Robert Ginn
PFD Report
Partially Responded
Ref: 2019-0372
Coroner's Concerns (AI summary)
Inadequate resuscitation efforts by prison nurses included failure to continuously check breathing for 11 minutes and insufficient oxygenation, alongside conflicting assessments of the patient's body temperature.
View full coroner's concerns
_ _ was able to view via body worn camera (BWC) footage part of the resuscitation attempt, and had the benefit of evidence from a senior London Ambulance Service (LAS) paramedic who had also viewed it:
1. The nurse (Hotel 12) who gave evidence at inquest said that Mr Ginn was cold when she got to him, but the LAS paramedic who arrived later was confident that he was still warm, and his temperature was recorded as 34.78C. Throughout the resuscitation attempt captured on BWC , no staff member checked Mr Ginn's breathing: It is possible that the breathing was checked before the commencement of the bodycam footage, and indeed one of the prison officers said he checked it at the outset; but the footage ran for nearly eleven minutes before the London Ambulance Service arrived and took over, and it was not checked in that time
3. At inquest, one of the nurses said that she looked at Mr Ginn's chest at the outset; but she did not put her cheek to his mouth to listen and feel for breath in order to confirm he was not breathing: After the first two minutes Of footage, the oxygen mask that had been in place was taken off and no further efforts were made to oxygenate Mr Ginn; 5_ Given that Mr Ginn's heart had stopped beating, he must have stopped breathing as well: A full, effective, nurse led resuscitation attempt should included an attempt to oxygenate throughout: have
Hotel 12 said that she did not do this because Mr Ginn's jaw was too stiff to insert an airway, but the LAS did
1. The nurse (Hotel 12) who gave evidence at inquest said that Mr Ginn was cold when she got to him, but the LAS paramedic who arrived later was confident that he was still warm, and his temperature was recorded as 34.78C. Throughout the resuscitation attempt captured on BWC , no staff member checked Mr Ginn's breathing: It is possible that the breathing was checked before the commencement of the bodycam footage, and indeed one of the prison officers said he checked it at the outset; but the footage ran for nearly eleven minutes before the London Ambulance Service arrived and took over, and it was not checked in that time
3. At inquest, one of the nurses said that she looked at Mr Ginn's chest at the outset; but she did not put her cheek to his mouth to listen and feel for breath in order to confirm he was not breathing: After the first two minutes Of footage, the oxygen mask that had been in place was taken off and no further efforts were made to oxygenate Mr Ginn; 5_ Given that Mr Ginn's heart had stopped beating, he must have stopped breathing as well: A full, effective, nurse led resuscitation attempt should included an attempt to oxygenate throughout: have
Hotel 12 said that she did not do this because Mr Ginn's jaw was too stiff to insert an airway, but the LAS did
Responses
Noted
Care UK expresses condolences and addresses the coroner's concerns regarding first aid quality at HMP Pentonville. They discuss training, national changes to resuscitation procedures, and staff safety, but ultimately do not support bodycams for nurses due to concerns about patient trust and rapport. (AI summary)
Care UK expresses condolences and addresses the coroner's concerns regarding first aid quality at HMP Pentonville. They discuss training, national changes to resuscitation procedures, and staff safety, but ultimately do not support bodycams for nurses due to concerns about patient trust and rapport. (AI summary)
View full response
Dear Madam,
Regulation 28: Prevention of Future Deaths report, Robert Ginn (died 29 November 2018)
Thank you for your Regulation 28 Prevention of Future Deaths Report issued to Care UK on 30 October 2019 following the inquest into the death of Mr Robert Ginn at HMP Pentonville.
Care UK would like to express its condolences to Mr Ginn’s family and friends.
Care UK is the main provider of healthcare services at HMP Pentonville.
You have directed your report to and myself. I am responding on behalf of Care UK.
I have addressed the issues you have raised at paragraphs 5.
The matters of concern are highlighted in bold with the response set out below each concern. I have set out the action taken in response to your report and the timetable for the action plan. Care UK are committed to ensuring that the lessons learnt following this inquest are not just implemented at HMP Pentonville but across Care UK’s services at other custodial sites where Care UK provide healthcare. I am therefore able to respond on the work that is being done on a national basis.
