Recurring concern

Unreliable operation of prison Code Blue emergency response

First to latest report 17 Oct 2014 — 23 Mar 2026

Reports that mention this concern
14
Times this concern has been raised
16
Stated actions linked to this concern
39

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.

What is 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 and published responses 14 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Mid Kent and Medway

    AI-generated summary

    Ronnie Olliffe · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Ronnie Olliffe collapsed in his cell at HMP Rochester on 1 October 2014 and was later confirmed dead at the scene; the medical cause of death was anabolic steroid-related cardiac hypertrophy. Concerns included failures to issue a required Code Blue, inadequate understanding that this would summon an ambulance, and failure to consider or use an available defibrillator.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of understanding of the consequences of issuing a Code Blue

    Wider context from the report

    “1) there was a failure to issue a Code Blue pursuant to both a local and national policy in circumstances where it was appropriate to do so 2) there was a lack of understanding as to what consequences flowed from the issuing of a Code Blue, namely that an ambulance would be summoned immediately 3) there was a failure to consider or use a defibrillator when it was appropriate to do so and when one was available ”

    Source location

    Ronnie Olliffe · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to issue a Code Blue when appropriate

    Wider context from the report

    “1) there was a failure to issue a Code Blue pursuant to both a local and national policy in circumstances where it was appropriate to do so 2) there was a lack of understanding as to what consequences flowed from the issuing of a Code Blue, namely that an ambulance would be summoned immediately 3) there was a failure to consider or use a defibrillator when it was appropriate to do so and when one was available ”

    Source location

    Ronnie Olliffe · Prevention of Future Deaths report
    Page 3 · concerns

    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

    Issue emergency-response policy guidance and brief staff on responsibilities, code use, ambulance summoning, and defibrillator deployment.

    Verbatim wording from the response

    “All night staff have been issued with a personal copy of Prison Service Instruction (PSI) 03/2013 Medical Emergency Response Codes and have each signed to say they understand the PSI and are fully aware of their responsibilities. A Notice to Staff setting out the policy has been issued and the remaining staff have been briefed at staff engagement sessions.”

    Source location

    2016-0224-Response-by-NOMS
    Page 1 · response
    Published 15 May 2016

    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

    Distribute pocket-sized cards explaining the emergency response codes to all staff.

    Verbatim wording from the response

    “The Notice to Staff described above also explains that when a code is used an ambulance will be called, and emphasises the importance of using the codes appropriately. Pocket-sized cards explaining the codes have been ordered and will be distributed to all staff.”

    Source location

    2016-0224-Response-by-NOMS
    Page 1 · response
    Published 15 May 2016

    Open published response

  2. County Durham and Darlington

    AI-generated summary

    Kevin Anthony Forster · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Kevin Anthony Forster died in his prison cell at HMP Durham on 14 September 2014 after taking drugs he had hidden within his body. Staff identified that he was under the influence of an unknown substance, but no thorough or clinical assessment was undertaken. The principal concerns included inadequate policies, training, assessment, observation, treatment planning, communication and emergency response to prisoners who may have overdosed.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Delays and uncertainty in calling an emergency ambulance and using the code blue call

    Wider context from the report

    “8. The evidence indicated that there was a delay (albeit a short one) in either healthcare or discipline staff calling for an emergency ambulance to attend and/or whether code blue as an expression was used. Other inquests have clearly identified issues at the establishment about the calling of an emergency ambulance. ”

    Source location

    Kevin Anthony Forster · Prevention of Future Deaths report
    Page 1 · concerns

    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

    Verify current staff understanding of the Emergency Code Protocol and obtain signed confirmation.

    Verbatim wording from the response

    “Following the death of Mr Kevin Anthony Forster on 14th September 2015, while in custody at HMP Durham, the following actions have already been taken by the prison to ensure all staff have a full understanding of the Emergency Code Protocol which covers the use of Codes Blue and Red. These steps were taken prior to the Inquest occurring and were in response to the concerns made by the Prison Probation Ombudsman Report and also from the prison’s own learning exercise that was undertaken following this death.”

    Source location

    2015-0453-Response2
    Page 1 · response
    Published 28 October 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

    Issue pocket-sized Emergency Code Protocol cards to staff.

