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. Kent and Medway

    AI-generated summary

    Thomas Daniel RUGGIERO · 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

    Thomas Daniel Ruggiero, a 39-year-old prisoner at HMP Swaleside, was found unresponsive in his cell on 16 November 2024 after ligaturing himself and died later that day. The report identifies concerns about the emergency cell bell system, incomplete ACCT documentation, confusion over calling a “code blue”, and staffing, experience and communication at the prison, with risks to future prisoners remaining.

    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

    Confusion among prison staff about when and how to call a code blue

    Wider context from the report

    “(3) 'Code Blue' During the evidence in the inquest hearing there was clear confusion among prison staff regarding the calling of a 'code blue' in an emergency situation. That confusion included if / when to call a code blue and how to do so. The evidence was such that not only was there confusion at the time of events in November 2024, but that it persisted to date. I was told in evidence that the prison has issued more guidance to officers in this regard, but I was insufficiently reassured that this guidance has either had time to take effect or has taken affect at all. There is clear evidence that this presents a risk of future deaths and I am of the opinion that action needs to be taken. ”

    Source location

    Thomas Daniel RUGGIERO · 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

    Reissue written Code Blue guidance and reinforce response expectations through daily briefings and Night Orderly Officer handovers.

    Verbatim wording from the response

    “Your third concern is about the emergency call code process. I have received assurance from the Governor that written guidance has been reissued to all staff clearly setting out when, how, and by whom a Code Blue must be initiated. Expectations of how a Code Blue response needs to be managed are reinforced through daily briefings and form part of the Night Orderly Officer handover.”

    Source location

    Response from HM Prison & Probation Service
    Page 2 · response
    Published 26 March 2026

    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 practical emergency-response simulations, including Code Blue scenarios, within local training and mentoring arrangements.

    Verbatim wording from the response

    “Practical emergency response simulations, including Code Blue scenarios, are being embedded within local training and mentoring arrangements. Compliance and learning will be monitored through incident reviews and feedback reported to the Safer Custody Management Team. Joint exercises with healthcare staff will continue, this joined up approach will strengthen shared understanding and embed a multidisciplinary approach when responding to medical emergencies.”

    Source location

    Response from HM Prison & Probation Service
    Page 2 · response
    Published 26 March 2026

    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

    Monitor Code Blue compliance and learning through incident reviews and feedback to the Safer Custody Management Team.

    Verbatim wording from the response

    “Practical emergency response simulations, including Code Blue scenarios, are being embedded within local training and mentoring arrangements. Compliance and learning will be monitored through incident reviews and feedback reported to the Safer Custody Management Team. Joint exercises with healthcare staff will continue, this joined up approach will strengthen shared understanding and embed a multidisciplinary approach when responding to medical emergencies.”

    Source location

    Response from HM Prison & Probation Service
    Page 2 · response
    Published 26 March 2026

    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

    Continue joint emergency-response exercises with healthcare staff to strengthen shared understanding and multidisciplinary response.

    Verbatim wording from the response

    “Practical emergency response simulations, including Code Blue scenarios, are being embedded within local training and mentoring arrangements. Compliance and learning will be monitored through incident reviews and feedback reported to the Safer Custody Management Team. Joint exercises with healthcare staff will continue, this joined up approach will strengthen shared understanding and embed a multidisciplinary approach when responding to medical emergencies.”

    Source location

    Response from HM Prison & Probation Service
    Page 2 · response
    Published 26 March 2026

    Open published response

  2. Buckinghamshire

    AI-generated summary

    George EMMETT · 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

    George Emmett died after taking synthetic cannabinoid in G-Wing at HMP Aylesbury on 25 May 2023. The report raises a continuing concern that emergency responses involving prisoners may be compromised if staff do not follow the HMPPS Medical Emergency Response Codes policy, including promptly summoning an ambulance and calling a Code Blue.

