Darren Adams
PFD Report
All Responded
Ref: 2021-0125
All 2 responses received
· Deadline: 24 Jun 2021
Coroner's Concerns (AI summary)
Nursing staff misdiagnosed post-mortem conditions due to inadequate training in identification, and resuscitation guidance documents contained confusing definitions, risking proper emergency response.
View full coroner's concerns
In the circumstances it is my statutory to report to you_ The Nursing Staff misdiagnosed hypostasis. It was apparent in evidence that did not have a sufficient understanding of the process and how to identify it_ The Nursing Staff misdiagnosed rigor mortis. It was apparent in evidence that did not have a sufficient understanding of the process and how to identify it_ Management of the nurses accepted in evidence that more focus on the identification of those conditions should have been covered in better depth during the nurse's life support training:
4. It was seen during the evidence that definitions in Annex A of the document "Guidance to support the decision-making process of when not to perform Cardiopulmonary Resuscitation in prisons and immigration removal centre (IRC)" could be confusing; for example the word 'mottling" was interpreted by different people in different ways (both Iay and medical):
4. It was seen during the evidence that definitions in Annex A of the document "Guidance to support the decision-making process of when not to perform Cardiopulmonary Resuscitation in prisons and immigration removal centre (IRC)" could be confusing; for example the word 'mottling" was interpreted by different people in different ways (both Iay and medical):
Responses
Action Taken
Practice Plus Group has mandated training on the identification of hypostasis and rigor mortis, using scenario-based simulations, and will raise concerns about confusing terminology in existing guidance with NHS England. (AI summary)
Practice Plus Group has mandated training on the identification of hypostasis and rigor mortis, using scenario-based simulations, and will raise concerns about confusing terminology in existing guidance with NHS England. (AI summary)
View full response
Dear Mrs Harris
Regulation 28: Prevention of Future Deaths report, Darren Adams (Deceased)
Thank you for your Regulation 28 Prevention of Future Deaths Report issued to Practice Plus Group following the inquest touching upon the death of Darren Adams at HMP Lindholme. Practice Plus Group would like to express its condolences to Mr Adams’ family and friends. Below you will find each of the matters of concern addressed in turn:
Matter of Concern 1. The Nursing Staff misdiagnosed hypostasis. It was apparent in evidence that they did not have a sufficient understanding of the process and how to identify it.
Response: This is addressed in the response to matter of concern 3.
Matter of Concern 2. The Nursing Staff misdiagnosed rigor mortis. It was apparent in evidence that they did not have a sufficient understanding of the process and how to identify it.
Response: This is addressed in the response to matter of concern 3.
Matter of Concern 3. Management of the nurses accepted in evidence that more focus on the identification of those conditions should have been covered in better depth during the nurse’s life support training.
Response: Practice Plus Group acknowledges the matters of concern raised and that they relate to insufficient understanding by staff in identification of hypostasis and rigor mortis. In order to address the concerns raised the following actions have been taken:
• Practice Plus Group mandates annual Intermediate Life Support Training (ILS) for all clinical staff in recognition of their critical role in providing pre hospital life support. Non clinical staff are trained in Basic Life Support and agency staff are required to have undertaken ILS training and can access the training provided by Practice Plus Group. The curriculum for PPG’s ILS training has been adapted by our training provider to include prison specific scenarios. The training is delivered by Resuscitation Council accredited trainers. Following this inquest, the training provider has spoken to staff who have been involved in resuscitation decision-making scenarios to hear their experiences and understand the issues that are faced, including the challenges of diagnosing hypostasis. Our training provider has amended the content of the previously provided ILS course to include:
(i) 45-minute theoretical session on assessment and presentation, factors for consideration and recognition of rigor mortis and lividity; and
(ii) Mandatory scenarios where decision-making is required (previously these were optional).
