PFD report

Martin Thomas Brown · Prevention of Future Deaths report

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Issued 15 Dec 2021•Lancashire and Blackburn with Darwen

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.

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Concerns
4

Raised in this report

Recipients
1

Named on the report

Responses found
2

Of 1 recipient

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 raised4

  1. Lack of prison staff familiarisation with the ERIC system
    Part of recurring concern: Inadequate prison staff training for responding to medical emergencies
  2. Inadequate communication between healthcare personnel at medical emergency scenes and prison or ambulance control
    Part of recurring concern: Ineffective communication during medical emergenciesPart of recurring concern: Unreliable multi-agency communication procedures
  3. Failure of healthcare to liaise with the ambulance service over medical emergencies
    Part of recurring concern: Ineffective communication during medical emergencies
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.12

  1. Action

    Liaise with NWAS to define clinician training needs and incorporate ambulance-control communication guidance into the HMP Lancaster Farms emergency-response procedure.

    Stated by SpectrumStated completedThe respondent said that this action was complete when they made their response on 16 December 2021.
  2. Action

    Conduct joint prison-healthcare debriefs after incidents to identify communication lessons involving healthcare, the communications department and NWAS.

    Stated by SpectrumStated completedThe respondent said that this action was complete when they made their response on 16 December 2021.
  3. Action

    Embed ERIC training and emergency-call appropriateness through Local Delivery Board discussions and staff induction and appraisal compliance reporting.

    Stated by SpectrumStated plannedThe respondent said that this action was planned when they made their response on 16 December 2021.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    A mobile phone was not a reliable communication solution because phone signal at HMP Lancaster Farms was unreliable.

    Stated by SpectrumUnable 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

Lack of prison staff familiarisation with the ERIC system

Wider context from the report

“(1) For the attention of the Governor, the evidence disclosed a need for the training of prison staff in relation to responses to medical emergencies and familiarisation with the ERIC (Emergency Response in Custody) system (2) For the attention of the Head of Healthcare, the evidence disclosed a need for healthcare to liaise with North West Ambulance Service over the handling of medical emergencies involving the ambulance service (3) For the attention of the Governor in partnership with the Head of Healthcare, the evidence disclosed a need to devise a better means of communication between healthcare personnel at the scene of a medical emergency and the prison control room / ambulance control. ”

Is this part of a recurring concern?

Yes — Inadequate prison staff training for responding to medical emergencies.

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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

Inadequate communication between healthcare personnel at medical emergency scenes and prison or ambulance control

Wider context from the report

“(1) For the attention of the Governor, the evidence disclosed a need for the training of prison staff in relation to responses to medical emergencies and familiarisation with the ERIC (Emergency Response in Custody) system (2) For the attention of the Head of Healthcare, the evidence disclosed a need for healthcare to liaise with North West Ambulance Service over the handling of medical emergencies involving the ambulance service (3) For the attention of the Governor in partnership with the Head of Healthcare, the evidence disclosed a need to devise a better means of communication between healthcare personnel at the scene of a medical emergency and the prison control room / ambulance control. ”

Is this part of a recurring concern?

Yes — Ineffective communication during medical emergencies; Unreliable multi-agency communication 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

Failure of healthcare to liaise with the ambulance service over medical emergencies

Wider context from the report

“(1) For the attention of the Governor, the evidence disclosed a need for the training of prison staff in relation to responses to medical emergencies and familiarisation with the ERIC (Emergency Response in Custody) system (2) For the attention of the Head of Healthcare, the evidence disclosed a need for healthcare to liaise with North West Ambulance Service over the handling of medical emergencies involving the ambulance service (3) For the attention of the Governor in partnership with the Head of Healthcare, the evidence disclosed a need to devise a better means of communication between healthcare personnel at the scene of a medical emergency and the prison control room / ambulance control. ”

Is this part of a recurring concern?

Yes — Ineffective communication during medical emergencies.

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

Lack of prison staff training in responses to medical emergencies

Wider context from the report

“(1) For the attention of the Governor, the evidence disclosed a need for the training of prison staff in relation to responses to medical emergencies and familiarisation with the ERIC (Emergency Response in Custody) system (2) For the attention of the Head of Healthcare, the evidence disclosed a need for healthcare to liaise with North West Ambulance Service over the handling of medical emergencies involving the ambulance service (3) For the attention of the Governor in partnership with the Head of Healthcare, the evidence disclosed a need to devise a better means of communication between healthcare personnel at the scene of a medical emergency and the prison control room / ambulance control. ”

Is this part of a recurring concern?

Yes — Inadequate prison staff training for responding to medical emergencies.

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

Liaise with NWAS to define clinician training needs and incorporate ambulance-control communication guidance into the HMP Lancaster Farms emergency-response procedure.

Verbatim wording from the response

“(2) For the attention of the Head of Healthcare, the evidence disclosed a need for healthcare to liaise with North West Ambulance Service over the handling of medical emergencies involving the ambulance service”

Source location

2021-0417-Response-from-Spectrum-at-HMP-Lancaster-Farms_Published
Page 1 · response
Published 16 December 2021

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

Conduct joint prison-healthcare debriefs after incidents to identify communication lessons involving healthcare, the communications department and NWAS.