    Verbatim wording from the response

    “All staff have been issued with pocket sized cards explaining the protocol.”

    Source location

    2015-0453-Response2
    Page 1 · response
    Published 28 October 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

    Display Emergency Code Protocol posters prominently in all residential areas.

    Verbatim wording from the response

    “All residential areas which are the wings on which prisoners live have displayed the protocol in bold colours in prominent places which are A4 size. These posters can be located in the wing main offices which everyone attending a wing must report to.”

    Source location

    2015-0453-Response2
    Page 1 · response
    Published 28 October 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

    Embed Emergency Code Protocol instruction, understanding checks, signed confirmation and card issuance in new-staff induction.

    Verbatim wording from the response

    “A Governors Notice to Staff has been issued to ensure that all new staff either directly or non-directly employed attend the Safer Custody department and receive a full explanation of the Emergency Code Protocol”

    Source location

    2015-0453-Response2
    Page 1 · response
    Published 28 October 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

    Reinforce the Emergency Code Protocol through staff meetings, management briefings, notices, email, intranet publication and line-manager cascades.

    Verbatim wording from the response

    “The Emergency Protocol has been an agenda item on monthly team meetings with staff and the protocol fully explained. It is also discussed at the Safer Prisons meeting as part of a wider discussion on deaths in custody. The Deputy Governor has addressed the emergency protocol issue with all functional heads at meetings and this has been cascaded to staff by line managers.”

    Source location

    2015-0453-Response2
    Page 2 · response
    Published 28 October 2015

    Open published response

  3. Norfolk

    AI-generated summary

    DARREN WRIGHT · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Darren Wright, aged 35, was found dead in his cell at HMP Norwich on 3 November 2013 after having been admitted to prison in September 2013. The report identified concerns about inconsistent sharing and access to information, the response to a Code Blue notification, and gaps in recent CPR training among attending prison officers.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to ensure Code Blue responders know where to go

    Wider context from the report

    “(1) On receiving Code Blue notification the Staff Nurse did not know where to go and had to call on her radio to be found and then taken to the cell; ”

    Source location

    DARREN WRIGHT · Prevention of Future Deaths report
    Page 2 · concerns

    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

    Revise new-starter and agency-staff induction to include prison-wide shadowing.

    Verbatim wording from the response

    “In terms of training, all new nurses working in HMP Norwich are required to undergo a two week ‘shadow’ period where they are fully inducted to all areas of the prison. During this time, emergency response kits are highlighted to staff. This amended process for shadowing of new staff was already in place on 1 April 2014 when Virgin Care’s contract to provide the service came into force. Unfortunately, whilst we did consider introducing maps of the prison to assist our staff in locating cell numbers, this is not permitted by the prison governor for security reasons in prisons.”

    Source location

    2015-0035-Response-by-Virgin-Care-Services-Limited
    Page 2 · response
    Published 2 February 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

    Develop and introduce a local induction process and checklist to record completion.

    Verbatim wording from the response

    “• The induction process has been reviewed and revised to include ‘shadowing’ time for all new starters and agency staff. To further evidence this, a local induction process and checklist template is being developed and introduced to record an individual’s completion of this process. This will therefore increase the knowledge of our staff in terms of the layout of cells when they are required to attend an emergency. This will be followed up with refresher training on an annual basis.”

    Source location

    2015-0035-Response-by-Virgin-Care-Services-Limited
    Page 2 · response
    Published 2 February 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 annual refresher training on prison layout and emergency attendance procedures.

    Verbatim wording from the response

    “• The induction process has been reviewed and revised to include ‘shadowing’ time for all new starters and agency staff. To further evidence this, a local induction process and checklist template is being developed and introduced to record an individual’s completion of this process. This will therefore increase the knowledge of our staff in terms of the layout of cells when they are required to attend an emergency. This will be followed up with refresher training on an annual basis.”

    Source location

    2015-0035-Response-by-Virgin-Care-Services-Limited
    Page 2 · response
    Published 2 February 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

    Arrange for prison officers to meet nurses at the entrance corridor and direct them to medical emergencies during patrol state.