This change in curriculum has been agreed will take effect from July 2021. Supplementary, additional education days have been developed for on-site training of clinical staff. These include a range of resuscitation scenarios to build staff confidence and encourage participation in group learning exercises; this is in addition to the ILS training provided. These simulation days are in the process of being rolled out across PPG’s sites, prioritising those where issues have been identified. A simulation training event at HMP Lindholme is being scheduled for the end of September 2021.
Records of training attendance and emergency scenario simulation events are kept on our Learning Management System to provide assurance of compliance with PPG requirements.
Matter of Concern 4. It was seen during the evidence that definitions in Annex A of the document “Guidance to support the decision-making process of when not to perform Cardiopulmonary Resuscitation in prisons and immigration removal centre (IRC)” could be
confusing, for example the word “mottling” was interpreted by different people in different ways (both lay and medical).
Response: This guidance was issued by the National Offender Management Service (NOMS), Royal College of Nursing (RCN) and the Royal College of General Practitioners (RCGP) in March 2016. Therefore, the terminology sits outside the control of Practice Plus Group. For Practice Plus Group we will:
- Teach clinical staff on how to diagnose death
- Teach our staff the practical meaning of the terminology used in the Resus Council UK guidance
- Raise the matter to NHS England by way of correspondence to indicate the concerns raised during this inquest.
Practice Plus Group will ensure that any revisions to the guidance are taken into account in our training.
Practice Plus Group are committed to providing a high quality healthcare service at HMP Lindholme and to ensuring that those detained there are as safe as possible and receive the best quality care. Practice Plus Group is deeply sorry that Mr Adams died while receiving care from our service and we will ensure that the lessons learnt are not just implemented at HMP Lindholme but across Practice Plus Group’s services.
I trust that the above responses provide the information that you require but please do not hesitate to contact me if Practice Plus Group can be of any further assistance.
Regulation 28: Prevention of Future Deaths report, Darren Adams (Deceased)
Thank you for your Regulation 28 Prevention of Future Deaths Report issued to Practice Plus Group following the inquest touching upon the death of Darren Adams at HMP Lindholme. Practice Plus Group would like to express its condolences to Mr Adams’ family and friends. Below you will find each of the matters of concern addressed in turn:
Matter of Concern 1. The Nursing Staff misdiagnosed hypostasis. It was apparent in evidence that they did not have a sufficient understanding of the process and how to identify it.
Response: This is addressed in the response to matter of concern 3.
Matter of Concern 2. The Nursing Staff misdiagnosed rigor mortis. It was apparent in evidence that they did not have a sufficient understanding of the process and how to identify it.
Response: This is addressed in the response to matter of concern 3.
Matter of Concern 3. Management of the nurses accepted in evidence that more focus on the identification of those conditions should have been covered in better depth during the nurse’s life support training.
Response: Practice Plus Group acknowledges the matters of concern raised and that they relate to insufficient understanding by staff in identification of hypostasis and rigor mortis. In order to address the concerns raised the following actions have been taken:
• Practice Plus Group mandates annual Intermediate Life Support Training (ILS) for all clinical staff in recognition of their critical role in providing pre hospital life support. Non clinical staff are trained in Basic Life Support and agency staff are required to have undertaken ILS training and can access the training provided by Practice Plus Group. The curriculum for PPG’s ILS training has been adapted by our training provider to include prison specific scenarios. The training is delivered by Resuscitation Council accredited trainers. Following this inquest, the training provider has spoken to staff who have been involved in resuscitation decision-making scenarios to hear their experiences and understand the issues that are faced, including the challenges of diagnosing hypostasis. Our training provider has amended the content of the previously provided ILS course to include:
(i) 45-minute theoretical session on assessment and presentation, factors for consideration and recognition of rigor mortis and lividity; and
(ii) Mandatory scenarios where decision-making is required (previously these were optional).
