Tedros Kahssay
PFD Report
Partially Responded
Ref: 2016-0437
Coroner's Concerns (AI summary)
Inadequate information transfer to prison healthcare, flawed nurse reception screening lacking objective analysis, and emergency response staff having insufficient understanding of medical emergency protocols.
View full coroner's concerns
I list the MATTERS OF CONCERN below, though I am conscious that some of these have now been the subject of remedial action.
Person Escort Record
1. The person escort record (PER) and appended report of the forensic medical examiner (FME) that accompanied Mr Kahssay to HMP Pentonville did not accompany him to nurse reception screening.
Circumstances of the Index Offence
2. The index offence is recorded on the PER (and inputted onto the prison computer system NOMIS, though not the healthcare computer system SystmOne), but not the circumstances. The circumstances – perhaps from the indictment read out in court – may be potentially helpful to healthcare and possibly also to discipline staff in prison.
This is not clear cut, because the logistics of obtaining the information and making it available to those who need it are complex; prosecutions must not be compromised; and there is the potential for making a prisoner’s mental state worse by probing the circumstances.
However, it seems that this is an issue that is worthy of consideration, preferably at a national level.
General Practitioner Records
3. The general practitioner records were never obtained (an issue that I have raised in the past), despite there being a system in place for Pentonville healthcare administrative staff to do this. Whilst that did not impact upon Mr Kahssay’s care, it might for another prisoner. Nurse Reception Screening
4. The first reception screen template contained questions that carried an inherent ambiguity, in that they related to a change in personal and family circumstances, which must always be the case when a person is incarcerated and therefore does not assist in determining which prisoners are at an increased risk.
(I did hear at inquest that any prisoner on a charge of murder will now be the subject of a psychiatric assessment.)
5. Both nurses conducting reception screening talked often in evidence about not being able to do anything other than accept the answers given by the prisoner. They did not seem to bring any objective analysis to the screening. The process of nurse screening appeared at times to be a tick box exercise.
6. The second reception (well man) screening nurse did not explore the history of depression recorded, he said because the prison general practitioner had not prescribed any medication for depression. On reflection, the nurse thought that he should have asked about it.
Resuscitation
7. The resuscitation led by the two nurses occupying the positions of primary (Hotel 7) and secondary (Hotel 12) leads for emergency healthcare in the prison that night, was significantly lacking in the following ways.
The nurse with primary responsibility for emergency care in the prison did not have a proper understanding of the nature of a code red and a code blue prison medical emergency. (I have raised this issue in the past.)
One minute and twelve seconds elapsed after nurse arrival before any substantive care was given. The action during that one minute and twelve seconds did not appear to progress the resuscitation attempt.
There seemed no clear demarcation of roles and responsibilities during the resuscitation. Of course these may change as those giving resuscitation tire, but the changes seemed haphazard.
There was no checking for breath or airway manoeuvre at the outset or at any time during the resuscitation.
There was no checking for pulse at the outset, before commencing chest compressions, or at any time during the resuscitation. The lead nurse attempted to justify this by saying that she had not wanted to waste time. This was despite the first action upon finding the casualty being to apply a blood pressure cuff, on the basis that this was part of the nurse assessment.
When giving evidence, the lead nurse appeared to conflate the casualty who is in cardiorespiratory arrest with the casualty who is merely unconscious. She repeatedly talked about the need to give cardiopulmonary resuscitation (CPR) to an unconscious casualty. She said that, at the time she started chest compressions, she did not know whether Mr Kahssay was breathing or not breathing.
When CPR was given, chest compressions were ineffective, being too quick and too shallow.
There was only one brief attempt to use an ambubag, the majority of the resuscitation taking place without airway assistance or with a non rebreathe oxygen mask.
It appeared that one oxygen cylinder was empty, as it had to be changed for another.
The nurse leading the resuscitation described it as chaotic. That is indeed how it appeared to me from her description and from viewing the bodycam footage.
