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.
Kent and Medway
Concerns raised1
Confusion among prison staff about when and how to call a code blue
This report raised 5 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.4
Action
Reissue written Code Blue guidance and reinforce response expectations through daily briefings and Night Orderly Officer handovers.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 26 March 2026.
Action
Embed practical emergency-response simulations, including Code Blue scenarios, within local training and mentoring arrangements.
Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 26 March 2026.
Action
Monitor Code Blue compliance and learning through incident reviews and feedback to the Safer Custody Management Team.
Stated by HM Prison and Probation ServiceStated plannedThe respondent said that this action was planned when they made their response on 26 March 2026.
Action
Continue joint emergency-response exercises with healthcare staff to strengthen shared understanding and multidisciplinary response.
Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 26 March 2026.
Buckinghamshire
Concerns raised1
Failure of operational staff to follow local medical emergency response protocols
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.6
Action
Reissue six-monthly Governor’s Notices and conduct regular staff briefings to reinforce medical emergency response procedures and emergency-code use.
Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 16 July 2025.
Action
Issue portable Code Red/Code Blue prompt cards and display posters as accessible reminders of emergency-code procedures.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 16 July 2025.
Action
Use mentoring, induction competency checks and radio communication training to train and test newly appointed officers on radios and emergency response procedures.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 16 July 2025.
Action
Brief the referenced Operational Support Grade individually on night procedures and the Local Security Strategy.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 16 July 2025.
Action
Use sign-off sheets for night Operational Support Grades to confirm understanding of routine duties, radio use and emergency-code procedures.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 16 July 2025.
Action
Issue a staff information notice, distribute Code Red/Code Blue prompt cards and remind control-room staff to follow emergency-services calling protocols.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 16 July 2025.
East Sussex
Concerns raised1
Inadequate understanding among prison staff about when to call Code Blue
This report raised 11 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.1
Action
Continue briefing, training and distributing reminders to staff on using Code Red and Code Blue and immediately calling emergency services.
Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 20 March 2024.
Nottinghamshire
Concerns raised1
Misunderstanding among discipline staff of medical emergency code criteria
This report raised 5 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.8
Action
Schedule live emergency-response simulations with prison colleagues across all sites over the next twelve months.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 4 January 2023.
Action
Develop a joint training programme with HMP Nottingham prioritising learning from the Regulation 28 notice.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 4 January 2023.
Action
Update and recirculate the joint urgent-assessment protocol for deteriorating patients, including emergency and code-response procedures.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 4 January 2023.
Action
Provide joint training for prison staff on the urgent-assessment and code-response process.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 4 January 2023.
Action
Implement an annual staff training plan covering emergency codes, medical emergencies and when officers should enter cells, with training repeated at least twice yearly.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 4 January 2023.
Action
Provide all new HMP Nottingham staff with pocket cards explaining emergency codes and required actions.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 4 January 2023.
Action
Review incidents in daily briefing sheets and address failures through targeted training, guidance or performance management.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 4 January 2023.
Action
Conduct monthly senior-management night visits to check staff understanding and reinforce medical emergency response procedures.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 4 January 2023.
Birmingham and Solihull
Concerns raised1
Delays in calling code blue emergencies
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.
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.3
Action
Deliver recurring safety talks and provide signage and leaflets to maintain staff awareness of medical emergency procedures.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 26 May 2022.
Action
Provide updated medical emergency response training, including refresher training for all staff.
Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 26 May 2022.
Action
Issue emergency response guides and pocket cards to prisons and staff to provide medical emergency response guidance.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 26 May 2022.
London (West)
Concerns raised1
Failure to use the code blue procedure to summon an immediate emergency ambulance
This report raised 13 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.
Northamptonshire
Concerns raised1
Lack of clarity about discretion to initiate a Code Blue response to complaints of chest pain
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
London (West)
Concerns raised2
Failure to immediately activate the Code Blue/Red system
Failure of officer training to ensure understanding of the importance and reasons for Code Blue/Red use
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
Publish notices, display signs, include emergency procedures in induction, and attach notices to First Night Centre cell doors.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 7 March 2018.
Action
Extend cell-door emergency-code notices to healthcare, segregation, and detox areas.
Stated by HM Prison and Probation ServiceStated plannedThe respondent said that this action was planned when they made their response on 7 March 2018.
Inner North London
Concerns raised1
Failure of prison officers to understand code blue and code red distinctions
This report raised 8 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.
Inner North London
Concerns raised1
Failure of emergency healthcare lead nurses to understand code red and code blue medical emergencies
This report raised 14 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.3
Action
Reinforce Code Red and Code Blue procedures through staff training and clinical-area posters.
Stated by Care UKStated completedThe respondent said that this action was complete when they made their response on 6 December 2016.
Action
Request 250 additional emergency-response aide-memoire cards for distribution across the establishment.
Stated by Care UKStated plannedThe respondent said that this action was planned when they made their response on 6 December 2016.
Action
Develop and circulate a standard operating procedure for emergency response.
Stated by Care UKStated in progressThe respondent said that this action was in progress when they made their response on 6 December 2016.
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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.
