Richard James Ormond · Prevention of Future Deaths report

On 23/01/2019 I commenced an investigation into the death of Richard James Ormond. The investigation concluded at the end of the inquest hearing on 29th April 2021. The conclusion of the inquest was that Mr. Ormond’s death was drug-related.

On 11.1.19 Mr. Ormond, who had a history of substance misuse whilst in prison, was found in his cell at HMP Long Lartin in a drug-related cardiac arrest. He was transferred to Worcestershire Royal Hospital, where he was declared deceased later that day. A post-mortem examination revealed the following cause of death: 1a synthetic cannabinoid toxicity.

1) During the course of the inquest I heard evidence that:
(a) Pursuant to an agreement between HM Prison Service and West Midlands Ambulance Service (WMAS):
(i) When a Code Blue or Code Red emergency is phoned through to WMAS by a prison, and no answer can be given by the prison control room to the questions “is the patient conscious?” and “is the patient breathing?”, then without further information a Category 2 response will be generated (i.e. average attendance time of c.18 minutes );
(ii) Should further information be relayed to WMAS by the prison control room that the patient is either in cardiac arrest or peri-arrest, or not breathing, or fitting, or choking, or that CPR is being administered, WMAS will upgrade the response to Category 1 (i.e. average attendance time of 7 minutes).
(b) In Mr. Ormond’s case:
(i) It was immediately apparent to prison officers who found Mr. Ormond in his cell that he was unresponsive and required CPR. When healthcare staff responded to the Code Blue call which went out over the radio, and attended the cell a short time later, they found those officers already giving Mr. Ormond CPR;
(ii) The prison control room initially informed WMAS that this was a Code Blue emergency, but were unable to say whether Mr. Ormond was conscious or breathing. The call was therefore given a Category 2 status;
(iii) There was then a delay of at least 9 minutes before the prison control room provided WMAS with information that Mr. Ormond was not breathing and was requiring CPR, at which point WMAS upgraded the response to Category 1;
(iv) In a Safer Custody Learning Bulletin issued in December 2016 to all prison staff, entitled “The Importance of Immediate Emergency Response”, the instruction was given to “Ensure that information on the condition of the patient is passed to the control room as soon as possible so that the ambulance service can be updated.”
(v) The 9 minute delay referred to at (iii) above occurred despite prison officers and healthcare staff who first attended the scene having radios, and therefore being in a position to share the control room the information that Mr. Ormond was not breathing and required CPR.

2) The failure to provide WMAS with critical information about Mr. Ormond’s condition, which would have resulted in the call being given the highest category of emergency response, did not appear to have been recognized by either HM Prison Service or Practice Plus Group until this inquest hearing. In the circumstances, there is concern that members of the prison and healthcare staff at HMP Long Lartin will not recognize the need to update WMAS with critical information about a patient’s condition in similar circumstances.