PFD report

Thomas Mark Anthony Moffett · Prevention of Future Deaths report

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Issued 22 Jan 2022•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
1

Raised in this report

Recipients
3

Named on the report

Responses found
1

Of 3 recipients

Stated actions
6

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 raised1

  1. Lack of effective communication between healthcare personnel at medical emergencies and prison or ambulance control
    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.3

  1. Action

    Provide supporting training on the new emergency response process to relevant staff and incorporate it into responses to all emergencies.

    Stated by Spectrum CICStated completedThe respondent said that this action was complete when they made their response on 25 January 2022.
  2. Action

    Develop and deliver clinician training on ambulance categorisation and challenging incorrect categorisation.

    Stated by Spectrum CICStated plannedThe respondent said that this action was planned when they made their response on 25 January 2022.
  3. Action

    Implement the revised emergency response process, including a second healthcare responder, scene SBAR completion and direct ambulance communication.

    Stated by Spectrum CICStated in progressThe respondent said that this action was in progress when they made their response on 25 January 2022.

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

  1. Position

    Access to mobile phones or alternative communication methods is the responsibility of HMPPS partners.

    Stated by Spectrum CICRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking 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 effective communication between healthcare personnel at medical emergencies and prison or ambulance control

Wider context from the report

“(1) The evidence disclosed the need for healthcare and the prison to devise a better means of communication between healthcare personnel at the scene of a medical emergency and the prison control room / ambulance control (2) Similar communication difficulties have already been reported in relation to the inquest into the death of Martin Brown who died at HMIP Lancaster Farms and the Prison and Probation Ombudsman has highlighted a delay in the provision of essential information to Ambulance Control in the case of ████████ who died on 9th December 2020 at HMP Garth (3) The fact that communication difficulties have arisen between healthcare and the ambulance service in three recent cases involving prisons in Lancashire may indicate a potentially national problem ”

Is this part of a recurring concern?

Yes — Ineffective communication during medical emergencies.

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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

Provide supporting training on the new emergency response process to relevant staff and incorporate it into responses to all emergencies.

Verbatim wording from the response

“The Healthcare team will receive training in ambulance categorisation to be able to effectively challenge if they feel it has been incorrectly categorised by the ambulance call handler. The Head of Healthcare at HMP Preston has contacted the Head of Healthcare at HMP Lancaster farms who has spoken directly to North West Ambulance Service (NWAS) to discuss training needs and scope training provision for clinicians within Spectrum prisons. NWAS have provided Spectrum with information (embedded in the action plan) which we can use to develop a staff training package. This information has been incorporated into the new Emergency Response Standard Operating Procedure at HMP Preston.”

Source location

2022-0018-Response-from-Spectrum-1.pdf
Page 2 · response
Published 25 January 2022

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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

Develop and deliver clinician training on ambulance categorisation and challenging incorrect categorisation.

Verbatim wording from the response

“The Healthcare team will receive training in ambulance categorisation to be able to effectively challenge if they feel it has been incorrectly categorised by the ambulance call handler. The Head of Healthcare at HMP Preston has contacted the Head of Healthcare at HMP Lancaster farms who has spoken directly to North West Ambulance Service (NWAS) to discuss training needs and scope training provision for clinicians within Spectrum prisons. NWAS have provided Spectrum with information (embedded in the action plan) which we can use to develop a staff training package. This information has been incorporated into the new Emergency Response Standard Operating Procedure at HMP Preston.”

Source location

2022-0018-Response-from-Spectrum-1.pdf
Page 2 · response
Published 25 January 2022

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

Implement the revised emergency response process, including a second healthcare responder, scene SBAR completion and direct ambulance communication.

Verbatim wording from the response

“It was therefore decided that Healthcare at HMP Preston would revise the Emergency Response Standard Operating Procedure to allow a second healthcare staff member to also attend any emergency codes or Hotel 2 calls. The second healthcare member of staff would carry Hotel 3 radio and would be responsible to immediately completing an SBAR at the scene and then use the wing phone to ring communications to speak directly with the ambulance to provide accurate updates.”