I was and remain very gravely concerned, not in this respect for Mr Kahssay who was in fact already dead when resuscitation commenced, but for anyone else in the prison in need of first aid.
Person Escort Record
1. The person escort record (PER) and appended report of the forensic medical examiner (FME) that accompanied Mr Kahssay to HMP Pentonville did not accompany him to nurse reception screening.
Circumstances of the Index Offence
2. The index offence is recorded on the PER (and inputted onto the prison computer system NOMIS, though not the healthcare computer system SystmOne), but not the circumstances. The circumstances – perhaps from the indictment read out in court – may be potentially helpful to healthcare and possibly also to discipline staff in prison.
This is not clear cut, because the logistics of obtaining the information and making it available to those who need it are complex; prosecutions must not be compromised; and there is the potential for making a prisoner’s mental state worse by probing the circumstances.
However, it seems that this is an issue that is worthy of consideration, preferably at a national level.
General Practitioner Records
3. The general practitioner records were never obtained (an issue that I have raised in the past), despite there being a system in place for Pentonville healthcare administrative staff to do this. Whilst that did not impact upon Mr Kahssay’s care, it might for another prisoner. Nurse Reception Screening
4. The first reception screen template contained questions that carried an inherent ambiguity, in that they related to a change in personal and family circumstances, which must always be the case when a person is incarcerated and therefore does not assist in determining which prisoners are at an increased risk.
(I did hear at inquest that any prisoner on a charge of murder will now be the subject of a psychiatric assessment.)
5. Both nurses conducting reception screening talked often in evidence about not being able to do anything other than accept the answers given by the prisoner. They did not seem to bring any objective analysis to the screening. The process of nurse screening appeared at times to be a tick box exercise.
6. The second reception (well man) screening nurse did not explore the history of depression recorded, he said because the prison general practitioner had not prescribed any medication for depression. On reflection, the nurse thought that he should have asked about it.
Resuscitation
7. The resuscitation led by the two nurses occupying the positions of primary (Hotel 7) and secondary (Hotel 12) leads for emergency healthcare in the prison that night, was significantly lacking in the following ways.
The nurse with primary responsibility for emergency care in the prison did not have a proper understanding of the nature of a code red and a code blue prison medical emergency. (I have raised this issue in the past.)
One minute and twelve seconds elapsed after nurse arrival before any substantive care was given. The action during that one minute and twelve seconds did not appear to progress the resuscitation attempt.
There seemed no clear demarcation of roles and responsibilities during the resuscitation. Of course these may change as those giving resuscitation tire, but the changes seemed haphazard.
There was no checking for breath or airway manoeuvre at the outset or at any time during the resuscitation.
There was no checking for pulse at the outset, before commencing chest compressions, or at any time during the resuscitation. The lead nurse attempted to justify this by saying that she had not wanted to waste time. This was despite the first action upon finding the casualty being to apply a blood pressure cuff, on the basis that this was part of the nurse assessment.
When giving evidence, the lead nurse appeared to conflate the casualty who is in cardiorespiratory arrest with the casualty who is merely unconscious. She repeatedly talked about the need to give cardiopulmonary resuscitation (CPR) to an unconscious casualty. She said that, at the time she started chest compressions, she did not know whether Mr Kahssay was breathing or not breathing.
When CPR was given, chest compressions were ineffective, being too quick and too shallow.
There was only one brief attempt to use an ambubag, the majority of the resuscitation taking place without airway assistance or with a non rebreathe oxygen mask.
It appeared that one oxygen cylinder was empty, as it had to be changed for another.
The nurse leading the resuscitation described it as chaotic. That is indeed how it appeared to me from her description and from viewing the bodycam footage.
I was and remain very gravely concerned, not in this respect for Mr Kahssay who was in fact already dead when resuscitation commenced, but for anyone else in the prison in need of first aid.
