PFD report

Adil HABIB · Prevention of Future Deaths report

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Issued 16 Sep 2015•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.

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Concerns
6

Raised in this report

Recipients
3

Named on the report

Responses found
2

Of 3 recipients

Stated actions
10

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

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

Concerns raised6

  1. Lack of prison officer training on choking risks during searches and control and restraint
  2. Lack of prison officer training on choking risks during searches and control and restraint
    Part of recurring concern: Unsafe police restraint practices and controls
  3. Failure to provide the attending ambulance service with the prison gate location
    Part of recurring concern: Unsafe emergency call handling
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.9

  1. Action

    Obtain postal addresses for prisons and young offender institutions to identify additional or temporary ambulance access gates.

    Stated by London Ambulance Service NHS TrustStated completedThe respondent said that this action was complete when they made their response on 16 September 2015.
  2. Action

    Add HMP Pentonville’s additional prison gate to the emergency gazetteer with accurate GPS information for satellite navigation.

    Stated by London Ambulance Service NHS TrustStated completedThe respondent said that this action was complete when they made their response on 16 September 2015.
  3. Action

    Request that prison staff state the ambulance access gate at the beginning of emergency calls.

    Stated by London Ambulance Service NHS TrustStated completedThe respondent said that this action was complete when they made their response on 16 September 2015.

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 officer training on choking risks during searches and control and restraint

Wider context from the report

“I heard evidence at inquest that there is no training for prison officers that specifically covers the risk of prisoners choking as a result of attempts to conceal an item from prison officers, most especially during a search and/or control & restraint. It seems to me that this is a significant omission, and it would be helpful if such training were mandatory and refreshed regularly. I have written to the National Offender Management Service as provider of prison officer training about this but, in addition, I wanted to bring this direct to your attention. It may be some months before there is any change to the national training offered. ”

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

Lack of prison officer training on choking risks during searches and control and restraint

Wider context from the report

“I heard evidence at inquest that there is no training for prison officers that specifically covers the risk of prisoners choking as a result of attempts to conceal an item from prison officers, most especially during a search and/or control & restraint. It seems to me that this is a significant omission, and it would be helpful if such training were mandatory and refreshed regularly. ”

Is this part of a recurring concern?

Yes — Unsafe police restraint practices and controls.

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 provide the attending ambulance service with the prison gate location

Wider context from the report

“When a prison officer at HMP Pentonville rang 999 to ask that paramedics attend the prison, the caller did not immediately offer the location of the prison gate that London Ambulance Service should attend. Whilst there is of course an issue for the prison in terms of offering the information, it would be helpful for LAS call handlers to be provided with a drop down menu showing the alternative gates when they input the prison details. I understand that the LAS computer system has been augmented in this respect since Mr Habib’s death for HMP Pentonville, but not for the other London prisons. Perhaps that would be a useful exercise? ”

Is this part of a recurring concern?

Yes — Unsafe emergency call handling.

Open source report

Source evidence

How this individual concern was interpreted

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

PFD Monitor interpretation

Failure of prison control room officers to immediately provide ambulance access-gate locations to emergency call handlers

Wider context from the report

“The prison officer who rang 999 from the control room did not immediately offer the LAS call handler the location of the prison gate to which the ambulance should be driven. I understand that your team has taken steps to remind all officers working in the control room that they must do this. I understand also that your team has an ongoing conversation with London Ambulance Service to enable best care to be given to those in the prison in need of paramedic attention. ”

Is this part of a recurring concern?

Yes — Unsafe emergency call handling.

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 alternative prison-gate information in LAS call-handler systems for other London prisons

Wider context from the report

“When a prison officer at HMP Pentonville rang 999 to ask that paramedics attend the prison, the caller did not immediately offer the location of the prison gate that London Ambulance Service should attend. Whilst there is of course an issue for the prison in terms of offering the information, it would be helpful for LAS call handlers to be provided with a drop down menu showing the alternative gates when they input the prison details. I understand that the LAS computer system has been augmented in this respect since Mr Habib’s death for HMP Pentonville, but not for the other London prisons. Perhaps that would be a useful exercise? ”

Is this part of a recurring concern?

Yes — Unreliable ambulance-service computer systems for safety-critical information; Unsafe emergency call handling.

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 Hotel 7 nurses to respond immediately to every emergency alarm

Wider context from the report

“The nurse who was on call as Hotel 7 at the prison did not respond to the emergency alarm that was activated at the start of the control & restraint of Mr Habib, as she should have. Instead, she only responded once a Level 1 emergency was radioed. I appreciate that this nurse no longer works at HMP Pentonville and that your team has taken steps to remind all nurses operating as Hotel 7 of their responsibility to respond to every alarm immediately. ”

Is this part of a recurring concern?

Yes — Failure of emergency alarm response.

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

Obtain postal addresses for prisons and young offender institutions to identify additional or temporary ambulance access gates.

Verbatim wording from the response

“With the assistance of the National Offender Management Service (NOMS) we have obtained a list of postal addresses for all prisons and young offender institutions in the UK and have been assured that the Local Safer Custody Leads have been asked to contact their respective local Ambulance Service Trusts to advise if there are additional or temporary gates to be used, either on a temporary or longer term basis, to those held by NOMS. We have made contact with the Safer Custody Lead for Greater London and established that aside from HMP Pentonville the thirteen prison and young offender institutions operate with a single vehicle access gate.”

Source location

2015-0380-Response-by-London-Ambulance-Service-NHS-Trust
Page 2 · response
Published 16 September 2015

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

Add HMP Pentonville’s additional prison gate to the emergency gazetteer with accurate GPS information for satellite navigation.

