(1) For the attention of the Governor, the evidence disclosed a need for the training of prison staff in relation to responses to medical emergencies and familiarisation with the ERIC (Emergency Response in Custody) system Although this recommendation has been made to the Governor, Spectrum wish to provide the following information which may assist. An Emergency Response in Custody (ERIC) presentation with added audio has been developed to address training needs for both healthcare team members and prison officers. The Head of Healthcare presented the ERIC training presentation at a prison induction on the 13th January 2022, a training session for Officer Support Grades who work in the prison communication room and custodial managers was held on the 20th January 2022. Further Sessions have been held with prison staff on the 27th of January and 3rd of February. There is a plan to roll this training out to all, the training will also be delivered at healthcare handovers. ERIC training and the appropriateness of emergency calls will be discussed with Governor at Local Delivery Board meetings to support the process of training is embedded with HMP Lancaster Farms. Healthcare will ensure compliance is maintained via reporting on staff induction and via the appraisal process. From an organisational perspective, Spectrum are supporting this process, we will be working with our training facilitators to launch a quality training day which links into our corporate induction for all new staff. These sessions will also be used for the support of any staff requiring an update and be provided by the cooperate quality team. The teams will continue to use the process of the newly induced site safety huddles to reflect and evaluate any incidents that arise. This will support reflective practice and mitigation of any issues that may arise e.g., training, awareness and education. All incidents related to emergency response will be reviewed via the incident reporting system (Datix) by the Head of Healthcare and appropriate level of investigation will be completed, this may include the completion of a root cause analysis. Assessment of training compliance as per ERIC standards will take place following the completion of emergency calls. Feedback will be provided to the team and individual as needed to provide continued support and learning. To provide further assurances, spot audits for ERIC competences will take place at least annually via team level professional development sessions. (2) For the attention of the Head of Healthcare, the evidence disclosed a need for healthcare to liaise with North West Ambulance Service over the handling of medical emergencies involving the ambulance service The Head of Healthcare has contacted Northwest Ambulance Service (NWAS) to discuss training needs and scope training provision for clinicians within Spectrum prisons. This will ensure that the quality and content of the information passed to the control room ensures accurate categorisation of ambulances. A meeting was held with NWAS on the 14th January 2022 to discuss these training options. NWAS have provided information (embedded in action plan) which we can use to develop a staff training package. This information has been incorporated into the new emergency response procedure at HMP Lancaster Farms, this is outlined in the attached below Governors notice staff, code red and blue.

Following incidents, debriefs occur jointly with the Prison and healthcare. This is an opportunity to consider the communication taken place between healthcare, the communication department and NWAS. Any emerging lesson learnt will be captured at this early stage .

Organisationally, Spectrum are commencing a Task and Finish Group led by the Patient Safety lead and will invite key partners from the Emergency service response, including paramedics who work within Spectrum. The objective for the group is to streamline all education material and ensure this is systematically applied. This group will focus on the PPO and Clinical Review recommendations. The first meeting of the Task and Finish Group is planned for 10th February 2022. This is a new approach to support continued integration and shared learning. The group will work within TOR agreed by all parties.

(3) For the attention of the Governor in partnership with the Head of Healthcare, the evidence disclosed a need to devise a better means of communication between healthcare personnel at the scene of a medical emergency and the prison control room / ambulance control. Work on integration and shared objectives for patient safety had commenced prior to the inquest and a meeting had taken place between the healthcare team, the previous Safer Custody Governor, and the Governing Governor at HMP Lancaster Farms to develop actions to address this recommendation.

Potential solutions were discussed, and these included accessing the wing phone to make the call, however, it was noted that this would mean the clinician leaving the patient to ring an outside line. Prison telecommunication systems require a phone code to access an outside line which further increases the time taken to make a call. The patient may then be left without a nurse in attendance whilst this telephone call is taking place.

An alternative solution was the provision of a mobile phone for healthcare to utilise to make the call, however, the phone signal in HMP Lancaster Farms is not reliable. Following the inquest, the Head of Healthcare met with the new Safer Custody Governor, and it was agreed that a spare radio net will be utilised so that the clinician can speak directly to the prison’s communications room (rather than via Oscar 1) to provide more information directly which can then be relayed to the clinician, who would also be able to answer any questions posed by the ambulance service. The clinician can also contact the communications room directly to ask for progress reports. As the net will only be accessible to the communications room and healthcare, this will mean confidential and sensitive information can be relayed.

This new system was trialled in an exercise on the 18th January 2022. This approached proved to be successful. This went live on the 31st of January. Supportive training regarding the new process has been provided to relevant staff and will now form part of the response process for all emergencies. This new system will be monitored via staff feedback and review of healthcare incidents which are logged for each Code Red/ Blue. This will be shared at the safety huddles and within the wider organisation to share best practice.

Dear Mr Rheinberg,

Thank you for your Regulation 28 report of 15 December 2021 following the inquest into the death of Martin Brown at HMP Lancaster Farms on 10 December 2018. I am responding on behalf of HMPPS as the Director General of Prisons.

I know that you will share a copy of this response with the family of Mr Brown and I would 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.

Following evidence heard at the inquest you have raised three concerns. The second concern is addressed solely to the Head of Healthcare who will be providing a separate response. I will be addressing the two concerns that relate to the prison: the need for prison staff to be trained in relation to medical emergency responses and the familiarisation of the ERIC (Emergency Response in Custody) system, and better communication between healthcare personnel at the scene of a medical emergency and the prison control room.

In January 2022 the Governor instructed that ERIC cards be distributed to all existing staff to provide a pocket guide on how to deal with emergency responses. Additional ERIC training has also commenced and is being delivered by the Head of Healthcare to all staff. This training is being delivered weekly until all staff have been trained or had any necessary refresher training. All new staff will now receive ERIC training and ERIC cards as part of their induction.

A new process has been implemented at HMP Lancaster Farms to ensure healthcare staff can communicate efficiently and effectively with the prison control room and the ambulance service during medical emergencies. By utilising a spare radio channel available on the prison radio network clinicians will now have the ability to speak directly to the ambulance service via the communication room when an emergency is underway. This will enable them to relay information and answer any questions posed by the ambulance service without disruption or delay, as well as receive progress reports on the ambulance’s arrival.

Also, the radio network will only be accessible to the communications room, healthcare and those first on scene to safeguard any confidential information.

Thank you again for bringing your concerns to my attention. I trust that this response provides assurance that action is being taken to address the matters that you have raised.