    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 of operational staff to follow local medical emergency response protocols

    Wider context from the report

    “Evidence at the inquest demonstrated a Code Blue should be called over the radio from the cell location where a situation such as that in which George was found has arisen. The evidence of OSG ████████ did not appear to demonstrate familiarity with the processes set out in this policy at the time of George's death, nor any greater familiarity during evidence given, some two years after George's death. It is understood OSG ████████ holds a similar role at HMP Woodhill. There is a continuing concern that optimum reaction to an emergency situation involving the health of a prisoner may be compromised if OSG ████████ were to react in a manner which was not in accordance with any local protocols reflective of the HMPPS Medical Emergency Response Codes policy. The circumstances anticipated by this policy include situations where a prisoner's death may be prevented with appropriate application of an emergency response. ”

    Source location

    George EMMETT · 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

    Reissue six-monthly Governor’s Notices and conduct regular staff briefings to reinforce medical emergency response procedures and emergency-code use.

    Verbatim wording from the response

    “HMP Aylesbury continue to take steps to ensure that staff can confidently take effective action in the event of a medical emergency and in particular in the calling of emergency codes. A Governor’s Notice is reissued every six months reminding staff of the emergency response protocols to embed this awareness as much as possible. Additionally, full staff briefings are regularly used to reinforce procedures.”

    Source location

    2025-0345 Response from HM Prison & Probation Service
    Page 1 · response
    Published 16 July 2025

    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 portable Code Red/Code Blue prompt cards and display posters as accessible reminders of emergency-code procedures.

    Verbatim wording from the response

    “Staff have also been issued with quick reference Code Red/Code Blue prompt cards which can be carried on the person and act as an immediately accessible reminder of the circumstances in which a Code Red or Code Blue should be called. This information is also provided on posters as an additional visual aid.”

    Source location

    2025-0345 Response from HM Prison & Probation Service
    Page 1 · response
    Published 16 July 2025

    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

    Use mentoring, induction competency checks and radio communication training to train and test newly appointed officers on radios and emergency response procedures.

    Verbatim wording from the response

    “The prison has a colleague mentor programme whereby newly trained officers are assigned a mentor to provide support, advice and guidance throughout their initial training and full probation period. An induction ‘passport’ is used to provide assurance that the individual is competent in their role before they become fully operational. The mentors play an active role in training and testing new staff, this includes the use of radios and emergency”

    Source location

    2025-0345 Response from HM Prison & Probation Service
    Page 1 · response
    Published 16 July 2025

    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

    Brief the referenced Operational Support Grade individually on night procedures and the Local Security Strategy.

    Verbatim wording from the response

    “HMP Woodhill have advised me that the Operational Support Grade (OSG) who you reference in your report has now received one-to-one briefing on night procedures and the Local Security Strategy. As a further training aid and audit tool, a sign-off sheet was introduced whereby all routine expectations of a night OSG had been listed, such as the use of the radio and the use of emergency codes, the expectation being that this record be discussed by the OSG and the Night Orderly Officer and signed to confirm understanding. The support of the establishment care team has also been offered to the OSG.”

    Source location

    2025-0345 Response from HM Prison & Probation Service
    Page 2 · response
    Published 16 July 2025

    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

    Use sign-off sheets for night Operational Support Grades to confirm understanding of routine duties, radio use and emergency-code procedures.

    Verbatim wording from the response

    “HMP Woodhill have advised me that the Operational Support Grade (OSG) who you reference in your report has now received one-to-one briefing on night procedures and the Local Security Strategy. As a further training aid and audit tool, a sign-off sheet was introduced whereby all routine expectations of a night OSG had been listed, such as the use of the radio and the use of emergency codes, the expectation being that this record be discussed by the OSG and the Night Orderly Officer and signed to confirm understanding. The support of the establishment care team has also been offered to the OSG.”

    Source location

    2025-0345 Response from HM Prison & Probation Service
    Page 2 · response
    Published 16 July 2025

    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 a staff information notice, distribute Code Red/Code Blue prompt cards and remind control-room staff to follow emergency-services calling protocols.

    Verbatim wording from the response

    “On 20 June 2025 a staff information notice was issued to all HMP Woodhill staff reminding them of the policy around medical emergency response procedures and the national guidance on the appropriate use of calling a Code Red or Code Blue during an emergency. Additionally, the establishment have also issued take-along, quick reference, Code Red/Code Blue prompt cards to staff, and control room staff have been reminded of the importance of following the national protocol for calling emergency services for all incidents where a Code Red or Code Blue has been called.”