Matter of Concern: This is the fifth occasion in five years that I have written to Care UK about the quality of first aid at HMP Pentonville. Given that fact, I wonder whether consideration could be given to nurses wearing bodycams and activating these in emergency situations
Response: In order to deal with your concern, I have discussed the following matters:
The training that nurses who are involved in resuscitation receive; The national changes in respect of resuscitation that are being implemented at Care UK; Healthcare staff wearing body worn cameras.
The training that nurses who are involved in resuscitation receive
Our policy for the standards of training for employed staff within our Health in Justice service who respond to resuscitation is Intermediate Life Support (ILS) training, provided by Resuscitation Council accredited trainers. Although the requirement from the Resuscitation Council is that attendee’s repeat this on a 3 yearly cycle, we mandate that all Care UK employed staff complete this annually. Assurance around the compliance of this training is monitored via monthly performance dashboards and reported to Care UK’s Resuscitation Committee.
All of our healthcare staff provided by agencies are required to provide evidence of up to date resuscitation training to at least Basic Life Support standard.
The national changes that are being implemented at Care UK
An alert has been issued to all Care UK Heads of Healthcare advising them to seek and provide assurance that all staff holding the emergency radio have the physical fitness to undertake full resuscitation and that those responsible for carrying the emergency radio are, and feel, confident to, lead a resuscitation. This will be followed up by our governance managers to ensure compliance.
Going forwards, we will contract with our ILS training provider to deliver additional training sessions, including some prison scenario based training. These will be in addition to the annual re-certification sessions. We anticipate that this will be rolled out across our sites nationally over 2020. In addition our intention is to film some of these scenario-based training exercises for use at in-house training events and induction.
Following a death in custody where resuscitation has taken place on site, a request is made to the prison for the opportunity to view or receive a copy of any CCTV or body worn camera footage so that this can be reviewed as part of Care UK’s 72hr immediate review process and Internal Learning Review. This is to enable is to identify issues or concerns and to assist in improving clinical care and identifying training needs.
Healthcare staff wearing body worn cameras
It is our understanding that body worn cameras were introduced to improve safety for staff working within the prisons. We have been keen to explore what governance has been put in place around the use of body worn cameras in clinical situations and have had conversations previously with both NHSE and NOMs. We are concerned that there is a risk of judgements being made regarding clinical quality from a tool not designed for use in the situation, and by people unused to either resuscitation scenarios or prison environments and from what may be poor quality footage.
Prior to the conclusion of Mr Ginn’s inquest Care UK had already considered the impact of the use of body worn cameras on healthcare teams working in prisons. In several prisons where Care UK operate, our healthcare staff have been offered body worn cameras as a measure to increase their personal safety. However, this is obviously very concerning as body worn cameras cannot replace officers or provide the same level of order, discipline and protection that physical officer presence does - particularly in predictably ill-disciplined situations such as medication queues
Whilst we are aware of the use of body worn cameras in some NHS and secure environments (for the purpose of staff safety), we have considerable concerns about the potential impact on the essential rapport building required between clinicians and patients if our clinicians start wearing body worn cameras. It can be challenging to gain trust with our patients in prison for a variety of reasons. Our concern is that simply wearing body worn cameras – even if not always turned on –could impact on the confidence patients have in the confidentiality of their consultation. Thus cameras could have an adverse impact on a prisoner’s engagement with health services and possibly lead to poorer health outcomes rather than result in any improvements in the quality of their clinical care.
Thus, following due consideration and debate, Care UK’s position remains that we neither support the filming of resuscitations by officers nor the wearing of body worn cameras by nursing staff. We have communicated this to NHSE and HMPPS
We trust that the above response provides the information that you require but please do not hesitate to contact us if Care UK can provide any further information to address your concerns.
Regulation 28: Prevention of Future Deaths report, Robert Ginn (died 29 November 2018)
Thank you for your Regulation 28 Prevention of Future Deaths Report issued to Care UK on 30 October 2019 following the inquest into the death of Mr Robert Ginn at HMP Pentonville.