Source location

2022-0018-Response-from-Spectrum-1.pdf
Page 1 · response
Published 25 January 2022

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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

Access to mobile phones or alternative communication methods is the responsibility of HMPPS partners.

Verbatim wording from the response

“Firstly, based on the number of occurrences of communication issues identified above, the issue of communication between prison healthcare teams, the communication room and the ambulance service, is clearly a national problem. The accessibility to mobile phones or alternative methods to improve communication remain in the gift of our HMPPS partners. The same issues arise for the use of Code Blue and Code Red with Spectrum Healthcare have no influence to change and may continue to be a wider concern”

Source location

2022-0018-Response-from-Spectrum-1.pdf
Page 1 · response
Published 25 January 2022

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

Spectrum Healthcare has no influence to change the Code Blue and Code Red communication arrangements.

Verbatim wording from the response

“Firstly, based on the number of occurrences of communication issues identified above, the issue of communication between prison healthcare teams, the communication room and the ambulance service, is clearly a national problem. The accessibility to mobile phones or alternative methods to improve communication remain in the gift of our HMPPS partners. The same issues arise for the use of Code Blue and Code Red with Spectrum Healthcare have no influence to change and may continue to be a wider concern”

Source location

2022-0018-Response-from-Spectrum-1.pdf
Page 1 · response
Published 25 January 2022

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

    Continue the patient-safety task-and-finish group to review recommendations and actions across the organisation.

    Stated by Spectrum CICStated in progressThe respondent said that this action was in progress when they made their response on 25 January 2022.
  2. 2

    Involve quality leads in auditing the emergency-response work and report findings through local and organisational governance boards.

    Stated by Spectrum CICStated plannedThe respondent said that this action was planned when they made their response on 25 January 2022.
  3. 3

    Share learning from emergency-response incidents at safety huddles and across the organisation as patient-safety best practice.

    Stated by Spectrum CICStated plannedThe respondent said that this action was planned when they made their response on 25 January 2022.

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

Continue the patient-safety task-and-finish group to review recommendations and actions across the organisation.

Verbatim wording from the response

“Any learning will be shared at the safety huddles and within the wider organisation to share best practice as part of the Patient Safety agenda led by the Patient Safety Recognising the medical emergency response is an area that is challenging within Health and Justice sites Spectrum is having an organisational approach to understanding the wider issues, reviewing all the recommendations and actions and are taking this forward with a Task and Finish group led by the patient safety lead for spectrum. Quality leads will be involved with audit which will feed into local and organisational governance boards for reporting and escalation as appropriate.”

Source location

2022-0018-Response-from-Spectrum-1.pdf
Page 2 · response
Published 25 January 2022

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

Involve quality leads in auditing the emergency-response work and report findings through local and organisational governance boards.

Verbatim wording from the response

“Any learning will be shared at the safety huddles and within the wider organisation to share best practice as part of the Patient Safety agenda led by the Patient Safety Recognising the medical emergency response is an area that is challenging within Health and Justice sites Spectrum is having an organisational approach to understanding the wider issues, reviewing all the recommendations and actions and are taking this forward with a Task and Finish group led by the patient safety lead for spectrum. Quality leads will be involved with audit which will feed into local and organisational governance boards for reporting and escalation as appropriate.”

Source location

2022-0018-Response-from-Spectrum-1.pdf
Page 2 · response
Published 25 January 2022

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 learning from emergency-response incidents at safety huddles and across the organisation as patient-safety best practice.

Verbatim wording from the response

“The new system explained above was trialled in an exercise on the (18/03/2022). This approach proved to be successful. There are plans for this to go live on the (20/03/2022). Supporting training around 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.”

Source location

2022-0018-Response-from-Spectrum-1.pdf
Page 2 · response
Published 25 January 2022

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