This change in curriculum has been agreed will take effect from July 2021. Supplementary, additional education days have been developed for on-site training of clinical staff. These include a range of resuscitation scenarios to build staff confidence and encourage participation in group learning exercises; this is in addition to the ILS training provided. These simulation days are in the process of being rolled out across PPG’s sites, prioritising those where issues have been identified. A simulation training event at HMP Lindholme is being scheduled for the end of September 2021.
Records of training attendance and emergency scenario simulation events are kept on our Learning Management System to provide assurance of compliance with PPG requirements.
Matter of Concern 4. It was seen during the evidence that definitions in Annex A of the document “Guidance to support the decision-making process of when not to perform Cardiopulmonary Resuscitation in prisons and immigration removal centre (IRC)” could be
confusing, for example the word “mottling” was interpreted by different people in different ways (both lay and medical).
Response: This guidance was issued by the National Offender Management Service (NOMS), Royal College of Nursing (RCN) and the Royal College of General Practitioners (RCGP) in March 2016. Therefore, the terminology sits outside the control of Practice Plus Group. For Practice Plus Group we will:
- Teach clinical staff on how to diagnose death
- Teach our staff the practical meaning of the terminology used in the Resus Council UK guidance
- Raise the matter to NHS England by way of correspondence to indicate the concerns raised during this inquest.
Practice Plus Group will ensure that any revisions to the guidance are taken into account in our training.
Practice Plus Group are committed to providing a high quality healthcare service at HMP Lindholme and to ensuring that those detained there are as safe as possible and receive the best quality care. Practice Plus Group is deeply sorry that Mr Adams died while receiving care from our service and we will ensure that the lessons learnt are not just implemented at HMP Lindholme but across Practice Plus Group’s services.
I trust that the above responses provide the information that you require but please do not hesitate to contact me if Practice Plus Group can be of any further assistance.
Noted
Resuscitation Council UK acknowledges the concerns but states that detailed training in the recognition of rigor mortis and hypostasis is outside the scope of RCUK training courses, though they encourage starting CPR unless irreversible death is certain. They have shared the response with relevant bodies. (AI summary)
Resuscitation Council UK acknowledges the concerns but states that detailed training in the recognition of rigor mortis and hypostasis is outside the scope of RCUK training courses, though they encourage starting CPR unless irreversible death is certain. They have shared the response with relevant bodies. (AI summary)
View full response
Dear Mrs Harris,
Response of Resuscitation Council UK Re: Regulation 28 Report to Prevent Future Deaths
1. This concerns the death of Darren Adams (date of birth 30 March 1962). He died following hanging in his prison cell. The specific concern was that cardiopulmonary resuscitation (CPR) was mistakenly not started by the prison nursing staff as they misdiagnosed the presence of hypostasis and rigor mortis.
2. The decision not to start CPR was based on the guidance from the National Offender Management Service, Royal College of Nursing, and Royal College of General Practitioners – Guidance to support the decision making process of when not to perform Cardiopulmonary Resuscitation in prisons and immigration removal centre (IRC) [March 2016].
3. The Coroner identified the following matters of concern at the Inquest:
1. The Nursing Staff misdiagnosed hypostasis. It was apparent in evidence that they did not have a sufficient understanding of the process and how to identify it.
2. The Nursing Staff misdiagnosed rigor mortis. It was apparent in evidence that they did not have a sufficient understanding of the process and how to identify it.
3. Management of the nurses accepted in evidence that more focus on the identification of those conditions should have been covered in better depth during the nurse's life support training.
4. It was seen during the evidence that definitions in Annex A of the document "Guidance to support the decision-making process of when not to perform Cardiopulmonary Resuscitation in prisons and immigration removal centre (IRC)" could be confusing, for
5th Floor, Tavistock House North Tavistock Square, London WC1H 9HR Registered Charity Number 1168914
example the word "mottling" was interpreted by different people in different ways (both lay and medical).
4. The Resuscitation Council UK (RCUK) sets out its response below. Specifically, it has been reviewed by Dr , Professor , Professor and Professor . All have expertise in the matters of concern.
