PFD report

Tedros Habtom KAHSSAY · Prevention of Future Deaths report

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Issued 6 Dec 2016•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
15

Raised in this report

Recipients
3

Named on the report

Responses found
1

Of 3 recipients

Stated actions
15

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 raised15

  1. Ineffective chest compressions during CPR
    Part of recurring concern: Unreliable resuscitation preparedness and response during cardiac arrest
  2. Failure to assess breathing and perform airway manoeuvres during resuscitation
    Part of recurring concern: Unreliable airway management during emergency carePart of recurring concern: Unreliable assessment of whether a person is breathing
  3. Unavailability of a serviceable oxygen cylinder during resuscitation
    Part of recurring concern: Failure to ensure essential clinical equipment and supplies are available and serviceablePart of recurring concern: Unreliable resuscitation preparedness and response during cardiac arrest
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.10

  1. Action

    Replace the reception templates with an auditable, task-driven referral pathway that assigns greater accountability to the screening clinician.

    Stated by Care UKStated completedThe respondent said that this action was complete when they made their response on 6 December 2016.
  2. Action

    Roll out the wellbeing wheel assessment, supported by online and face-to-face training, to explore mental health, physical health and substance-misuse issues in greater depth.

    Stated by Care UKStated in progressThe respondent said that this action was in progress when they made their response on 6 December 2016.
  3. Action

    Discuss resuscitation and emergency-bag issues regularly during Friday afternoon healthcare training sessions.

    Stated by Care UKStated plannedThe respondent said that this action was planned when they made their response on 6 December 2016.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    GP practices cannot be guaranteed to send requested medical records, limiting the ability to obtain them.

    Stated by Care UKUnable to actThe respondent said that a constraint prevented them from taking the relevant action.

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

Ineffective chest compressions during CPR

Wider context from the report

“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. ”

Is this part of a recurring concern?

Yes — Unreliable resuscitation preparedness and response during cardiac arrest.

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 assess breathing and perform airway manoeuvres during resuscitation

Wider context from the report

“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. ”

Is this part of a recurring concern?

Yes — Unreliable airway management during emergency care; Unreliable assessment of whether a person is breathing.

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

Unavailability of a serviceable oxygen cylinder during resuscitation

Wider context from the report

“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. ”

Is this part of a recurring concern?

Yes — Failure to ensure essential clinical equipment and supplies are available and serviceable; Unreliable resuscitation preparedness and response during cardiac arrest.

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 emergency healthcare lead nurses to understand code red and code blue medical emergencies

Wider context from the report

“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. ”

Is this part of a recurring concern?

Yes — Unreliable operation of prison Code Blue emergency response.

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 distinguish cardiorespiratory arrest from unconsciousness during emergency assessment

Wider context from the report

“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. ”

Is this part of a recurring concern?

Yes — Failure to reliably recognise and assess unconsciousness.

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

Delay in providing substantive resuscitation care after nurse arrival

Wider context from the report

“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. ”

Is this part of a recurring concern?

Yes — Unreliable resuscitation preparedness and response during cardiac arrest.

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 explore recorded history of depression during reception screening

Wider context from the report

“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. ”

Is this part of a recurring concern?

Yes — Inadequate prison reception safeguards; Incomplete clinical history-taking.

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 record circumstances of the index offence in the healthcare record

Wider context from the report

“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. ”

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 obtain general practitioner records

Wider context from the report

“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. ”

Is this part of a recurring concern?

Yes — Unreliable access to relevant clinical records for safe 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

Failure to apply objective clinical analysis during nurse reception screening

Wider context from the report

“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. ”

Is this part of a recurring concern?

Yes — Inadequate prison reception safeguards.

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 check pulse during resuscitation

Wider context from the report

“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. ”

Is this part of a recurring concern?

Yes — Unreliable resuscitation preparedness and response during cardiac arrest.

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

Insufficient airway ventilation assistance during resuscitation

Wider context from the report

“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. ”

Is this part of a recurring concern?

Yes — Unreliable airway management during emergency 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

Failure to maintain clear resuscitation roles and responsibilities

Wider context from the report

“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. ”

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

Ambiguity in reception screening questions for identifying increased-risk prisoners

Wider context from the report

“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. ”

Is this part of a recurring concern?

Yes — Inadequate prison reception safeguards.

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 transfer person escort and forensic medical records to nurse reception screening

Wider context from the report

“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. ”

Is this part of a recurring concern?

Yes — Unreliable completion and transfer of Prisoner Escort Records; Unreliable transfer and consideration of medical information during custody transitions.

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

Replace the reception templates with an auditable, task-driven referral pathway that assigns greater accountability to the screening clinician.

Verbatim wording from the response

“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.”

Source location

2016-0437-Response-by-Care-UK.pdf
Page 2 · response
Published 6 December 2016

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

Roll out the wellbeing wheel assessment, supported by online and face-to-face training, to explore mental health, physical health and substance-misuse issues in greater depth.

Verbatim wording from the response

“We accept that the nurse could have explored the history 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”

Source location

2016-0437-Response-by-Care-UK.pdf
Page 2 · response
Published 6 December 2016

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

Discuss resuscitation and emergency-bag issues regularly during Friday afternoon healthcare training sessions.