    Source location

    2025-0345 Response from HM Prison & Probation Service
    Page 2 · response
    Published 16 July 2025

    Open published response

  3. East Sussex

    AI-generated summary

    Stephen COSTER · 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

    Stephen Coster died from meningoencephalitis owing to Streptococcus pneumoniae after becoming seriously unwell while detained at HMP Lewes. The inquest found delays in providing treatment and transferring him to hospital, with concerns including inadequate observations and assessment, poor record keeping, failures to escalate, and breakdowns in communication and leadership between prison and healthcare staff.

    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

    Inadequate understanding among prison staff about when to call Code Blue

    Wider context from the report

    “d. There was inadequate understanding amongst prison staff about when to call Code Blue. ”

    Source location

    Stephen COSTER · 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

    Continue briefing, training and distributing reminders to staff on using Code Red and Code Blue and immediately calling emergency services.

    Verbatim wording from the response

    “The prison continues to brief staff regularly regarding the appropriate use of Code Red and Code Blue, and the importance of using them to ensure the emergency services are called immediately. Shortly after Mr Coster's death, a Notice to Staff was sent out to raise awareness and remind staff of their responsibilities. This was followed up by reminders in the Safety Newsletter later in the year and the Safety Nudge the following year. A number of training events have also taken place, delivered by the Safety Team, on the emergency”

    Source location

    Response from HM Prison and Probation Service
    Page 1 · response
    Published 20 March 2024

    Open published response

  4. Nottinghamshire

    AI-generated summary

    Alexander Michael BRAUND · 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

    Alexander Michael Braund was a 25-year-old remand prisoner at HMP Nottingham who became acutely unwell with an undetected atypical pneumonia and died on 10 March 2020 after cardiac arrest and withdrawal of life support. The principal concerns included failures in NEWS2 assessment and monitoring, the absence of a joint healthcare and prison-staff care plan, delays in entering his cell and calling a medical emergency code, and potential weaknesses in the integrity of amended electronic medical records.

    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

    Misunderstanding among discipline staff of medical emergency code criteria

    Wider context from the report

    “3. (HM PRISON SERVICE) There continues to be a misunderstanding across discipline staff as to what constitutes a CODE BLUE/CODE RED situation, and in what circumstances a cell can be entered by a prison officer for the purpose of preserving life, despite this having been enshrined in Prison Service Instruction for many years. I heard evidence from the PCO that he erroneously believed it was necessary for 3 discipline staff to be present before a cell door could be opened during night state even in circumstances where Alex was collapsed and unresponsive on the floor. This is not the first-time issues of this nature have been identified at HMP Nottingham. Indeed, successive Prison and Probation Ombudsman reports have recommended that the Governor take action to address these issues since the cluster of deaths in 2017/2018, and while the prison has been subject to Urgent Notification procedures. I heard evidence from a medical expert that post-cardiac arrest, every minute which elapses without appropriate CPR and defibrillator use reduces the patient’s chances of survival. Timely life support is critical, and staff must be clear on when to call a medical emergency code, and when to enter the cell, subject to their dynamic risk assessment. ”

    Source location

    Alexander Michael BRAUND · 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

    Schedule live emergency-response simulations with prison colleagues across all sites over the next twelve months.

    Verbatim wording from the response

    “Heads of Healthcare and Clinical Matrons undertake regular audits on SystmOne as part of monitoring staff compliance to the training with NEWS2. We have engaged with the Trustwide resuscitation trainers to explore using live simulations on sites to ensure that emergency responses are fully tested with our Prison colleagues. This will be scheduled throughout the next twelve months on all sites.”

    Source location

    Response from Nottingham Healthcare NHS Foundation Trust
    Page 2 · response
    Published 4 January 2023

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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

    Develop a joint training programme with HMP Nottingham prioritising learning from the Regulation 28 notice.

    Verbatim wording from the response

    “The Head of Healthcare and the Prison Governor are working in partnership to devise a joint training programme for all staff, ensuring the learning from the Regulation 28 Notice has been prioritised.”

