Sharon Butcher
PFD Report
Partially Responded
Ref: 2015-0129
Coroner's Concerns (AI summary)
There was a delay in calling for an ambulance after an emergency medical code was broadcast, and a recurring issue of lack of clarity in response to medical emergencies at HMP Frankland and HMP Durham.
View full coroner's concerns
_ The PPO report highlights an issue relating to the delay in calling for an ambulance as soon as an emergency medical code was broadcast. There was a 10 minute delay and the prisons local protocol for summoning an ambulance was not followed. There have been a series of similar failings in dealing with medical emergencies at HMP Frankland and HMP Durham with either staff using wrong or inappropriate codes, or there delays in the control room and this recurring issue of lack of clarity in response to a medical emergency could well lead to a fatality in the future.
Responses
Action Taken
HMP Frankland revised local contingency plans and re-issued instructions to staff following Sharon Butcher's death to ensure that staff do not delay in calling an ambulance in all cases where there are serious concerns about an offender's health. The local protocols provide clear guidance to all staff to ensure timely, appropriate and effective response to medical emergencies. (AI summary)
HMP Frankland revised local contingency plans and re-issued instructions to staff following Sharon Butcher's death to ensure that staff do not delay in calling an ambulance in all cases where there are serious concerns about an offender's health. The local protocols provide clear guidance to all staff to ensure timely, appropriate and effective response to medical emergencies. (AI summary)
View full response
Dear Coroner; RE: the death of Sharon Butcher on 25 August 2014 whilst In HMP Frankland Thank YOu for your ketter dated 31 March addressed to the Govemor of HMP Frankland and the National Offender Management Service conceming the Inquest into the death of Ms. Sharon Butcher: Your letter has been passed to Equality Rights &d Decency (ERD) Group in the National Offender ement Service (NOMS) to respond, a8 we have policy responsibllity for sulckde prevention and selcham management and for sharing keaming from deaths In custody: am als0 responding on behali HMP Frankland: In your report,_YOU expressed your concem about the delay in for an ambulance when the emergency medical code was broadcast You may be aware of PSI 03/2013 Medical Emergency Response Codes which sets the national instructions for calling & medical emergency over the establishment radio network in all prisons and NpMS operated Immigration Removal Centers. HMP Frankland revised their local contingency plans and re-issued instructions follwing death of MMs: Sharon Butcher t0 ensure that all staff understand, that must not delay in calling an ambulance irall cases where there are serous concems about the health ofan offender; The local protocols now provide clear guldance to all staff to ensure timely, appropriate and efiective response to medical emergencles and thereby maximise the likelihood of a positive outcome for the patient: The protocol defines the nature of the medical emergency with the use of a two level code (code Red and Code Blue) system that differentiates between blood and other injuries, such as breathing difficulties, unconscious casualties as specified by PSI 03/2013. In April 2015 an additional learing bullketin was issued nationally by ERDG (please see attached): In addition HMP Frankland are also working with the North East Prisons cluster and the North East Ambulance Service to ensure joint working and conslstency of approach across all establishments. hope that you find this response helpful and reassuring:
Sent To
- National Offender Management Service
Response Status
Linked responses
1 of 2
56-Day Deadline
26 May 2015
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 26ih August 2014 commenced an investigation into the death of Sharon Louise Suki Butcher: The investigation concluded at the end of the inquest on 31st March 2015. The conclusion of the inquest was Natural Causes with a cause of death given as Ia) Ischaemic Heart Disease, Ib) Coronary artery Atheroma, 2) Diabetes Mellitus and Cirrhosis of the Liver.
Circumstances of the Death
The deceased died of natural causes.
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you your organisation have the power to take such action:
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.