
(8) The value of all night patrol staff (particularly in a prison without 24 hour healthcare provision) being trained to provide effective CPR and use a defibrillator competently was recognised at the inquest, along with the wisdom of this being refreshed annually.
(9) The inquest noted that there is currently no express direction in PSI 03/2013 or other instruction to carry out CPR pending the arrival of paramedics or other qualified medical professional, when a prisoner is found in an unresponsive condition following a ligature incident.
Responses
Action Planned
HMPPS will update a training video for staff on emergency response, ligature use, and CPR (available Spring 2023). HMP Wealstun will resume FAW and EFAW training from April 2023, prioritizing night staff and custodial managers. HMPPS is reviewing the first aid policy and will update guidance on CPR commencement. (AI summary)
HMPPS will update a training video for staff on emergency response, ligature use, and CPR (available Spring 2023). HMP Wealstun will resume FAW and EFAW training from April 2023, prioritizing night staff and custodial managers. HMPPS is reviewing the first aid policy and will update guidance on CPR commencement. (AI summary)
View full response
Dear Mr McLoughlin
Thank you for your Regulation 28 report of 2 December 2022, addressed to the Governor of HMP Wealstun and the Secretary of State for Justice, following the recent inquest into the death of Lewis Johnson at HMP Wealstun on 12 December 2019. I am responding as Director General of Operations for HMPPS.
I know that you will share a copy of this response with Mr Johnson’s family and I would like to first express my condolences for their loss. Each 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 have raised some concerns regarding the first aid training for staff particularly in relation to the use of CPR, and I will address these below.
It may be helpful for me to clarify the requirements currently in place for all establishments around the provision of first aid trained staff. Whilst there is currently no requirement for all prison staff to be trained in first aid, all prison officers receive emergency first-aid at work (EFAW) training, including how to administer CPR, during their entry level training, for use in their duties. Governors are required to ensure that there are sufficient numbers of trained staff on duty at all times. They do this by producing a detailed local first aid risk assessment to determine the number of first aid at work (FAW) and EFAW trained staff needed at the establishment, and by ensuring that they are deployed appropriately.
At HMP Wealstun the local risk assessment was last reviewed in October 2022. Consideration was given to the risk profile across all areas of the prison, paying particular attention to the night provision, due to there being no healthcare staff available during that time to provide emergency assistance should the need arise. Regular reviews will continue to be conducted to ensure that the needs of the prison continue to be met.
In respect of the EFAW training all prison officers receive during their entry level training, all first aid training certificates are valid for three years and although not mandatory, staff are encouraged to undertake refresher training to maintain their basic skills and keep up to date with any changes to first-aid procedures. The initial training for staff includes an HMPPS video which shows how to respond to an emergency situation where a prisoner has attempted suicide. This is currently being updated to reflect changes to policy and equipment available since the original video was produced. This video covers the use of prison issue ligature tools, emergency response codes, placing someone in the recovery position and considerations such as when to initiate first aid and the use of defibrillators. Once complete, the updated video will be made available to all training centres for new staff and for prisons. It is anticipated that this will be available to staff by Spring 2023.
While the delivery of staff training has been severely impacted as a result of restrictions put in place due to the COVID-19 pandemic, with prisons only being able to deliver limited safety critical training, from April 2023 HMP Wealstun will be able to resume the delivery of FAW and EFAW training locally, and will prioritise all those on the dedicated night group, which includes Operation Support Grade staff. The intention is also for all Custodial Managers to receive this training, as well as a significant proportion of the wider officer group, to ensure that an effective emergency response can be provided when required.
Looking ahead, HMPPS is currently reviewing the first aid policy with the view to replacing this with updated guidance. As the new the guidance develops, collaboration will take place amongst teams to ensure there is reference to the commencement of CPR and to ensure we signpost the current safer custody guidance available on the HMPPS intranet which sets out the circumstances in which CPR should be commenced. This is designed to be read in conjunction with the current the Prison Service Instruction which makes clear that all staff must be aware of their responsibilities and of the local procedures that are in place to enable an effective response to medical emergencies.
Thank you again for bringing these matters of concern to my attention and I hope this provides you with the reassurances that you seek.
Thank you for your Regulation 28 report of 2 December 2022, addressed to the Governor of HMP Wealstun and the Secretary of State for Justice, following the recent inquest into the death of Lewis Johnson at HMP Wealstun on 12 December 2019. I am responding as Director General of Operations for HMPPS.