Verbatim wording from the response

“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.”

Source location

2016-0437-Response-by-Care-UK.pdf
Page 3 · response
Published 6 December 2016

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

Develop and circulate a standard operating procedure for emergency response.

Verbatim wording from the response

“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.”

Source location

2016-0437-Response-by-Care-UK.pdf
Page 3 · response
Published 6 December 2016

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

Request 250 additional emergency-response aide-memoire cards for distribution across the establishment.

Verbatim wording from the response

“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.”

Source location

2016-0437-Response-by-Care-UK.pdf
Page 3 · response
Published 6 December 2016

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

Replace the prescriptive self-harm and suicide risk score with clinician-led exploration of presentation and relevant risk factors.

Verbatim wording from the response

“You heard evidence with regard to the new reception screening template and process. The scoring system in relation to the risk of self-harm or suicide has now gone as this was found to be too prescriptive. The focus is now placed on the member of healthcare who is screening the patient to explore the presentation and look into factors that may be relevant to suicide and or self-harm.”

Source location

2016-0437-Response-by-Care-UK.pdf
Page 2 · response
Published 6 December 2016

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

Reinforce Code Red and Code Blue procedures through staff training and clinical-area posters.

Verbatim wording from the response

“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.”

Source location

2016-0437-Response-by-Care-UK.pdf
Page 3 · response
Published 6 December 2016

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

Check that all Care UK clinical staff receive mandatory intermediate life-support training.

Verbatim wording from the response

“All clinical staff that are employed by Care UK have ILS as a 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.”

Source location

2016-0437-Response-by-Care-UK.pdf
Page 3 · response
Published 6 December 2016

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

Obtain consent for general practitioner records during reception screening and trigger an auditable SystmOne task for administrative staff to request them.

Verbatim wording from the response

“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”

Source location

2016-0437-Response-by-Care-UK.pdf
Page 1 · response
Published 6 December 2016

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

Require nurses to confirm they have seen the person escort record and possess the CSRA and PER before completing reception screening.

Verbatim wording from the response

“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 stop and answer the question. It asks if the nurse has seen the PER. All 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.”

Source location

2016-0437-Response-by-Care-UK.pdf
Page 1 · response
Published 6 December 2016

Open published response

Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation

GP practices cannot be guaranteed to send requested medical records, limiting the ability to obtain them.

Verbatim wording from the response

“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.”

Source location

2016-0437-Response-by-Care-UK.pdf
Page 2 · response
Published 6 December 2016

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.5

  1. 1

    Develop a new suicide and self-harm risk assessment based on learning from deaths in custody, professional concerns, national reports and available evidence.

    Stated by Care UKStated in progressThe respondent said that this action was in progress when they made their response on 6 December 2016.
  2. 2

    Circulate national guidance on resuscitating patients with rigor mortis and publish it on the Health in Justice intranet.

    Stated by Care UKStated completedThe respondent said that this action was complete when they made their response on 6 December 2016.
  3. 3

    Require psychiatric assessment for prisoners charged with murder, identified through an auditable SystmOne task and involving mental-health staff and a psychiatrist.

    Stated by Care UKStated completedThe respondent said that this action was complete when they made their response on 6 December 2016.
  4. 4

    Deliver suicide and self-harm risk-assessment training to clinical leads and publish the training materials on the Health in Justice intranet.

    Stated by Care UKStated completedThe respondent said that this action was complete when they made their response on 6 December 2016.
  5. 5

    Consider adding Recognition of Life Extinct training to intermediate life-support training.

    Stated by Care UKStated in progressThe respondent said that this action was in progress when they made their response on 6 December 2016.

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 a new suicide and self-harm risk assessment based on learning from deaths in custody, professional concerns, national reports and available evidence.

Verbatim wording from the response

“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.”

Source location

2016-0437-Response-by-Care-UK.pdf
Page 2 · response
Published 6 December 2016

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

Circulate national guidance on resuscitating patients with rigor mortis and publish it on the Health in Justice intranet.

Verbatim wording from the response

“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 being considered by the Care UK resuscitation committee as an ‘add on’ to the ILS training.”

Source location

2016-0437-Response-by-Care-UK.pdf
Page 3 · response
Published 6 December 2016

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

Require psychiatric assessment for prisoners charged with murder, identified through an auditable SystmOne task and involving mental-health staff and a psychiatrist.

Verbatim wording from the response

“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. I 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 a psychiatrist. The need for an assessment will be identified via a task on SystmOne which can be audited.”

Source location

2016-0437-Response-by-Care-UK.pdf
Page 2 · response
Published 6 December 2016

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 suicide and self-harm risk-assessment training to clinical leads and publish the training materials on the Health in Justice intranet.

Verbatim wording from the response

“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.”

Source location

2016-0437-Response-by-Care-UK.pdf
Page 2 · response
Published 6 December 2016

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

Consider adding Recognition of Life Extinct training to intermediate life-support training.

Verbatim wording from the response

“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 being considered by the Care UK resuscitation committee as an ‘add on’ to the ILS training.”

Source location

2016-0437-Response-by-Care-UK.pdf
Page 3 · response
Published 6 December 2016

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