Responses
Action Taken
Care UK has changed the reception screening template to include mandatory PER review, seeks consent for GP records during screening, and reinforced Code Red/Blue training with staff and displayed posters. All clinical staff receive mandatory ILS training, and guidance on resuscitation with rigor mortis present has been circulated. (AI summary)
Care UK has changed the reception screening template to include mandatory PER review, seeks consent for GP records during screening, and reinforced Code Red/Blue training with staff and displayed posters. All clinical staff receive mandatory ILS training, and guidance on resuscitation with rigor mortis present has been circulated. (AI summary)
View full response
Dear Madam; Requlation 28; Prevention of Euture_Deaths_ report The inquest touching the death of Tedros Habtom Kahssay Deceased HMP Pentonville Date_of death: 19th January 2016 Thank you for your Regulation 28 Prevention of Future Deaths Report dated 6 December 2016 issued to Care UK following the inquest into the death of Mr Kahssay: Care UK is the provider of primary healthcare and mental health services at HMP Pentonville. The matters of concern to you in so far as relate to healthcare are highlighted in bold with the response set out below each concern: Concern 1_ The person escort record (PER) and appended report of the forensic medical examiner (FME) that accompanied Mr Kahssay to HMP Pentonville did not accompany him to nurse reception screening: As you heard in evidence at the inquest, the reception screening template has been changed. The change that has been implemented is a control question in the first reception screen which is a mandatory field so the nurse needs to and answer the question_ It asks if the nurse has seen the PER_ AII nursing staff have been instructed and are aware that they are not to screen any prisoner without a CSRA and PER as minimum requirement to aid screening Concern 3_ The general practitioner records were never obtained (an issue that have raised in the past), despite there being a system in place for Pentonville healthcare administrative staff to do this. Whilst that did not impact upon Mr Kahssay's care, it might for another prisoner_ As you heard in evidence, consent for the obtaining of general practitioner records is now sought as part of the reception screen and it is also a mandatory field that needs to be completed by the member of healthcare prior to finishing the screen When consent is taken; the screening tool requires a task be sent to the Administrative staff to make them aware that Care UK Clinical Services Limited - Registered in England No 03462881 Registered Office Connaughi House 850 The Crescenl Colchester Business Colchoster, Essex C04 9QB Tedros they stop Park
consent has been gained and that a request for notes needs forwarding to the patient's general practitioner: There is now an auditable process as it is sent by task on SystmOne. Whilst we have a system in place to request medical records and follow up, it is important to highlight that we cannot ensure that a GP practice will send records to us It is anticipated that this is an issue which will be eased once the new clinical IT system is in place providing access to the NHS spine and patients Summary Care Records_ Concern 4. The first reception screen template contained questions that carried an inherent ambiguity: in that they related to a change in personal and family circumstances, which must always be the case when a person is incarcerated and therefore does not assist in determining which prisoners are at an increased risk: You heard evidence at the inquest as to how the first night reception template and part 2 reception template have been completely changed_ There is now a referral pathway which is task driven and can be audited and gives more accountability to the person undertaking the screening: These changes to the Reception templates took place in early December 2016. You referred to evidence you heard at the inquest that any prisoner on a charge of murder will now be the subject of a psychiatric assessment: can confirm this requirement is posted on the opening page of the First Night Reception Screen. The psychiatric assessment will take the form of an assessment with both a member of the prison mental health in-reach team and psychiatrist The need for an assessment will be identified via task on SystmOne which can be audited. Concern 5. Both nurses conducting reception screening talked often in evidence about not being able to do anything other than accept the answers given by the prisoner did not seem to bring any objective analysis to the screening: The process of nurse screening appeared at times to be a tick box exercise Both members of nursing staff,who were not directly employed by Care UK no longer work at HMP Pentonville or any Care UK establishment You heard evidence with regard to the new reception screening template and process. The scoring system in relation to the risk of self-harm and or suicide has now gone as this was found to be prescriptive_ The focus is now placed on the member of healthcare who is screening the patient to explore the presentation and Iook