    Source location

    Response from Nottingham Healthcare NHS Foundation Trust
    Page 4 · response
    Published 4 January 2023

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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

    Update and recirculate the joint urgent-assessment protocol for deteriorating patients, including emergency and code-response procedures.

    Verbatim wording from the response

    “The joint protocol for the urgent assessment process for the deteriorating patient is to be updated and re-circulated to all prison and healthcare staff. This includes the PSO 1300 emergency response and the management of code red and code blue. Joint training is to be provided to Prison staff to ensure they are familiar with the process and are confident in its use.”

    Source location

    Response from Nottingham Healthcare NHS Foundation Trust
    Page 5 · response
    Published 4 January 2023

    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 joint training for prison staff on the urgent-assessment and code-response process.

    Verbatim wording from the response

    “The joint protocol for the urgent assessment process for the deteriorating patient is to be updated and re-circulated to all prison and healthcare staff. This includes the PSO 1300 emergency response and the management of code red and code blue. Joint training is to be provided to Prison staff to ensure they are familiar with the process and are confident in its use.”

    Source location

    Response from Nottingham Healthcare NHS Foundation Trust
    Page 5 · response
    Published 4 January 2023

    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

    Implement an annual staff training plan covering emergency codes, medical emergencies and when officers should enter cells, with training repeated at least twice yearly.

    Verbatim wording from the response

    “A number of new measures including a robust training programme have been implemented to address these concerns. An annual training plan for staff has been introduced, and this includes training on the role of staff during a medical emergency, including the specific issues of the correct use of the emergency codes and the expectations about when staff should enter a cell during a patrol state. Staff received this training in May and September 2022 and it will be repeated at least twice yearly. An additional measure introduced in February 2022 is for all staff who join HMP Nottingham, irrespective of their grade or department, to be given a pocket size card that clearly explains the codes and what to do in an emergency.”

    Source location

    Response from HM Prison and Probation Service
    Page 1 · response
    Published 4 January 2023

    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 all new HMP Nottingham staff with pocket cards explaining emergency codes and required actions.

    Verbatim wording from the response

    “A number of new measures including a robust training programme have been implemented to address these concerns. An annual training plan for staff has been introduced, and this includes training on the role of staff during a medical emergency, including the specific issues of the correct use of the emergency codes and the expectations about when staff should enter a cell during a patrol state. Staff received this training in May and September 2022 and it will be repeated at least twice yearly. An additional measure introduced in February 2022 is for all staff who join HMP Nottingham, irrespective of their grade or department, to be given a pocket size card that clearly explains the codes and what to do in an emergency.”

    Source location

    Response from HM Prison and Probation Service
    Page 1 · response
    Published 4 January 2023

    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

    Review incidents in daily briefing sheets and address failures through targeted training, guidance or performance management.

    Verbatim wording from the response

    “A process is now in place to review all incidents included in the daily briefing sheet, and where it is found that the process was not followed, the member of staff concerned is identified and their behaviour is addressed, through targeted training or guidance and/or through the performance management system. Senior Management Team members conduct monthly night visits and use these to check staff understanding of their responsibilities and to reiterate the importance of the medical emergency response procedures.”

    Source location

    Response from HM Prison and Probation Service
    Page 2 · response
    Published 4 January 2023

    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

    Conduct monthly senior-management night visits to check staff understanding and reinforce medical emergency response procedures.

    Verbatim wording from the response

    “A process is now in place to review all incidents included in the daily briefing sheet, and where it is found that the process was not followed, the member of staff concerned is identified and their behaviour is addressed, through targeted training or guidance and/or through the performance management system. Senior Management Team members conduct monthly night visits and use these to check staff understanding of their responsibilities and to reiterate the importance of the medical emergency response procedures.”

    Source location

    Response from HM Prison and Probation Service
    Page 2 · response
    Published 4 January 2023

    Open published response

  5. Birmingham and Solihull

    AI-generated summary

    SAIFUR RAHMAN · 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

    Saifur Rahman was found in cardiac arrest in his cell at HMP Birmingham on 20 January 2021, was taken to hospital after resuscitation, and died on 23 January 2021. The post-mortem recorded hypoxic/ischaemic encephalopathy associated with external neck compression, and the jury found that his intention was to commit suicide. The report raised concerns about delayed emergency calls, inadequate records of cell history, insufficient cell risk assessments, and the lack of a formal process for prison and mental health staff to inspect and act on cell risks.

