Kevin John LOVATT · Prevention of Future Deaths report

On 27 December 2017 I commenced an investigation into the death of Kevin John LOVATT. The investigation concluded at the end of the inquest on 14 January 2021. The conclusion of the inquest was accident with the cause of Kevin’s death being obstruction of the internal airways with close temporal relationship to restrain

a) Kevin was a serving prisoner at HMP Dovegate. He died at prison on 22.12.17 having swallowed a package of illicit drugs on which he chokeded.
b) Probable causative issues
The deliberate swallowing of too large a package of illicit drugs
c) Possible causative issues
i) Communication
It was not communicated to officers that Kevin had something in his mouth prior to handcuffs being applied.
Code Blue was not sounded immediately it was noted Kevin was choking.
No one person on the scene took immediate control leading to too many people in a confined space and consequent confusion.
ii) Vomiting may have had an additional causative effect.
iii) Lack of ALS trained staff who had access to forceps.
iv) The use of fingers in the throat in an attempt to remove the obstruction contrary to accepted practice (but heavily caveated by the fact that Kevin may already have been dead and the fact that those involved were desperately trying to save his life).
v) Insufficient training to ensure that medical staff were put in a position where they could make an immediate medical assessment.

Following the investigation by the Prisons and Probation Ombudsman a recommendation was made that you should ensure that there is clear guidance and training on the safe use of force when resistant prisoners have items in their mouth which might compromise their breathing. In evidence at the inquest I heard that suitable training on this topic did not appear to have been delivered and that it would be appreciated by prison staff. I wonder therefore if the national training you provide could include control and restraint for prisoners with items in their mouths.

During evidence at the inquest I heard that nursing staff at HMP Dovegate (and throughout the prison estate) are trained to an Intermediate Life Support level. I realise it would be impractical for all nursing staff at prisons to be trained to an Advanced Life Support level however I was informed that at some stage there was at least one paramedic employed at HMP Dovegate who was trained to ALS level. I wonder if there might be some limited provision of ALS trained staff in the prison estate and if this could be part of the appropriate commissioning arrangements.