into factors that may be relevant to suicide and or self-harm_ To support this, a new risk assessment is currently in development by the national team and is based on learning from previous deaths in custody, concerns raised by the Learned Coroner; national reports and best available evidence_ In addition training has been delivered to clinical leads across the country on suicide and self-harm risk assessment and the materials from this training are available on the Care UK Health in Justice intranet pages. Concern 6_ The second reception (well man) screening nurse did not explore the history of depression recorded; he said because the prison general practitioner had not prescribed any medication for depression. On reflection, the nurse thought that he should have asked about it. We accept that the nurse could have explored the of depression in greater detail. Our secondary reception screening process provides more time for this and we are in process of rolling out our wellbeing wheel assessment to support this assessment The wellbeing wheel provides a structure for clinical staff to explore mental health issues in more depth alongside They too history
their physical health and substance misuse issues. Training, both online and face to face, has been developed to support the use of the wellbeing wheel and the Pentonville team are expected to have completed the implementation by end of March 2017. Concern 7 The resuscitation led by the two nurses occupying the positions of primary (Hotel 7) and secondary (Hotel 12) ieads for emergency healthcare in the prison that night; was significantly lacking: The Hotel 7 agency nurse no longer works in any Care UK establishment: The Second Nurse who was designated Hotel 12 is subject to an investigation which is being undertaken locally within the organisation in the first instance You heard that all nursing staff are given training by senior nurses who discuss scenarios and staff are issued with a card as an aide memoir. Both Nurses had attended that training which was delivered in July 2016. The use and meaning of Code Red and Code Blue has again been strongly reinforced to the nursing staff. Training sessions have taken place for all the staff and attendance sheets have been collected. Posters re-affirming the criteria of Code Red and Code Blue were displayed in clinical areas in December 2016. Furthermore , Safer Custody have been requested to re-order 250 of the aide-memoire cards for distribution across the establishment All clinical staff that are employed by Care UK have ILS as mandatory training requirement: A check has been undertaken to ensure that all Care UK clinical staff are receiving the ILS training: This has been confirmed to be the case. Guidance from NHSE regarding the resuscitation of patients where there is rigor mortis present has been circulated to staff and is accessible on the Care UK Health in Justice intranet pages_ Where staff are not confident in recognising rigor mortis they should proceed with resuscitation until someone arrives who is competent to recognise life extinct Recognition of Life Extinct (ROLE) training is considered by the Care UK resuscitation committee as an 'add on' to the ILS training: In addition to this, the healthcare team plan to discuss issues relating to resuscitation and use of emergency bags regularly in their Friday afternoon training sessions A SOP for emergency response is in development by the national team and is due for circulation shortly: We trust that the above response provides the information that you require but please do not hesitate to contact us if Care UK can be of further assistance
consent has been gained and that a request for notes needs forwarding to the patient's general practitioner: There is now an auditable process as it is sent by task on SystmOne. Whilst we have a system in place to request medical records and follow up, it is important to highlight that we cannot ensure that a GP practice will send records to us It is anticipated that this is an issue which will be eased once the new clinical IT system is in place providing access to the NHS spine and patients Summary Care Records_ Concern 4. The first reception screen template contained questions that carried an inherent ambiguity: in that they related to a change in personal and family circumstances, which must always be the case when a person is incarcerated and therefore does not assist in determining which prisoners are at an increased risk: You heard evidence at the inquest as to how the first night reception template and part 2 reception template have been completely changed_ There is now a referral pathway which is task driven and can be audited and gives more accountability to the person undertaking the screening: These changes to the Reception templates took place in early December 2016. You referred to evidence you heard at the inquest that any prisoner on a charge of murder will now be the subject of a psychiatric assessment: can confirm this requirement is posted on the opening page of the First Night Reception Screen. The psychiatric assessment will take the form of an assessment with both a member of the prison mental health in-reach team