    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 in calling code blue emergencies

    Wider context from the report

    “1. Calling a “code blue”: the evidence revealed that the safety critical code blue call – automatically triggering an emergency response - was delayed by up to 2 minutes. The evidence was inconsistent on whether the cell entry briefing included the identification of an extra officer with a radio, and why therefore an officer in full person protective equipment ran out of the cell and across the ward to where she had left her radio to call the code blue. Delayed code blue calls have been a repeated problem at HMP Birmingham despite it being raised by the Prison and Probation Ombudsman and coroners in earlier regulation 28 reports. My ongoing concern is that delayed code blue calls will continue, and consideration should be given to the effectiveness of training in light of the evidence given by the prison officers at the inquest. ”

    Source location

    SAIFUR RAHMAN · 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

    Deliver recurring safety talks and provide signage and leaflets to maintain staff awareness of medical emergency procedures.

    Verbatim wording from the response

    “Given the often traumatic circumstances in which staff are expected to call a medical emergency code, it is recognised that this issue is one that must be continually reinforced to ensure it is fully embedded and staff are able to respond effectively. At a local level, HMP Birmingham have undertaken a range of initiatives to maintain staff awareness of the procedures, including ‘pop-up’ safety talks run by the prison’s safety team which continue to be delivered during staff briefings, prominent signage that provides guidance, and the issuing of leaflets to all staff members.”

    Source location

    Response from HMPPS
    Page 1 · response
    Published 26 May 2022

    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 medical emergency response training, including refresher training for all staff.

    Verbatim wording from the response

    “Additionally, the Governor has reviewed HMP Birmingham’s local medical emergency response code protocol to ensure that staff training is a central focus and that all staff have up to date training, including refresher training for all staff, which is currently in progress.”

    Source location

    Response from HMPPS
    Page 1 · response
    Published 26 May 2022

    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 emergency response guides and pocket cards to prisons and staff to provide medical emergency response guidance.

    Verbatim wording from the response

    “At a national level new emergency response guides were issued to all prisons which set out the actions required of staff in a medical emergency, including all the circumstances listed in the PSI 03/2013 Medical Emergency Response Codes under which a medical emergency response code should be called. In 2021, all Prisons were also issued with a supply of emergency response pocket cards which were shared with staff. The cards provided an instant reminder of how to respond to a medical emergency. In March 2022, a further supply of the emergency response pocket cards were issued to Regional Group Safety Leads for them to share with their prisons.”

    Source location

    Response from HMPPS
    Page 1 · response
    Published 26 May 2022

    Open published response

  6. London (West)

    AI-generated summary

    Amir Siman-Tov · 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

    Amir Siman-Tov died at Colnbrook Immigration Removal Centre on 17 February 2016 after taking an overdose of codeine. The concerns included inconsistent involvement of healthcare staff in the ACDT self-harm reduction process, inconsistent medication checks, inadequate hospital discharge information and handover, insufficient monitoring after his return, and shortcomings in the emergency response.

    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 the code blue procedure to summon an immediate emergency ambulance

    Wider context from the report

    “12. At approximately 3.10 on the 17ᵗʰ February 2016 Mr Siman-Tov was found to be unresponsive by custody officers. Medical assistance was called for but the required “code blue” for summoning an immediate emergency ambulance was not used. ”

    Source location

    Amir Siman-Tov · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  7. Northamptonshire

    AI-generated summary

    Andrew Crane · 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

    Andrew Crane suffered a cardiac arrest in his prison cell on 16 November 2016 and died despite resuscitation efforts. The report identified concerns about the response to his complaint of chest pain, including a lack of clarity about when a Code Blue should be called, and the failure to pass information about his lack of breathing and CPR to the ambulance service, which would have changed the response priority.

