PFD report

William DAVIES · Prevention of Future Deaths report

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Issued 5 Nov 2014•Inner North London

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
6

Raised in this report

Recipients
2

Named on the report

Responses found
1

Of 2 recipients

Stated actions
5

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised6

  1. Failure of GPs to know that they are allowed to verify death
  2. Failure to request an ambulance promptly after a level one call
    Part of recurring concern: Failure to call an ambulance promptly when emergency assistance is requiredPart of recurring concern: Unreliable decisions about when ambulance attendance is requiredPart of recurring concern: Unreliable emergency access to hospital care
  3. Unclear responsibility for attending prisoners with life-threatening conditions
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.3

  1. Action

    Review emergency care arrangements, including staff training and standardisation of emergency bags.

    Stated by Care UK LimitedStated in progressThe respondent said that this action was in progress when they made their response on 5 November 2014.
  2. Action

    Brief and reinforce all HMP Pentonville GPs’ responsibilities and legal authority to declare life extinct after emergency examination.

    Stated by Care UK LimitedStated completedThe respondent said that this action was complete when they made their response on 5 November 2014.
  3. Action

    Deliver and disseminate an emergency healthcare response publicity campaign to operational, non-operational and healthcare staff.

    Stated by Care UK LimitedStated completedThe respondent said that this action was complete when they made their response on 5 November 2014.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure of GPs to know that they are allowed to verify death

Wider context from the report

“There seems to be confusion in the prison regarding the requesting of an ambulance after a level one (i.e. regarding a potentially life threatening situation) call has been made by a prison officer. The whole process of attending a prisoner with a life threatening condition seemed unclear to the prison general practitioner (now GP lead) giving evidence. She assumed that a prison officer had responsibility for calling an ambulance, but she was not sure. The GP also did not know that she was allowed to verify the fact of death, and told me that, as a consequence, she carried on with CPR after she knew that Mr Davies had died. And if the GP lead has not got a good understanding of the procedures in place, then other GPs in the prison may not have either. This could prove fatal, depending upon the circumstances. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to request an ambulance promptly after a level one call

Wider context from the report

“There seems to be confusion in the prison regarding the requesting of an ambulance after a level one (i.e. regarding a potentially life threatening situation) call has been made by a prison officer. 1. I have been told in other inquests (and delay in HMP Pentonville ensuring ambulance attendance has been a feature since the first prison death inquest I heard in Inner North London, on 30 September 2013) that prison comms should call an ambulance as soon as they have been notified of a level one. However, the prison duty governor on the day of Mr Davies’ death, ████████ said that when he arrived two or three minutes after the prison officer who found Mr Davies had contacted comms, no ambulance had been called. ████████ told me that he did not know why this was, though he was duty governor that day and the most senior person from the prison in court. 2. The whole process of attending a prisoner with a life threatening condition seemed unclear to the prison general practitioner (now GP lead) giving evidence. She assumed that a prison officer had responsibility for calling an ambulance, but she was not sure. The GP also did not know that she was allowed to verify the fact of death, and told me that, as a consequence, she carried on with CPR after she had learnt that Mr Davies had died. And if the GP lead has not got a good understanding of the procedures in place, then other GPs in the prison may not have either. ”

Is this part of a recurring concern?

Yes — Failure to call an ambulance promptly when emergency assistance is required; Unreliable decisions about when ambulance attendance is required; Unreliable emergency access to hospital care.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Unclear responsibility for attending prisoners with life-threatening conditions

Wider context from the report

“There seems to be confusion in the prison regarding the requesting of an ambulance after a level one (i.e. regarding a potentially life threatening situation) call has been made by a prison officer. 1. I have been told in other inquests (and delay in HMP Pentonville ensuring ambulance attendance has been a feature since the first prison death inquest I heard in Inner North London, on 30 September 2013) that prison comms should call an ambulance as soon as they have been notified of a level one. However, the prison duty governor on the day of Mr Davies’ death, ████████ said that when he arrived two or three minutes after the prison officer who found Mr Davies had contacted comms, no ambulance had been called. ████████ told me that he did not know why this was, though he was duty governor that day and the most senior person from the prison in court. 2. The whole process of attending a prisoner with a life threatening condition seemed unclear to the prison general practitioner (now GP lead) giving evidence. She assumed that a prison officer had responsibility for calling an ambulance, but she was not sure. The GP also did not know that she was allowed to verify the fact of death, and told me that, as a consequence, she carried on with CPR after she had learnt that Mr Davies had died. And if the GP lead has not got a good understanding of the procedures in place, then other GPs in the prison may not have either. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Unclear process for attending prisoners with life-threatening conditions

Wider context from the report

“There seems to be confusion in the prison regarding the requesting of an ambulance after a level one (i.e. regarding a potentially life threatening situation) call has been made by a prison officer. The whole process of attending a prisoner with a life threatening condition seemed unclear to the prison general practitioner (now GP lead) giving evidence. She assumed that a prison officer had responsibility for calling an ambulance, but she was not sure. The GP also did not know that she was allowed to verify the fact of death, and told me that, as a consequence, she carried on with CPR after she knew that Mr Davies had died. And if the GP lead has not got a good understanding of the procedures in place, then other GPs in the prison may not have either. This could prove fatal, depending upon the circumstances. ”

Is this part of a recurring concern?