and psychiatrist The need for an assessment will be identified via task on SystmOne which can be audited. Concern 5. Both nurses conducting reception screening talked often in evidence about not being able to do anything other than accept the answers given by the prisoner did not seem to bring any objective analysis to the screening: The process of nurse screening appeared at times to be a tick box exercise Both members of nursing staff,who were not directly employed by Care UK no longer work at HMP Pentonville or any Care UK establishment You heard evidence with regard to the new reception screening template and process. The scoring system in relation to the risk of self-harm and or suicide has now gone as this was found to be prescriptive_ The focus is now placed on the member of healthcare who is screening the patient to explore the presentation and Iook into factors that may be relevant to suicide and or self-harm_ To support this, a new risk assessment is currently in development by the national team and is based on learning from previous deaths in custody, concerns raised by the Learned Coroner; national reports and best available evidence_ In addition training has been delivered to clinical leads across the country on suicide and self-harm risk assessment and the materials from this training are available on the Care UK Health in Justice intranet pages. Concern 6_ The second reception (well man) screening nurse did not explore the history of depression recorded; he said because the prison general practitioner had not prescribed any medication for depression. On reflection, the nurse thought that he should have asked about it. We accept that the nurse could have explored the of depression in greater detail. Our secondary reception screening process provides more time for this and we are in process of rolling out our wellbeing wheel assessment to support this assessment The wellbeing wheel provides a structure for clinical staff to explore mental health issues in more depth alongside They too history
their physical health and substance misuse issues. Training, both online and face to face, has been developed to support the use of the wellbeing wheel and the Pentonville team are expected to have completed the implementation by end of March 2017. Concern 7 The resuscitation led by the two nurses occupying the positions of primary (Hotel 7) and secondary (Hotel 12) ieads for emergency healthcare in the prison that night; was significantly lacking: The Hotel 7 agency nurse no longer works in any Care UK establishment: The Second Nurse who was designated Hotel 12 is subject to an investigation which is being undertaken locally within the organisation in the first instance You heard that all nursing staff are given training by senior nurses who discuss scenarios and staff are issued with a card as an aide memoir. Both Nurses had attended that training which was delivered in July 2016. The use and meaning of Code Red and Code Blue has again been strongly reinforced to the nursing staff. Training sessions have taken place for all the staff and attendance sheets have been collected. Posters re-affirming the criteria of Code Red and Code Blue were displayed in clinical areas in December 2016. Furthermore , Safer Custody have been requested to re-order 250 of the aide-memoire cards for distribution across the establishment All clinical staff that are employed by Care UK have ILS as mandatory training requirement: A check has been undertaken to ensure that all Care UK clinical staff are receiving the ILS training: This has been confirmed to be the case. Guidance from NHSE regarding the resuscitation of patients where there is rigor mortis present has been circulated to staff and is accessible on the Care UK Health in Justice intranet pages_ Where staff are not confident in recognising rigor mortis they should proceed with resuscitation until someone arrives who is competent to recognise life extinct Recognition of Life Extinct (ROLE) training is considered by the Care UK resuscitation committee as an 'add on' to the ILS training: In addition to this, the healthcare team plan to discuss issues relating to resuscitation and use of emergency bags regularly in their Friday afternoon training sessions A SOP for emergency response is in development by the national team and is due for circulation shortly: We trust that the above response provides the information that you require but please do not hesitate to contact us if Care UK can be of further assistance
Sent To
- Care UK
- HMP Pentonville
- National Offender Management Service
Response Status
Linked responses
1 of 3
56-Day Deadline
31 Jan 2017
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 21 January 2016, I commenced an investigation into the death of Tedros Habtom Kahssay, aged 29 years. The investigation concluded at the end of the inquest yesterday. The jury made a narrative determination, which I attach.
Circumstances of the Death
Tedros Kahssay killed himself by hanging in HM Prison Pentonville, having been admitted a month earlier on a charge of murdering his pregnant partner.
Copies Sent To
friend of Tedros Kahssay
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.