A prison has been told to issue clear guidance to staff on when to attempt resuscitation after nurses carried out cardiopulmonary resuscitation (CPR) on an inmate who was “clearly dead”.
Ashley Ansell-Austin hanged himself at HMP Chelmsford on 16 October last year. Despite “obvious signs of death”, including the fact his body was cold and there were indicators of rigor mortis, two nurses carried out CPR.
“They believed that, regardless of the circumstances, they had to perform CPR until paramedics arrived”
While a report by the Prisons and Probation Ombudsman said their wish to attempt resuscitation was “commendable”, it concluded that their actions were “undignified for the deceased”.
The report also found there was a “missed opportunity” to try and prevent Mr Ansell-Austin’s death just days before he died.
According to the report, one nurse had “flat refused” to carry out a mental health assessment the day before Mr Ansell-Austin took his own life.
The report shows Mr Ansell-Austin, who was serving a sentence for robbery and possession of blade, had a history of attempted suicide and self-harm in custody.
Staff at HMP Chelmsford had initiated self-harm and suicide prevention procedures – known as Assessment, Care in Custody and Teamwork (ACCT) – on 4 October after he cut off part of his ear.
“Trying to resuscitate someone who is clearly dead is distressing for staff and undignified for the deceased”
However, the ACCT process was closed on 12 October and not re-started, despite concerning changes in Mr Ansell-Austin’s behaviour.
The report also showed that prison and healthcare staff requested a mental health assessment just days before he died but this did not happen.
“Two days before he died, an urgent mental health assessment was requested when he refused his medications, but this was not carried out,” said the report.
“We consider this was a significant oversight and a missed opportunity to protect Mr Ansell-Austin,” it stated.
According to the report, a supervising officer (SO) asked a mental health nurse – referred to in the document as Nurse F – to assess Mr Ansell-Austin on 15 October.
“The SO told the investigator when he made this request, Nurse F ‘flat refused’ to see Mr Ansell-Austin,” said the report.
The document revealed that the nurse in question no longer works at Chelmsford and had “subsequently been suspended from work for an unrelated matter at another prison”.
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The ombudsman said the Essex prison must ensure staff had adequate ACCT training and that urgent mental health referrals were “actioned urgently”.
The report also called for clear guidance on resuscitation, after investigators found the nurses who attempted to revive Mr Austin-Ansell were under the impression they must attempt CPR – no matter what the circumstances – until death had been officially confirmed.
“Both said they believed that, regardless of the circumstances, they had to perform CPR until paramedics arrived,” said the report.
This was despite guidance issued by NHS England to prisons in 2016, which makes it clear resuscitation should not be attempted after a sudden death when it was clear this would be “futile”.
The ombudsman’s report showed the prison governor had alerted staff to the guidelines – based on European Resuscitation Council guidance – in October of that year.
“However, it was clear from all staff that were interviewed, that they believed CPR must always be started,” the report added.
A clinical reviewer for the case found the emergency response to Mr Ansell-Austin’s death had been “inappropriately managed”, said the report.
“We understand the commendable wish to attempt and continue resuscitation until death has been formally recognised, but staff should understand that they are not required to carry out CPR in these circumstances,” it said.
“Trying to resuscitate someone who is clearly dead is distressing for staff and undignified for the deceased,” it noted.
“We will make sure we learn any possible lessons from Mr Ansell-Austin’s death”
Prison Service spokeswoman
The Ministry of Justice said the prison had accepted all the ombudsman’s recommendations and had boosted mental health provision, including taking steps to ensure safe nurse staffing.
“Every death in custody is a tragedy and our thoughts are with Ashley Ansell-Austin’s family and friends,” said a Prison Service spokeswoman.
“We have accepted all the recommendations from the Prisons and Probation Ombudsman and the prison has already increased and improved mental health provision, she said.
She added: “We will make sure we learn any possible lessons from Mr Ansell-Austin’s death.”
Among measures to improve mental health care and reduce self-harm, the prison has introduced a new referral system that uses a threshold assessment grid (TAG) score to triage referrals appropriately.
Meanwhile, a dedicated mental health manager now co-ordinates the staffing rota to ensure there is “sufficient nursing cover to carry out assessments”.