Yes — Failure of emergency response leadership and coordination; Unsafe interoperability between prison custody and healthcare procedures.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Confusion over requesting an ambulance after a level one call

Wider context from the report

“There seems to be confusion in the prison regarding the requesting of an ambulance after a level one (i.e. regarding a potentially life threatening situation) call has been made by a prison officer. The whole process of attending a prisoner with a life threatening condition seemed unclear to the prison general practitioner (now GP lead) giving evidence. She assumed that a prison officer had responsibility for calling an ambulance, but she was not sure. The GP also did not know that she was allowed to verify the fact of death, and told me that, as a consequence, she carried on with CPR after she knew that Mr Davies had died. And if the GP lead has not got a good understanding of the procedures in place, then other GPs in the prison may not have either. This could prove fatal, depending upon the circumstances. ”

Is this part of a recurring concern?

Yes — Failure to call an ambulance promptly when emergency assistance is required; Unreliable decisions about when ambulance attendance is required.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure of prison GPs to understand procedures for verifying death

Wider context from the report

“There seems to be confusion in the prison regarding the requesting of an ambulance after a level one (i.e. regarding a potentially life threatening situation) call has been made by a prison officer. 1. I have been told in other inquests (and delay in HMP Pentonville ensuring ambulance attendance has been a feature since the first prison death inquest I heard in Inner North London, on 30 September 2013) that prison comms should call an ambulance as soon as they have been notified of a level one. However, the prison duty governor on the day of Mr Davies’ death, ████████ said that when he arrived two or three minutes after the prison officer who found Mr Davies had contacted comms, no ambulance had been called. ████████ told me that he did not know why this was, though he was duty governor that day and the most senior person from the prison in court. 2. The whole process of attending a prisoner with a life threatening condition seemed unclear to the prison general practitioner (now GP lead) giving evidence. She assumed that a prison officer had responsibility for calling an ambulance, but she was not sure. The GP also did not know that she was allowed to verify the fact of death, and told me that, as a consequence, she carried on with CPR after she had learnt that Mr Davies had died. And if the GP lead has not got a good understanding of the procedures in place, then other GPs in the prison may not have either. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Review emergency care arrangements, including staff training and standardisation of emergency bags.

Verbatim wording from the response

“• A publicity campaign (based on PSI 2013/03 Emergency Response Codes) has taken place reminding staff of who can call a medical emergency, who calls the ambulance, the use of the correct medical emergency codes, and what information they should be communicating with the control room (See Appendix 3 – Emergency Healthcare Response). This document was jointly developed with prison service colleagues prior to us taking over healthcare services in HMP Pentonville and our Health in Justice team are reviewing this as part of a wider piece of work around emergency care, including training of staff and standardisation of the emergency bags.”

Source location

Response from Care UK
Page 1 · response
Published 5 November 2014

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Brief and reinforce all HMP Pentonville GPs’ responsibilities and legal authority to declare life extinct after emergency examination.

Verbatim wording from the response

“The Care UK National Medical Director for Health in Justice has spoken with the lead GP to clarify her role regarding decision to cease CPR and declare life extinct. The Head of Healthcare has additionally briefed all General Practitioners working at HMP Pentonville about their responsibility and legal right to declare life extinct following their examination in an emergency situation. All doctors are given orientation and induction prior to working at HMP Pentonville; this has been reinforced with the existing team and any locum providers. This is also included in all GP inductions.”

Source location

Response from Care UK
Page 2 · response
Published 5 November 2014

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Deliver and disseminate an emergency healthcare response publicity campaign to operational, non-operational and healthcare staff.

Verbatim wording from the response

“• A publicity campaign (based on PSI 2013/03 Emergency Response Codes) has taken place reminding staff of who can call a medical emergency, who calls the ambulance, the use of the correct medical emergency codes, and what information they should be communicating with the control room (See Appendix 3 – Emergency Healthcare Response). This document was jointly developed with prison service colleagues prior to us taking over healthcare services in HMP Pentonville and our Health in Justice team are reviewing this as part of a wider piece of work around emergency care, including training of staff and standardisation of the emergency bags.”

Source location

Response from Care UK
Page 1 · response
Published 5 November 2014

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.2

  1. 1

    Develop guidance and additional training to support decision-making about commencing or stopping CPR after unexpected collapse or death.

    Stated by Care UK LimitedStated in progressThe respondent said that this action was in progress when they made their response on 5 November 2014.
  2. 2

    Share established do-not-attempt-resuscitation practice across prisons through the wider end-of-life-care improvement project.

    Stated by Care UK LimitedStated in progressThe respondent said that this action was in progress when they made their response on 5 November 2014.

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Develop guidance and additional training to support decision-making about commencing or stopping CPR after unexpected collapse or death.

Verbatim wording from the response

“Decisions to cease CPR or to not commence CPR can be difficult in emergency situations so in addition to the above actions, our National Medical Director and National Lead Nurse are currently working with our networks of lead GPs and lead nurses to develop guidance and additional training to help support good decision making in cases of unexpected collapse or death. In the case of expected deaths and palliative care situations we have well established protocols for DNAR (do not actively resuscitate) forms to be used in our prisons elsewhere and are in the process of sharing this practice as part of a wider project on improving end of life care across our prisons.”

Source location

Response from Care UK
Page 2 · response
Published 5 November 2014

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Share established do-not-attempt-resuscitation practice across prisons through the wider end-of-life-care improvement project.

Verbatim wording from the response

“Decisions to cease CPR or to not commence CPR can be difficult in emergency situations so in addition to the above actions, our National Medical Director and National Lead Nurse are currently working with our networks of lead GPs and lead nurses to develop guidance and additional training to help support good decision making in cases of unexpected collapse or death. In the case of expected deaths and palliative care situations we have well established protocols for DNAR (do not actively resuscitate) forms to be used in our prisons elsewhere and are in the process of sharing this practice as part of a wider project on improving end of life care across our prisons.”

Source location

Response from Care UK
Page 2 · response
Published 5 November 2014

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026