5. The RCUK was not involved in the guidance document about CPR in prisons and immigration removal centres and was not involved in implementing the guidance and training in its use.
6. Training and clinical experience are required to be able to reliably diagnose irreversible death based on the presence of rigor mortis and hypostasis. Detailed training in the recognition of rigor mortis and hypostasis is outside the scope of RCUK training courses.
7. The RCUK encourages rescuers to start CPR and await more experienced help (e.g. a paramedic) to arrive to make decisions about stopping CPR when the diagnosis of irreversible death is uncertain.
8. The guidance for prisons explicitly states in section 2.7 – Staff who are not able to recognise rigor mortis should start resuscitation until advised otherwise by a competent member of staff. In our opinion, prison nursing staff are unlikely to have the experience to reliably diagnose rigor mortis and hypostasis.
9. The prison guidance is based on the Ambulance Service guidelines for ambulance staff to guide decision-making on when to start CPR. Ambulance paramedics routinely use this guidance in the UK and have training and, importantly, experience in its use.
10. Rigor mortis and hypostasis are mentioned but not addressed in detail in RCUK adult Immediate and Advanced Life Support courses. The default position in the RCUK life support courses is to start CPR when the diagnosis of irreversible death is not certain. Further assessments based on heart rhythm (presence of asystole – 'flat line') and a lack of response to CPR (persistent asystole despite 20 minutes of CPR) can help confirm the diagnosis of irreversible death.
11. Finally, RCUK has shared this response with:
5th Floor, Tavistock House North Tavistock Square, London WC1H 9HR Registered Charity Number 1168914
a. National Offender Management Service, Royal College of Nursing, and Royal College of General Practitioners who prepared the original guidance and has offered to liaise on any future update on their guidance.
b. RCUK Community and Ambulance Resuscitation (CARe) committee.
Response of Resuscitation Council UK Re: Regulation 28 Report to Prevent Future Deaths
1. This concerns the death of Darren Adams (date of birth 30 March 1962). He died following hanging in his prison cell. The specific concern was that cardiopulmonary resuscitation (CPR) was mistakenly not started by the prison nursing staff as they misdiagnosed the presence of hypostasis and rigor mortis.
2. The decision not to start CPR was based on the guidance from the National Offender Management Service, Royal College of Nursing, and Royal College of General Practitioners – Guidance to support the decision making process of when not to perform Cardiopulmonary Resuscitation in prisons and immigration removal centre (IRC) [March 2016].
3. The Coroner identified the following matters of concern at the Inquest:
1. The Nursing Staff misdiagnosed hypostasis. It was apparent in evidence that they did not have a sufficient understanding of the process and how to identify it.
2. The Nursing Staff misdiagnosed rigor mortis. It was apparent in evidence that they did not have a sufficient understanding of the process and how to identify it.
3. Management of the nurses accepted in evidence that more focus on the identification of those conditions should have been covered in better depth during the nurse's life support training.
4. It was seen during the evidence that definitions in Annex A of the document "Guidance to support the decision-making process of when not to perform Cardiopulmonary Resuscitation in prisons and immigration removal centre (IRC)" could be confusing, for
5th Floor, Tavistock House North Tavistock Square, London WC1H 9HR Registered Charity Number 1168914
example the word "mottling" was interpreted by different people in different ways (both lay and medical).
4. The Resuscitation Council UK (RCUK) sets out its response below. Specifically, it has been reviewed by Dr , Professor , Professor and Professor . All have expertise in the matters of concern.
5. The RCUK was not involved in the guidance document about CPR in prisons and immigration removal centres and was not involved in implementing the guidance and training in its use.
6. Training and clinical experience are required to be able to reliably diagnose irreversible death based on the presence of rigor mortis and hypostasis. Detailed training in the recognition of rigor mortis and hypostasis is outside the scope of RCUK training courses.