Care UK would like to express its condolences to Mr Ginn’s family and friends.
Care UK is the main provider of healthcare services at HMP Pentonville.
You have directed your report to and myself. I am responding on behalf of Care UK.
I have addressed the issues you have raised at paragraphs 5.
The matters of concern are highlighted in bold with the response set out below each concern. I have set out the action taken in response to your report and the timetable for the action plan. Care UK are committed to ensuring that the lessons learnt following this inquest are not just implemented at HMP Pentonville but across Care UK’s services at other custodial sites where Care UK provide healthcare. I am therefore able to respond on the work that is being done on a national basis.
Matter of Concern: This is the fifth occasion in five years that I have written to Care UK about the quality of first aid at HMP Pentonville. Given that fact, I wonder whether consideration could be given to nurses wearing bodycams and activating these in emergency situations
Response: In order to deal with your concern, I have discussed the following matters:
The training that nurses who are involved in resuscitation receive; The national changes in respect of resuscitation that are being implemented at Care UK; Healthcare staff wearing body worn cameras.
The training that nurses who are involved in resuscitation receive
Our policy for the standards of training for employed staff within our Health in Justice service who respond to resuscitation is Intermediate Life Support (ILS) training, provided by Resuscitation Council accredited trainers. Although the requirement from the Resuscitation Council is that attendee’s repeat this on a 3 yearly cycle, we mandate that all Care UK employed staff complete this annually. Assurance around the compliance of this training is monitored via monthly performance dashboards and reported to Care UK’s Resuscitation Committee.
All of our healthcare staff provided by agencies are required to provide evidence of up to date resuscitation training to at least Basic Life Support standard.
The national changes that are being implemented at Care UK
An alert has been issued to all Care UK Heads of Healthcare advising them to seek and provide assurance that all staff holding the emergency radio have the physical fitness to undertake full resuscitation and that those responsible for carrying the emergency radio are, and feel, confident to, lead a resuscitation. This will be followed up by our governance managers to ensure compliance.
Going forwards, we will contract with our ILS training provider to deliver additional training sessions, including some prison scenario based training. These will be in addition to the annual re-certification sessions. We anticipate that this will be rolled out across our sites nationally over 2020. In addition our intention is to film some of these scenario-based training exercises for use at in-house training events and induction.
Following a death in custody where resuscitation has taken place on site, a request is made to the prison for the opportunity to view or receive a copy of any CCTV or body worn camera footage so that this can be reviewed as part of Care UK’s 72hr immediate review process and Internal Learning Review. This is to enable is to identify issues or concerns and to assist in improving clinical care and identifying training needs.
Healthcare staff wearing body worn cameras
It is our understanding that body worn cameras were introduced to improve safety for staff working within the prisons. We have been keen to explore what governance has been put in place around the use of body worn cameras in clinical situations and have had conversations previously with both NHSE and NOMs. We are concerned that there is a risk of judgements being made regarding clinical quality from a tool not designed for use in the situation, and by people unused to either resuscitation scenarios or prison environments and from what may be poor quality footage.
Prior to the conclusion of Mr Ginn’s inquest Care UK had already considered the impact of the use of body worn cameras on healthcare teams working in prisons. In several prisons where Care UK operate, our healthcare staff have been offered body worn cameras as a measure to increase their personal safety. However, this is obviously very concerning as body worn cameras cannot replace officers or provide the same level of order, discipline and protection that physical officer presence does - particularly in predictably ill-disciplined situations such as medication queues
Whilst we are aware of the use of body worn cameras in some NHS and secure environments (for the purpose of staff safety), we have considerable concerns about the potential impact on the essential rapport building required between clinicians and patients if our clinicians start wearing body worn cameras. It can be challenging to gain trust with our patients in prison for a variety of reasons. Our concern is that simply wearing body worn cameras – even if not always turned on –could impact on the confidence patients have in the confidentiality of their consultation. Thus cameras could have an adverse impact on a prisoner’s engagement with health services and possibly lead to poorer health outcomes rather than result in any improvements in the quality of their clinical care.