I know that you will share a copy of this response with Mr Johnson’s family and I would like to first express my condolences for their loss. Each 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 have raised some concerns regarding the first aid training for staff particularly in relation to the use of CPR, and I will address these below.
It may be helpful for me to clarify the requirements currently in place for all establishments around the provision of first aid trained staff. Whilst there is currently no requirement for all prison staff to be trained in first aid, all prison officers receive emergency first-aid at work (EFAW) training, including how to administer CPR, during their entry level training, for use in their duties. Governors are required to ensure that there are sufficient numbers of trained staff on duty at all times. They do this by producing a detailed local first aid risk assessment to determine the number of first aid at work (FAW) and EFAW trained staff needed at the establishment, and by ensuring that they are deployed appropriately.
At HMP Wealstun the local risk assessment was last reviewed in October 2022. Consideration was given to the risk profile across all areas of the prison, paying particular attention to the night provision, due to there being no healthcare staff available during that time to provide emergency assistance should the need arise. Regular reviews will continue to be conducted to ensure that the needs of the prison continue to be met.
In respect of the EFAW training all prison officers receive during their entry level training, all first aid training certificates are valid for three years and although not mandatory, staff are encouraged to undertake refresher training to maintain their basic skills and keep up to date with any changes to first-aid procedures. The initial training for staff includes an HMPPS video which shows how to respond to an emergency situation where a prisoner has attempted suicide. This is currently being updated to reflect changes to policy and equipment available since the original video was produced. This video covers the use of prison issue ligature tools, emergency response codes, placing someone in the recovery position and considerations such as when to initiate first aid and the use of defibrillators. Once complete, the updated video will be made available to all training centres for new staff and for prisons. It is anticipated that this will be available to staff by Spring 2023.
While the delivery of staff training has been severely impacted as a result of restrictions put in place due to the COVID-19 pandemic, with prisons only being able to deliver limited safety critical training, from April 2023 HMP Wealstun will be able to resume the delivery of FAW and EFAW training locally, and will prioritise all those on the dedicated night group, which includes Operation Support Grade staff. The intention is also for all Custodial Managers to receive this training, as well as a significant proportion of the wider officer group, to ensure that an effective emergency response can be provided when required.
Looking ahead, HMPPS is currently reviewing the first aid policy with the view to replacing this with updated guidance. As the new the guidance develops, collaboration will take place amongst teams to ensure there is reference to the commencement of CPR and to ensure we signpost the current safer custody guidance available on the HMPPS intranet which sets out the circumstances in which CPR should be commenced. This is designed to be read in conjunction with the current the Prison Service Instruction which makes clear that all staff must be aware of their responsibilities and of the local procedures that are in place to enable an effective response to medical emergencies.
Thank you again for bringing these matters of concern to my attention and I hope this provides you with the reassurances that you seek.
Part of a Series
3 separate reports were issued from this inquest, each sent to different organisations.
-
2025-0241
Sent to: Metropolitan Police Service;All responded
-
2025-0242
Sent to: Independent Office for Police ConductAll responded
This report (2022-0397) is shown above.
Sent To
- Ministry of Justice
Response Status
Linked responses
1 of 2
56-Day Deadline
6 Feb 2023
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 23rd December 2019 an investigation was commenced into the death of Lewis Steven Johnson, aged 34. The investigation concluded at the end of the Inquest on 2nd December 2022. The conclusion of the Inquest was a Narrative Conclusion that Mr Johnson died due to 1(a) Hypoxic-ischaemia Encephalopathy 1(b) Hanging after being found suspended by a neck ligature at approximately 04:45 hours on 12th December 2019 at HMP Wealstun.
Circumstances of the Death
Lewis Steven Johnson was held at HMP Wealstun from May 2019 until his death 7 months later. He had been seen frequently by healthcare staff, a keyworker, other prison officers and had been subject to an ACCT for a brief period in October 2019. When found with a neck ligature around 04:45 on 12th December in an unresponsive condition, he was cut down, but the various prison officers present then left him in the cell in a seated position without considering CPR, using a defibrillator or considering whether to place him in the recovery position. Approximately five minutes later another prison officer mentioned CPR. Prison officers then returned to his cell and conducted CPR until paramedics arrived. The paramedics succeeded in restoring Mr Johnson's circulation. He was taken to hospital but following a further cardiac arrest, was pronounced dead at 10:56 on 12th December 2019 at Leeds General Infirmary.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.