7. The RCUK encourages rescuers to start CPR and await more experienced help (e.g. a paramedic) to arrive to make decisions about stopping CPR when the diagnosis of irreversible death is uncertain.
8. The guidance for prisons explicitly states in section 2.7 – Staff who are not able to recognise rigor mortis should start resuscitation until advised otherwise by a competent member of staff. In our opinion, prison nursing staff are unlikely to have the experience to reliably diagnose rigor mortis and hypostasis.
9. The prison guidance is based on the Ambulance Service guidelines for ambulance staff to guide decision-making on when to start CPR. Ambulance paramedics routinely use this guidance in the UK and have training and, importantly, experience in its use.
10. Rigor mortis and hypostasis are mentioned but not addressed in detail in RCUK adult Immediate and Advanced Life Support courses. The default position in the RCUK life support courses is to start CPR when the diagnosis of irreversible death is not certain. Further assessments based on heart rhythm (presence of asystole – 'flat line') and a lack of response to CPR (persistent asystole despite 20 minutes of CPR) can help confirm the diagnosis of irreversible death.
11. Finally, RCUK has shared this response with:
5th Floor, Tavistock House North Tavistock Square, London WC1H 9HR Registered Charity Number 1168914
a. National Offender Management Service, Royal College of Nursing, and Royal College of General Practitioners who prepared the original guidance and has offered to liaise on any future update on their guidance.
b. RCUK Community and Ambulance Resuscitation (CARe) committee.
Sent To
- Practice Plus Group and Resuscitation Council UK
Response Status
Linked responses
2 of 1
56-Day Deadline
24 Jun 2021
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 15th November 2017 commenced an investigation into the death of Darren Adams (DOB 30th March 1962). The investigation concluded at the end of the inquest on 28th April 2021. The conclusion of the inquest was suicide, the medical cause of death was 1a Hypoxic Brain Injury 1b Hanging: CIRCUMSTANCES OF THE DEATH On 7th November 2017 Darren Adams was transferred from HMP Garth (HMPG) to HMP Lindholme (HMPL): It appears he believed, incorrectly, that there was a Vulnerable Prisoner Unit (VPU) at HMPL. Staff at HMPG accepted Mr Adams had asked about a VPU but the fact there was no such unit at HMPL was not relayed back to him. There was no evidence to say that he would have been placed on a VPU even if there had been one at HMPL. Mr Adams had a history of unsettled when moved, even within a prison. The jury found that there was insufficient information regarding Mr Adam'$ on his transfer and arrival at HMPL. Within 24 hours of arrival his mental health deteriorated to such an extent he was placed on an ACCT. There were insufficient records of his behaviour in the ACCT and a full picture of his mental health was not recorded_ Darren was alive at 0641 hours on 12th November 2017 but discovered ligatured in his cell at 0738 hours. The officer discovering Mr Adams waited for additional staff assistance before attempting to enter the cell however Darren had erected a barricade at his door which caused an additional slight delay in accessing him: Once the door was opened and barricade removed nursing staff from prison healthcare entered the cell: The nursing staff carried out a clinical assessment but misdiagnosed him, Floor, being believing him to have hypostasis and rigor mortis. They decided not to commence CPR_ The nurses had previously been advised by the Prison Service and Probation Ombudsman against commencing CPR when someone is obviously deceased. referred to the guidance "Guidance to support the decision-making process of when not to perform Cardiopulmonary Resuscitation in prisons and immigration removal centre (IRC)" When paramedics arrived their clinical assessment found no hypostasis, no rigor mortis and they also stated he was still warm. commenced CPR and obtained a return of spontaneous circulation 4 times, the last as he was conveyed to Doncaster Royal Infirmary (DRI): Once at DRI, after a period of observation and tests Mr Adams was declared dead at 13th November 2017. CORONER'S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory to report to you_ The MATTERS OF CONCERN are as follows: The Nursing Staff misdiagnosed hypostasis. It was apparent in evidence that did not have a sufficient understanding of the process and how to identify it_ The Nursing Staff misdiagnosed rigor mortis. It was apparent in evidence that did not have a sufficient understanding of the process and how to identify it_ Management of the nurses accepted in evidence that more focus on the identification of those conditions should have been covered in better depth during the nurse's life support training:
4. It was seen during the evidence that definitions in Annex A of the document "Guidance to support the decision-making process of when not to perform Cardiopulmonary Resuscitation in prisons and immigration removal centre (IRC)" could be confusing; for example the word 'mottling" was interpreted by different people in different ways (both Iay and medical): ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and believe your organisation have the power to take such action: YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 24th June 2021. !,the Assistant Coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed They They duty they they