    Verbatim wording from the response

    “• A review of the response procedure – the Head of Healthcare at HMP Norwich has met with the Operations Governor within the prison and agreed where a medical emergency arises when the prison is in patrol state, a prison officer will wait for the nurse in the entrance corridor and direct the nurse to the medical emergency. This has already been put into place and a joint protocol will be ratified by both ourselves and HMP Norwich by 31 March 2015. This will ensure that our nurses can be directed to the correct cell to attend to medical emergencies.”

    Source location

    2015-0035-Response-by-Virgin-Care-Services-Limited
    Page 2 · response
    Published 2 February 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

    Ratify a joint medical-emergency response protocol with HMP Norwich.

    Verbatim wording from the response

    “• A review of the response procedure – the Head of Healthcare at HMP Norwich has met with the Operations Governor within the prison and agreed where a medical emergency arises when the prison is in patrol state, a prison officer will wait for the nurse in the entrance corridor and direct the nurse to the medical emergency. This has already been put into place and a joint protocol will be ratified by both ourselves and HMP Norwich by 31 March 2015. This will ensure that our nurses can be directed to the correct cell to attend to medical emergencies.”

    Source location

    2015-0035-Response-by-Virgin-Care-Services-Limited
    Page 2 · response
    Published 2 February 2015

    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

    Serco no longer provides services at HMP Norwich and has no power to implement the recommendations there.

    Verbatim wording from the response

    “Whilst at the time of Mr Wright's unfortunate death Serco was the healthcare provider at HMP Norwich, as from 1st April 2014 all responsibility for delivery of healthcare services passed to Virgin Care. Accordingly, Serco no longer have any involvement in service delivery at HMP Norwich.”

    Source location

    2015-0035-Response-by-Serco
    Page 1 · response
    Published 2 February 2015

    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

    HMP Norwich and Virgin Care have the power to implement the recommendations.

    Verbatim wording from the response

    “As stated above, Serco does not provide any services to HMP Norwich (either custodial or healthcare). Therefore, the company has no power to implement these recommendations at HMP Norwich. However, we note that the Regulation 28 report has been sent to HMP Norwich and Virgin Care Limited and these parties do have power to implement the recommendations.”

    Source location

    2015-0035-Response-by-Serco
    Page 1 · response
    Published 2 February 2015

    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

    Prison maps cannot be introduced because the prison governor does not permit them for security reasons.

    Verbatim wording from the response

    “In terms of training, all new nurses working in HMP Norwich are required to undergo a two week ‘shadow’ period where they are fully inducted to all areas of the prison. During this time, emergency response kits are highlighted to staff. This amended process for shadowing of new staff was already in place on 1 April 2014 when Virgin Care’s contract to provide the service came into force. Unfortunately, whilst we did consider introducing maps of the prison to assist our staff in locating cell numbers, this is not permitted by the prison governor for security reasons in prisons.”

    Source location

    2015-0035-Response-by-Virgin-Care-Services-Limited
    Page 2 · response
    Published 2 February 2015

    Open published response

  4. West Yorkshire Eastern

    AI-generated summary

    William Thomas Anderson · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    William Thomas Anderson died in his cell at HMP Wealstun on 19 September 2010 after taking prescription medication belonging to others and drinking hooch, having appeared intoxicated or under the influence of alcohol or drugs the previous afternoon. The concerns included insufficient vigilance around inmate gatherings involving drugs and alcohol, incomplete staff training and recording of observations, failure to use an emergency code, and delay in summoning paramedic assistance.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to use emergency codes when required

    Wider context from the report

    “(4) The members of staff who observed the Deceased at around 5.45am on the 19th September 2010 did not “put out” a Code Blue. It was explained in the course of the Inquest that Codes Blue and Red are basic emergency codes which have been in existence for very many years. Despite the fact that, in this instance, the failure to call a Code Blue would not have affected the outcome, it is not inconceivable that to omit to use such emergency codes could, in certain circumstances, jeopardise an inmate’s chances of survival. In the circumstances, all Prison staff should be fully acquainted with the use of such codes and should use them accordingly; ”

    Source location

    William Thomas Anderson · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026