Thus, following due consideration and debate, Care UK’s position remains that we neither support the filming of resuscitations by officers nor the wearing of body worn cameras by nursing staff. We have communicated this to NHSE and HMPPS
We trust that the above response provides the information that you require but please do not hesitate to contact us if Care UK can provide any further information to address your concerns.
Sent To
- Care UK
- HMP Pentonville
Response Status
Linked responses
1 of 2
56-Day Deadline
7 Feb 2020
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 13 December 2018, one of my assistant coroners, William Dolman; commenced an investigation into the death of Robert Ginn, aged 54 years_ The investigation concluded at the end of the inquest yesterday: The jury made a narrative determination, a copy of which attach: CIRCUMSTANCES OF THE DEATH
Mr Ginn hanged himself in his cell at HM Prison Pentonville: He was discovered by an operational support grade at around 1.05am on 29 November 2018. She raised the alarm and the two Care UK nurses on call for emergencies overnight (Hotel 7 and Hotel 12) attended to lead the resuscitation attempt: 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 will occur unless action is taken. In the circumstances, it is my statutory duty to report to you_ The MATTERS OF CONCERN are as follows_ was able to view via body worn camera (BWC) footage part of the resuscitation attempt, and had the benefit of evidence from a senior London Ambulance Service (LAS) paramedic who had also viewed it:
1. The nurse (Hotel 12) who gave evidence at inquest said that Mr Ginn was cold when she got to him, but the LAS paramedic who arrived later was confident that he was still warm, and his temperature was recorded as 34.78C. Throughout the resuscitation attempt captured on BWC , no staff member checked Mr Ginn's breathing: It is possible that the breathing was checked before the commencement of the bodycam footage, and indeed one of the prison officers said he checked it at the outset; but the footage ran for nearly eleven minutes before the London Ambulance Service arrived and took over, and it was not checked in that time
3. At inquest, one of the nurses said that she looked at Mr Ginn's chest at the outset; but she did not put her cheek to his mouth to listen and feel for breath in order to confirm he was not breathing: After the first two minutes Of footage, the oxygen mask that had been in place was taken off and no further efforts were made to oxygenate Mr Ginn; 5_ Given that Mr Ginn's heart had stopped beating, he must have stopped breathing as well: A full, effective, nurse led resuscitation attempt should included an attempt to oxygenate throughout: have
Hotel 12 said that she did not do this because Mr Ginn's jaw was too stiff to insert an airway, but the LAS did SO without any difficulty: And if he had been cold and stiff when arrived, the LAS paramedics would not have commenced resuscitation. In any event, an oxygen mask can be applied even if there is stiffness (as it was here, but then it was removed two minutes into resuscitation and nearly nine minutes before LAS took over): Chest compressions given by different members of staff were variable and some, including those of one of the nurses, were sub optimal: At one point, chest compressions were given by a staff member sandwiched between Mr Ginn and the wall, where there was not enough space to be effective. No attempt was made by either of the nurses to coach the prison officer to improve the quality of chest compressions:
8. One of the nurses (Hotel 7) did not administer chest compressions at all: She did not give evidence at inquest and so the reason for this is unclear.