Verbatim wording from the response

“The evidence submitted to the Court during the inquest outlined the actions the London Ambulance Service NHS Trust (LAS) had taken since the death of Mr Habib to ensure that we attend the correct prison gate at HMP Pentonville. At the time of the 999 call to attend Mr. Habib, the Gazetteer in the Emergency Operations Centre (EOC) only held the main postal address in Caledonian Road for HMP Pentonville and the prison officer making the 999 call did not volunteer that a different prison gate was to be used. After being advised that a second gate was operated in Roman Way the address was added to the Gazetteer with accurate GPS information so that when selected, ambulance staff would be guided to the address by satellite navigation.”

Source location

2015-0380-Response-by-London-Ambulance-Service-NHS-Trust
Page 1 · response
Published 16 September 2015

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 that prison staff state the ambulance access gate at the beginning of emergency calls.

Verbatim wording from the response

“Following the inquest HMP Pentonville’s Head of Residence, ████████ has confirmed to the LAS’s Senior Quality Assurance Manager, ████████, that HMP Pentonville will continue to operate two prison gates. We requested that staff at HMP Pentonville are prompted to give the address of the prison gate ambulance staff are to attend at the beginning of the emergency call to the LAS.”

Source location

2015-0380-Response-by-London-Ambulance-Service-NHS-Trust
Page 1 · response
Published 16 September 2015

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

Disseminate learning to emergency operations centre staff through the November Control Services Team Talk, requiring confirmation of the prison address to attend.

Verbatim wording from the response

“To share the learning about the call to attend Mr Habib with EOC staff, the November Control Services Team Talk disseminated on 6 November 2015, see copy enclosed, asked staff to confirm the address to attend when taking a call from any prison or young offender institution. Further, as is our practice, a copy of this reply will be shared with the Association of Ambulance Chief Executives and the National Ambulance Service Medical Directors to share our learning with other ambulance services.”

Source location

2015-0380-Response-by-London-Ambulance-Service-NHS-Trust
Page 2 · response
Published 16 September 2015

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

Send the DVD and a Notice to Governors to all prison Governors for viewing by operational staff.

Verbatim wording from the response

“The DVD will be sent to all prison Governors by Christmas along with a Notice to Governors advising them of the content and that it should be made available for all operational staff to view. The content will be reinforced in due course when all operation staff receive updated control and restraint training from the National Control & Restraint Instructors. It is expected that the roll out of training will commence in January 2016. All Prison Officer Entry Level Trainees (POELTs) will receive training relating to the contents of this DVD from in December.”

Source location

2015-0380-Response-by-NOMS
Page 1 · response
Published 16 September 2015

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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

Consult key stakeholders on the accompanying training material for the control and restraint DVD.

Verbatim wording from the response

“I can confirm that the DVD has been completed and that the accompanying training material has been prepared and is out for consultation with key stakeholders. I can also confirm that the DVD includes medical advice related to the use of control and restraint and covers:”

Source location

2015-0380-Response-by-NOMS
Page 1 · response
Published 16 September 2015

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

Complete a training DVD covering medical advice and safe use of control and restraint.

Verbatim wording from the response

“In your letter you raise concern that the national training for search and restraint does not cover those situations where a prisoner is at risk of choking after attempting to conceal an item during control and restraint procedures. You will be aware that the Chief Executive of NOMS accepted the Prisons and Probation Ombudsman’s recommendation that clear guidance and training be given on the safe use of force, including pain compliance techniques, when resistant prisoners have items in their mouths, which might compromise their breathing. In the response, NOMS confirmed that a DVD was being produced to aid staff training in the safe use of force, in conjunction with current medical advice, and that NOMS would consider the best way to include specific guidance within the DVD on what action should be taken where items are concealed in a resistant prisoner’s mouth.”

Source location

2015-0380-Response-by-NOMS
Page 1 · response
Published 16 September 2015

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 updated control and restraint training to operational staff through National Control & Restraint Instructors.

Verbatim wording from the response

“The DVD will be sent to all prison Governors by Christmas along with a Notice to Governors advising them of the content and that it should be made available for all operational staff to view. The content will be reinforced in due course when all operation staff receive updated control and restraint training from the National Control & Restraint Instructors. It is expected that the roll out of training will commence in January 2016. All Prison Officer Entry Level Trainees (POELTs) will receive training relating to the contents of this DVD from in December.”

Source location

2015-0380-Response-by-NOMS
Page 1 · response
Published 16 September 2015

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 Prison Officer Entry Level Trainees with training on the DVD’s contents.

Verbatim wording from the response

“The DVD will be sent to all prison Governors by Christmas along with a Notice to Governors advising them of the content and that it should be made available for all operational staff to view. The content will be reinforced in due course when all operation staff receive updated control and restraint training from the National Control & Restraint Instructors. It is expected that the roll out of training will commence in January 2016. All Prison Officer Entry Level Trainees (POELTs) will receive training relating to the contents of this DVD from in December.”

Source location

2015-0380-Response-by-NOMS
Page 1 · response
Published 16 September 2015

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.1

  1. 1

    Share the response’s learning with the Association of Ambulance Chief Executives and National Ambulance Service Medical Directors.

    Stated by London Ambulance Service NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 16 September 2015.

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 the response’s learning with the Association of Ambulance Chief Executives and National Ambulance Service Medical Directors.

Verbatim wording from the response

“To share the learning about the call to attend Mr Habib with EOC staff, the November Control Services Team Talk disseminated on 6 November 2015, see copy enclosed, asked staff to confirm the address to attend when taking a call from any prison or young offender institution. Further, as is our practice, a copy of this reply will be shared with the Association of Ambulance Chief Executives and the National Ambulance Service Medical Directors to share our learning with other ambulance services.”

Source location

2015-0380-Response-by-London-Ambulance-Service-NHS-Trust
Page 2 · response
Published 16 September 2015

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