First reported 17 Oct 2014•Latest report 23 Mar 2026
Definition
What this concern includes
Includes failures of controls specifically dedicated to the prison Code Blue emergency response, including recognition of qualifying emergencies, understanding the consequences and criteria for activation, prompt code activation, responder direction and coordination, and associated emergency equipment or immediate-response arrangements when directly tied to Code Blue operation.
Not included
Excludes generic emergency-response, staffing, training or communication deficiencies that are not explicitly tied to the prison Code Blue system.
Excludes Code Red or other emergency codes unless the report directly links the failure to the same Code Blue response system.
Excludes clinical treatment failures after the Code Blue response has been reliably activated unless they concern a dedicated Code Blue control.
Excludes ambulance-resource, hospital-transfer or general resuscitation failures that do not concern operation of the prison Code Blue system.
Reports
14
Distinct published reports
Individual concerns
16
A report can raise multiple concerns
Date range
2014–2026
First to latest report issue date
Stated actions
39
Described in published responses
Reports over time
Reports over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
HM Prison and Probation Service6
Care UK2
Ministry of Justice2
Pentonville Prison2
Recipient name withheld2
Birmingham and Solihull Mental Health NHS Foundation Trust1
Central and North West London NHS Foundation Trust1
G4S1
HCRG Care Ltd1
Home Office1
Langley Health Centre1
Leeds Community Healthcare NHS Trust1
Mitie1
Mitie Care And Custody Limited1
National Offender Management Service Equality, Rights and Decency Group1
Prison or young offender institution9
Executive agency6
NHS trust4
Ministerial department3
Prison operator3
Private limited company3
Multi-service care provider2
Type not available2
Coronial office1
Executive non-departmental public body1
Healthcare site1
Sub-organisation1
Concerns and responses across reports
Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.
Mid Kent and Medway
Concerns raised2
Lack of understanding of the consequences of issuing a Code Blue
Failure to issue a Code Blue when appropriate
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
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 respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Issue emergency-response policy guidance and brief staff on responsibilities, code use, ambulance summoning, and defibrillator deployment.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 15 May 2016.
Action
Distribute pocket-sized cards explaining the emergency response codes to all staff.
Stated by HM Prison and Probation ServiceStated plannedThe respondent said that this action was planned when they made their response on 15 May 2016.
County Durham and Darlington
Concerns raised1
Delays and uncertainty in calling an emergency ambulance and using the code blue call
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
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 respondent says it has done, is doing, or plans to do in response to the concern raised.5
Action
Verify current staff understanding of the Emergency Code Protocol and obtain signed confirmation.
Stated by Durham PrisonStated completedThe respondent said that this action was complete when they made their response on 28 October 2015.
Action
Issue pocket-sized Emergency Code Protocol cards to staff.
Stated by Durham PrisonStated completedThe respondent said that this action was complete when they made their response on 28 October 2015.
Action
Display Emergency Code Protocol posters prominently in all residential areas.
Stated by Durham PrisonStated completedThe respondent said that this action was complete when they made their response on 28 October 2015.
Action
Embed Emergency Code Protocol instruction, understanding checks, signed confirmation and card issuance in new-staff induction.
Stated by Durham PrisonStated completedThe respondent said that this action was complete when they made their response on 28 October 2015.
Action
Reinforce the Emergency Code Protocol through staff meetings, management briefings, notices, email, intranet publication and line-manager cascades.
Stated by Durham PrisonStated completedThe respondent said that this action was complete when they made their response on 28 October 2015.
Norfolk
Concerns raised1
Failure to ensure Code Blue responders know where to go
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
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 respondent says it has done, is doing, or plans to do in response to the concern raised.5
Action
Revise new-starter and agency-staff induction to include prison-wide shadowing.
Stated by HCRG Care Services LtdStated completedThe respondent said that this action was complete when they made their response on 2 February 2015.
Action
Develop and introduce a local induction process and checklist to record completion.
Stated by HCRG Care Services LtdStated in progressThe respondent said that this action was in progress when they made their response on 2 February 2015.
Action
Provide annual refresher training on prison layout and emergency attendance procedures.
Stated by HCRG Care Services LtdStated plannedThe respondent said that this action was planned when they made their response on 2 February 2015.
Action
Arrange for prison officers to meet nurses at the entrance corridor and direct them to medical emergencies during patrol state.
Stated by HCRG Care Services LtdStated completedThe respondent said that this action was complete when they made their response on 2 February 2015.
Action
Ratify a joint medical-emergency response protocol with HMP Norwich.
Stated by HCRG Care Services LtdStated plannedThe respondent said that this action was planned when they made their response on 2 February 2015.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
Serco no longer provides services at HMP Norwich and has no power to implement the recommendations there.
Stated by Mr Rupert SoamesOutside remitThe respondent said that this matter was outside its role or authority.
Position
HMP Norwich and Virgin Care have the power to implement the recommendations.
Stated by Mr Rupert SoamesRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Prison maps cannot be introduced because the prison governor does not permit them for security reasons.
Stated by HCRG Care Services LtdUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
West Yorkshire Eastern
Concerns raised1
Failure to use emergency codes when required
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
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Includes failures of controls specifically dedicated to the prison Code Blue emergency response, including recognition of qualifying emergencies, understanding the consequences and criteria for activation, prompt code activation, responder direction and coordination, and associated emergency equipment or immediate-response arrangements when directly tied to Code Blue operation.