9. The defibrillator pads were incorrectly applied by the nursing team, rendering the defibrillator reading unreliable. In fact, it was highly unlikely that Mr Ginn could have been saved_ whatever the quality of resuscitation attempts, but that might not be the case for another prisoner or visitor, or member of staff: This is the fifth occasion in five years that have written to Care UK about the quality of first aid at HMP Pentonville_ Given that fact, wonder whether consideration could be given to nurses wearing bodycams and activating these in emergency situations? ACTION SHOULD BE TAKEN In my opinion, action should be taken to prevent future deaths and believe that you 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 30 December 2019. 1, the coroner, may extend the period: they = the
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: COPIES and PUBLICATION have sent a copy of my report to the following: HHJ Mark Lucraft QC , the Chief Coroner of England & Wales Care Quality Commission for England HM Inspectorate of Prisons National Offender Management Service Mr Ginn's sister Mr Ginn's wife am also under duty to send the Chief Coroner copy of your response The Chief Coroner may 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 Senior Coroner, at the time of your response_ about the release or the publication of your response by the Chief Coroner_ DATE SIGNED BY SENIOR CORONER 30.10.19 W#ta~ul
Mr Ginn hanged himself in his cell at HM Prison Pentonville: He was discovered by an operational support grade at around 1.05am on 29 November 2018. She raised the alarm and the two Care UK nurses on call for emergencies overnight (Hotel 7 and Hotel 12) attended to lead the resuscitation attempt: 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 will occur unless action is taken. In the circumstances, it is my statutory duty to report to you_ The MATTERS OF CONCERN are as follows_ was able to view via body worn camera (BWC) footage part of the resuscitation attempt, and had the benefit of evidence from a senior London Ambulance Service (LAS) paramedic who had also viewed it:
1. The nurse (Hotel 12) who gave evidence at inquest said that Mr Ginn was cold when she got to him, but the LAS paramedic who arrived later was confident that he was still warm, and his temperature was recorded as 34.78C. Throughout the resuscitation attempt captured on BWC , no staff member checked Mr Ginn's breathing: It is possible that the breathing was checked before the commencement of the bodycam footage, and indeed one of the prison officers said he checked it at the outset; but the footage ran for nearly eleven minutes before the London Ambulance Service arrived and took over, and it was not checked in that time
3. At inquest, one of the nurses said that she looked at Mr Ginn's chest at the outset; but she did not put her cheek to his mouth to listen and feel for breath in order to confirm he was not breathing: After the first two minutes Of footage, the oxygen mask that had been in place was taken off and no further efforts were made to oxygenate Mr Ginn; 5_ Given that Mr Ginn's heart had stopped beating, he must have stopped breathing as well: A full, effective, nurse led resuscitation attempt should included an attempt to oxygenate throughout: have
Hotel 12 said that she did not do this because Mr Ginn's jaw was too stiff to insert an airway, but the LAS did SO without any difficulty: And if he had been cold and stiff when arrived, the LAS paramedics would not have commenced resuscitation. In any event, an oxygen mask can be applied even if there is stiffness (as it was here, but then it was removed two minutes into resuscitation and nearly nine minutes before LAS took over): Chest compressions given by different members of staff were variable and some, including those of one of the nurses, were sub optimal: At one point, chest compressions were given by a staff member sandwiched between Mr Ginn and the wall, where there was not enough space to be effective. No attempt was made by either of the nurses to coach the prison officer to improve the quality of chest compressions:
8. One of the nurses (Hotel 7) did not administer chest compressions at all: She did not give evidence at inquest and so the reason for this is unclear.
9. The defibrillator pads were incorrectly applied by the nursing team, rendering the defibrillator reading unreliable. In fact, it was highly unlikely that Mr Ginn could have been saved_ whatever the quality of resuscitation attempts, but that might not be the case for another prisoner or visitor, or member of staff: This is the fifth occasion in five years that have written to Care UK about the quality of first aid at HMP Pentonville_ Given that fact, wonder whether consideration could be given to nurses wearing bodycams and activating these in emergency situations? ACTION SHOULD BE TAKEN In my opinion, action should be taken to prevent future deaths and believe that you 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 30 December 2019. 1, the coroner, may extend the period: they = the
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: COPIES and PUBLICATION have sent a copy of my report to the following: HHJ Mark Lucraft QC , the Chief Coroner of England & Wales Care Quality Commission for England HM Inspectorate of Prisons National Offender Management Service Mr Ginn's sister Mr Ginn's wife am also under duty to send the Chief Coroner copy of your response The Chief Coroner may 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 Senior Coroner, at the time of your response_ about the release or the publication of your response by the Chief Coroner_ DATE SIGNED BY SENIOR CORONER 30.10.19 W#ta~ul
Circumstances of the Death
Mr Ginn hanged himself in his cell at HM Prison Pentonville: He was discovered by an operational support grade at around 1.05am on 29 November 2018. She raised the alarm and the two Care UK nurses on call for emergencies overnight (Hotel 7 and Hotel 12) attended to lead the resuscitation attempt:
Action Should Be Taken
In my opinion, action should be taken to prevent future deaths and believe that you have the power to take such action:
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.