Verbatim wording from the response

“Following incidents, debriefs occur jointly with the Prison and healthcare. This is an opportunity to consider the communication taken place between healthcare, the communication department and NWAS. Any emerging lesson learnt will be captured at this early stage.”

Source location

2021-0417-Response-from-Spectrum-at-HMP-Lancaster-Farms_Published
Page 2 · response
Published 16 December 2021

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

Embed ERIC training and emergency-call appropriateness through Local Delivery Board discussions and staff induction and appraisal compliance reporting.

Verbatim wording from the response

“ERIC training and the appropriateness of emergency calls will be discussed with Governor at Local Delivery Board meetings to support the process of training is embedded with HMP Lancaster Farms.”

Source location

2021-0417-Response-from-Spectrum-at-HMP-Lancaster-Farms_Published
Page 1 · response
Published 16 December 2021

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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

Implement a dedicated radio net enabling clinicians and the prison communications room to communicate directly and relay information securely during medical emergencies.

Verbatim wording from the response

“An alternative solution was the provision of a mobile phone for healthcare to utilise to make the call, however, the phone signal in HMP Lancaster Farms is not reliable. Following the inquest, the Head of Healthcare met with the new Safer Custody Governor, and it was agreed that a spare radio net will be utilised so that the clinician can speak directly to the prison’s communications room (rather than via Oscar 1) to provide more information directly which can then be relayed to the clinician, who would also be able to answer any questions posed by the ambulance service. The clinician can also contact the communications room directly to ask for progress reports. As the net will only be accessible to the communications room and healthcare, this will mean confidential and sensitive information can be relayed.”

Source location

2021-0417-Response-from-Spectrum-at-HMP-Lancaster-Farms_Published
Page 2 · response
Published 16 December 2021

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 deliver ERIC emergency-response training to healthcare and prison staff, with further rollout through inductions, handovers and update sessions.

Verbatim wording from the response

“An Emergency Response in Custody (ERIC) presentation with added audio has been developed to address training needs for both healthcare team members and prison officers. The Head of Healthcare presented the ERIC training presentation at a prison induction on the 13th January 2022, a training session for Officer Support Grades who work in the prison communication room and custodial managers was held on the 20th January 2022. Further sessions have been held with prison staff on the 27th of January and 3rd of February. There is a plan to roll this training out to all, the training will also be delivered at healthcare handovers.”

Source location

2021-0417-Response-from-Spectrum-at-HMP-Lancaster-Farms_Published
Page 1 · response
Published 16 December 2021

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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

Assess ERIC training compliance after emergency calls, provide feedback and conduct at least annual spot audits of ERIC competencies.

Verbatim wording from the response

“Assessment of training compliance as per ERIC standards will take place following the completion of emergency calls. Feedback will be provided to the team and individual as needed to provide continued support and learning. To provide further assurances, spot audits for ERIC competences will take place at least annually via team level professional development sessions.”

Source location

2021-0417-Response-from-Spectrum-at-HMP-Lancaster-Farms_Published
Page 1 · response
Published 16 December 2021

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

Monitor the new emergency-communication system through staff feedback, healthcare incident reviews and safety-huddle and organisational learning.

Verbatim wording from the response

“This new system was trialled in an exercise on the 18th January 2022. This approach proved to be successful. This went live on the 31st of January. Supportive training regarding the new process has been provided to relevant staff and will now form part of the response process for all emergencies. This new system will be monitored via staff feedback and review of healthcare incidents which are logged for each Code Red/ Blue. This will be shared at the safety huddles and within the wider organisation to share best practice.”

Source location

2021-0417-Response-from-Spectrum-at-HMP-Lancaster-Farms_Published
Page 2 · response
Published 16 December 2021

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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 weekly ERIC training and refresher training to all staff until completed.

Verbatim wording from the response

“In January 2022 the Governor instructed that ERIC cards be distributed to all existing staff to provide a pocket guide on how to deal with emergency responses. Additional ERIC training has also commenced and is being delivered by the Head of Healthcare to all staff. This training is being delivered weekly until all staff have been trained or had any necessary refresher training. All new staff will now receive ERIC training and ERIC cards as part of their induction.”

Source location

2021-0417-Response-from-HMPPS-response_Published
Page 1 · response
Published 16 December 2021

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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

Restrict access to the emergency radio network to the communications room, healthcare staff and first responders on scene.

Verbatim wording from the response

“Also, the radio network will only be accessible to the communications room, healthcare and those first on scene to safeguard any confidential information.”

Source location

2021-0417-Response-from-HMPPS-response_Published
Page 2 · response
Published 16 December 2021

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

Use a dedicated radio channel to connect clinicians directly with ambulance services through the communications room during medical emergencies.

Verbatim wording from the response

“A new process has been implemented at HMP Lancaster Farms to ensure healthcare staff can communicate efficiently and effectively with the prison control room and the ambulance service during medical emergencies. By utilising a spare radio channel available on the prison radio network clinicians will now have the ability to speak directly to the ambulance service via the communication room when an emergency is underway. This will enable them to relay information and answer any questions posed by the ambulance service without disruption or delay, as well as receive progress reports on the ambulance’s arrival.”