COPIES AND PUBLICATION Ihave sent a copy of my report to the Chief Coroner and the following interested persons: The family represented by Ison Harrison Solicitors HMP Lindholme represented by Government Legal Department have also sent it to the following people who may find it useful or of interest: Her Majesty' s Inspectorate of Prisons Her Majesty' s Prison and Probation Service The Prison and Probation Service Ombudsman Independent Advisory Panel on Deaths In Custody am also under a duty to send a copy of your responses to the Chief Coroner and all interested persons who in my opinion should receive it. Imay also send vour responses to any other person who believe may find it useful or of interest_ The Chief Coroner publish either or both in a complete or redacted or summary form: He may send a copy of this report to any person who he believes may find it useful or of interest: You may make representations to me, the Assistant Coroner, at the time of your response; about the release or the publication of your response_ borraing tarris (Signed Electronically) 29th April 2021 may
4. It was seen during the evidence that definitions in Annex A of the document "Guidance to support the decision-making process of when not to perform Cardiopulmonary Resuscitation in prisons and immigration removal centre (IRC)" could be confusing; for example the word 'mottling" was interpreted by different people in different ways (both Iay and medical): ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and believe your organisation have the power to take such action: YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 24th June 2021. !,the Assistant Coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed They They duty they they
COPIES AND PUBLICATION Ihave sent a copy of my report to the Chief Coroner and the following interested persons: The family represented by Ison Harrison Solicitors HMP Lindholme represented by Government Legal Department have also sent it to the following people who may find it useful or of interest: Her Majesty' s Inspectorate of Prisons Her Majesty' s Prison and Probation Service The Prison and Probation Service Ombudsman Independent Advisory Panel on Deaths In Custody am also under a duty to send a copy of your responses to the Chief Coroner and all interested persons who in my opinion should receive it. Imay also send vour responses to any other person who believe may find it useful or of interest_ The Chief Coroner publish either or both in a complete or redacted or summary form: He may send a copy of this report to any person who he believes may find it useful or of interest: You may make representations to me, the Assistant Coroner, at the time of your response; about the release or the publication of your response_ borraing tarris (Signed Electronically) 29th April 2021 may
Circumstances of the Death
On 7th November 2017 Darren Adams was transferred from HMP Garth (HMPG) to HMP Lindholme (HMPL): It appears he believed, incorrectly, that there was a Vulnerable Prisoner Unit (VPU) at HMPL. Staff at HMPG accepted Mr Adams had asked about a VPU but the fact there was no such unit at HMPL was not relayed back to him. There was no evidence to say that he would have been placed on a VPU even if there had been one at HMPL. Mr Adams had a history of unsettled when moved, even within a prison. The jury found that there was insufficient information regarding Mr Adam'$ on his transfer and arrival at HMPL. Within 24 hours of arrival his mental health deteriorated to such an extent he was placed on an ACCT. There were insufficient records of his behaviour in the ACCT and a full picture of his mental health was not recorded_ Darren was alive at 0641 hours on 12th November 2017 but discovered ligatured in his cell at 0738 hours. The officer discovering Mr Adams waited for additional staff assistance before attempting to enter the cell however Darren had erected a barricade at his door which caused an additional slight delay in accessing him: Once the door was opened and barricade removed nursing staff from prison healthcare entered the cell: The nursing staff carried out a clinical assessment but misdiagnosed him, Floor, being believing him to have hypostasis and rigor mortis. They decided not to commence CPR_ The nurses had previously been advised by the Prison Service and Probation Ombudsman against commencing CPR when someone is obviously deceased. referred to the guidance "Guidance to support the decision-making process of when not to perform Cardiopulmonary Resuscitation in prisons and immigration removal centre (IRC)" When paramedics arrived their clinical assessment found no hypostasis, no rigor mortis and they also stated he was still warm. commenced CPR and obtained a return of spontaneous circulation 4 times, the last as he was conveyed to Doncaster Royal Infirmary (DRI): Once at DRI, after a period of observation and tests Mr Adams was declared dead at 13th November 2017.