    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 clarity about discretion to initiate a Code Blue response to complaints of chest pain

    Wider context from the report

    “(1) Mr Crane had complained of chest pain shortly before his cardiac arrest. The prison officer did not consider that he was unwell and so asked the healthcare nurse to attend. According to PSI 3/2013 and the prison’s emergency response policy, a complaint of chest pain should result in a Code Blue call. There was a lack of clarity amongst witnesses as to what, if any, discretion should be given in these circumstances to a prison officer who thinks that a complaint of chest pain does not require a Code Blue response. ”

    Source location

    Andrew Crane · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  8. London (West)

    AI-generated summary

    John Kevin O’MEARA · 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

    John Kevin O’MEARA suffered respiratory failure and died on 29 March 2016 in a cell at HM Prison Wormwood Scrubs. The report identifies insufficient staffing, inadequate medical monitoring, and a missed opportunity to raise concerns about his health. It also raises concerns about delays in activating emergency codes and the availability of trained passive dogs to help control novel psychoactive substances in prisons.

    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 immediately activate the Code Blue/Red system

    Wider context from the report

    “Activation of Code Blue/Red The sad facts leading up to the death of John Kevin O’MEARA have not been the first set of facts where I have heard about a death where the activation of codes has not been immediate. I am concerned that Prison Officers are not strictly following the Code Blue/Red system which is meaning there is a delay in the London Ambulance being called. Whilst I can see in many cases that, by the time the prisoner has been found, there may be nothing that can be done to resuscitate them with the number of deaths happening relating to opiate use, the prompt administration of Naloxone is important to give the deceased the best chance; and this is only one responsive measure. I gather the current way that Officers are trained is by the use of Notices and Pocket-sized Cards. The Officer finding Mr O’Meara, even after questioning by myself and the Counsel for Interested Persons, left the witness stand still not understanding that by not immediately calling a Code Blue, and despite prison medical staff coming quickly, an ambulance would not have been called. Even presumably having reflected on the case, she did not appear to understand the reason why a Code is called. I am asking for more consideration to be given to ensure the right message is getting across and that Prison Officers understand the importance of and reasons for the use of the codes. ”

    Source location

    John Kevin O’MEARA · Prevention of Future Deaths report
    Page 2 · 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 of officer training to ensure understanding of the importance and reasons for Code Blue/Red use

    Wider context from the report

    “Activation of Code Blue/Red The sad facts leading up to the death of John Kevin O’MEARA have not been the first set of facts where I have heard about a death where the activation of codes has not been immediate. I am concerned that Prison Officers are not strictly following the Code Blue/Red system which is meaning there is a delay in the London Ambulance being called. Whilst I can see in many cases that, by the time the prisoner has been found, there may be nothing that can be done to resuscitate them with the number of deaths happening relating to opiate use, the prompt administration of Naloxone is important to give the deceased the best chance; and this is only one responsive measure. I gather the current way that Officers are trained is by the use of Notices and Pocket-sized Cards. The Officer finding Mr O’Meara, even after questioning by myself and the Counsel for Interested Persons, left the witness stand still not understanding that by not immediately calling a Code Blue, and despite prison medical staff coming quickly, an ambulance would not have been called. Even presumably having reflected on the case, she did not appear to understand the reason why a Code is called. I am asking for more consideration to be given to ensure the right message is getting across and that Prison Officers understand the importance of and reasons for the use of the codes. ”

    Source location

    John Kevin O’MEARA · 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

    Publish notices, display signs, include emergency procedures in induction, and attach notices to First Night Centre cell doors.

    Verbatim wording from the response

    “Your first concern is with the failure immediately to use an emergency response code, something that has also occurred in other cases. I understand that you heard evidence about a variety of steps that are being taken locally to ensure that staff are aware of the importance of using the correct emergency code. Regular notices to staff are published, signs are displayed in all offices and information about emergency response procedures is included in the induction for all new staff. More recently, notices have been attached to all cell doors in the First Night Centre, and early indications are that staff have found this useful. Plans are in place to extend this”

    Source location

    2018-0012-Response-by-HM-Prison-and-Probation-Service
    Page 1 · response
    Published 7 March 2018

    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

    Extend cell-door emergency-code notices to healthcare, segregation, and detox areas.