Source location

2021-0417-Response-from-HMPPS-response_Published
Page 1 · response
Published 16 December 2021

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

Provide ERIC training and pocket cards to all new staff during induction.

Verbatim wording from the response

“In January 2022 the Governor instructed that ERIC cards be distributed to all existing staff to provide a pocket guide on how to deal with emergency responses. Additional ERIC training has also commenced and is being delivered by the Head of Healthcare to all staff. This training is being delivered weekly until all staff have been trained or had any necessary refresher training. All new staff will now receive ERIC training and ERIC cards as part of their induction.”

Source location

2021-0417-Response-from-HMPPS-response_Published
Page 1 · response
Published 16 December 2021

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

Distribute ERIC pocket cards to all existing staff.

Verbatim wording from the response

“In January 2022 the Governor instructed that ERIC cards be distributed to all existing staff to provide a pocket guide on how to deal with emergency responses. Additional ERIC training has also commenced and is being delivered by the Head of Healthcare to all staff. This training is being delivered weekly until all staff have been trained or had any necessary refresher training. All new staff will now receive ERIC training and ERIC cards as part of their induction.”

Source location

2021-0417-Response-from-HMPPS-response_Published
Page 1 · response
Published 16 December 2021

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

A mobile phone was not a reliable communication solution because phone signal at HMP Lancaster Farms was unreliable.

Verbatim wording from the response

“An alternative solution was the provision of a mobile phone for healthcare to utilise to make the call, however, the phone signal in HMP Lancaster Farms is not reliable. Following the inquest, the Head of Healthcare met with the new Safer Custody Governor, and it was agreed that a spare radio net will be utilised so that the clinician can speak directly to the prison’s communications room (rather than via Oscar 1) to provide more information directly which can then be relayed to the clinician, who would also be able to answer any questions posed by the ambulance service. The clinician can also contact the communications room directly to ask for progress reports. As the net will only be accessible to the communications room and healthcare, this will mean confidential and sensitive information can be relayed.”

Source location

2021-0417-Response-from-Spectrum-at-HMP-Lancaster-Farms_Published
Page 2 · response
Published 16 December 2021

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

Using the wing phone could delay emergency communication and leave the patient without a nurse while the clinician makes the call.

Verbatim wording from the response

“Potential solutions were discussed, and these included accessing the wing phone to make the call, however, it was noted that this would mean the clinician leaving the patient to ring an outside line. Prison telecommunication systems require a phone code to access an outside line which further increases the time taken to make a call. The patient may then be left without a nurse in attendance whilst this telephone call is taking place.”

Source location

2021-0417-Response-from-Spectrum-at-HMP-Lancaster-Farms_Published
Page 2 · response
Published 16 December 2021

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.3

  1. 1

    Establish a cross-organisational Task and Finish Group to standardise education materials and systematically apply them for continued integration and shared learning.

    Stated by SpectrumStated plannedThe respondent said that this action was planned when they made their response on 16 December 2021.
  2. 2

    Review emergency-response incidents through Datix and complete proportionate investigations, including root-cause analysis where appropriate.

    Stated by SpectrumStated in progressThe respondent said that this action was in progress when they made their response on 16 December 2021.
  3. 3

    Use site safety huddles to reflect on emergency-response incidents and identify training, awareness and education improvements.

    Stated by SpectrumStated completedThe respondent said that this action was complete when they made their response on 16 December 2021.

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

Establish a cross-organisational Task and Finish Group to standardise education materials and systematically apply them for continued integration and shared learning.

Verbatim wording from the response

“Organisationally, Spectrum are commencing a Task and Finish Group led by the Patient Safety lead and will invite key partners from the Emergency service response, including paramedics who work within Spectrum. The objective for the group is to streamline all education material and ensure this is systematically applied. This group will focus on the PPO and Clinical Review recommendations. The first meeting of the Task and Finish Group is planned for 10th February 2022. This is a new approach to support continued integration and shared learning. The group will work within TOR agreed by all parties.”

Source location

2021-0417-Response-from-Spectrum-at-HMP-Lancaster-Farms_Published
Page 2 · response
Published 16 December 2021

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

Review emergency-response incidents through Datix and complete proportionate investigations, including root-cause analysis where appropriate.

Verbatim wording from the response

“All incidents related to emergency response will be reviewed via the incident reporting system (Datix) by the Head of Healthcare and appropriate level of investigation will be completed, this may include the completion of a root cause analysis.”

Source location

2021-0417-Response-from-Spectrum-at-HMP-Lancaster-Farms_Published
Page 1 · response
Published 16 December 2021

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

Use site safety huddles to reflect on emergency-response incidents and identify training, awareness and education improvements.

Verbatim wording from the response

“The teams will continue to use the process of the newly induced site safety huddles to reflect and evaluate any incidents that arise. This will support reflective practice and mitigation of any issues that may arise e.g., training, awareness and education.”

Source location

2021-0417-Response-from-Spectrum-at-HMP-Lancaster-Farms_Published
Page 1 · response
Published 16 December 2021

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