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe your organisation have the power to take such action:
Inquest Conclusion
The Nursing Staff misdiagnosed hypostasis. It was apparent in evidence that did not have a sufficient understanding of the process and how to identify it_ The Nursing Staff misdiagnosed rigor mortis. It was apparent in evidence that did not have a sufficient understanding of the process and how to identify it_ Management of the nurses accepted in evidence that more focus on the identification of those conditions should have been covered in better depth during the nurse's life support training:
4. It was seen during the evidence that definitions in Annex A of the document "Guidance to support the decision-making process of when not to perform Cardiopulmonary Resuscitation in prisons and immigration removal centre (IRC)" could be confusing; for example the word 'mottling" was interpreted by different people in different ways (both Iay and medical): ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and believe your organisation have the power to take such action: YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 24th June 2021. !,the Assistant Coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed They They duty they they
COPIES AND PUBLICATION Ihave sent a copy of my report to the Chief Coroner and the following interested persons: The family represented by Ison Harrison Solicitors HMP Lindholme represented by Government Legal Department have also sent it to the following people who may find it useful or of interest: Her Majesty' s Inspectorate of Prisons Her Majesty' s Prison and Probation Service The Prison and Probation Service Ombudsman Independent Advisory Panel on Deaths In Custody am also under a duty to send a copy of your responses to the Chief Coroner and all interested persons who in my opinion should receive it. Imay also send vour responses to any other person who believe may find it useful or of interest_ The Chief Coroner publish either or both in a complete or redacted or summary form: He may send a copy of this report to any person who he believes may find it useful or of interest: You may make representations to me, the Assistant Coroner, at the time of your response; about the release or the publication of your response_ borraing tarris (Signed Electronically) 29th April 2021 may
4. It was seen during the evidence that definitions in Annex A of the document "Guidance to support the decision-making process of when not to perform Cardiopulmonary Resuscitation in prisons and immigration removal centre (IRC)" could be confusing; for example the word 'mottling" was interpreted by different people in different ways (both Iay and medical): ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and believe your organisation have the power to take such action: YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 24th June 2021. !,the Assistant Coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed They They duty they they
COPIES AND PUBLICATION Ihave sent a copy of my report to the Chief Coroner and the following interested persons: The family represented by Ison Harrison Solicitors HMP Lindholme represented by Government Legal Department have also sent it to the following people who may find it useful or of interest: Her Majesty' s Inspectorate of Prisons Her Majesty' s Prison and Probation Service The Prison and Probation Service Ombudsman Independent Advisory Panel on Deaths In Custody am also under a duty to send a copy of your responses to the Chief Coroner and all interested persons who in my opinion should receive it. Imay also send vour responses to any other person who believe may find it useful or of interest_ The Chief Coroner publish either or both in a complete or redacted or summary form: He may send a copy of this report to any person who he believes may find it useful or of interest: You may make representations to me, the Assistant Coroner, at the time of your response; about the release or the publication of your response_ borraing tarris (Signed Electronically) 29th April 2021 may
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