    Verbatim wording from the response

    “Your first concern is with the failure immediately to use an emergency response code, something that has also occurred in other cases. I understand that you heard evidence about a variety of steps that are being taken locally to ensure that staff are aware of the importance of using the correct emergency code. Regular notices to staff are published, signs are displayed in all offices and information about emergency response procedures is included in the induction for all new staff. More recently, notices have been attached to all cell doors in the First Night Centre, and early indications are that staff have found this useful. Plans are in place to extend this”

    Source location

    2018-0012-Response-by-HM-Prison-and-Probation-Service
    Page 1 · response
    Published 7 March 2018

    Open published response

  9. Inner North London

    AI-generated summary

    John WILLIAMS · 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

    John Williams hanged himself while he was a prisoner at HM Prison Pentonville, after telling staff that he would do so if his perceived needs were not met rather than intending to take his life. Concerns included inaccuracies and omissions in reception screening and referrals, inadequate understanding and use of the ACCT document, insufficient training for some support staff, confusion about emergency codes, and a lack of basic first aid and CPR training among 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 of prison officers to understand code blue and code red distinctions

    Wider context from the report

    “6. The issue of the difference between a code blue and a code red is one about which I have written before. One senior prison officer said in evidence that if she did not know the difference between a code blue and a code red, then there would be some serious concerns. She did not. She had been given a small card describing code blue and code red (a card which another officer kept about her person and even produced from the witness box), and she still retained that card. However, she had never considered it worthwhile to read. She said in court that she still thought it appropriate that she had never read the card. ”

    Source location

    John WILLIAMS · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  10. Inner North London

    AI-generated summary

    Tedros Habtom KAHSSAY · 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

    Tedros Kahssay killed himself by hanging in HM Prison Pentonville about a month after being admitted on a charge of murdering his pregnant partner. Concerns included incomplete transfer and recording of information, shortcomings in reception screening, and significantly deficient and chaotic resuscitation procedures. The report states that he was already dead when resuscitation commenced, while expressing concern for other prisoners requiring first aid.

    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 of emergency healthcare lead nurses to understand code red and code blue medical emergencies

    Wider context from the report

    “7. The resuscitation led by the two nurses occupying the positions of primary (Hotel 7) and secondary (Hotel 12) leads for emergency healthcare in the prison that night, was significantly lacking in the following ways. • The nurse with primary responsibility for emergency care in the prison did not have a proper understanding of the nature of a code red and a code blue prison medical emergency. (I have raised this issue in the past.) • One minute and twelve seconds elapsed after nurse arrival before any substantive care was given. The action during that one minute and twelve seconds did not appear to progress the resuscitation attempt. • There seemed no clear demarcation of roles and responsibilities during the resuscitation. Of course these may change as those giving resuscitation tire, but the changes seemed haphazard. • There was no checking for breath or airway manoeuvre at the outset or at any time during the resuscitation. • There was no checking for pulse at the outset, before commencing chest compressions, or at any time during the resuscitation. The lead nurse attempted to justify this by saying that she had not wanted to waste time. This was despite the first action upon finding the casualty being to apply a blood pressure cuff, on the basis that this was part of the nurse assessment. • When giving evidence, the lead nurse appeared to conflate the casualty who is in cardiorespiratory arrest with the casualty who is merely unconscious. She repeatedly talked about the need to give cardiopulmonary resuscitation (CPR) to an unconscious casualty. She said that, at the time she started chest compressions, she did not know whether Mr Kahssay was breathing or not breathing. • When CPR was given, chest compressions were ineffective, being too quick and too shallow. • There was only one brief attempt to use an ambubag, the majority of the resuscitation taking place without airway assistance or with a non rebreathe oxygen mask. • It appeared that one oxygen cylinder was empty, as it had to be changed for another. The nurse leading the resuscitation described it as chaotic. That is indeed how it appeared to me from her description and from viewing the bodycam footage. I was and remain very gravely concerned, not in this respect for Mr Kahssay who was in fact already dead when resuscitation commenced, but for anyone else in the prison in need of first aid. ”

    Source location

    Tedros Habtom KAHSSAY · 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

    Reinforce Code Red and Code Blue procedures through staff training and clinical-area posters.

    Verbatim wording from the response

    “The use and meaning of Code Red and Code Blue has again been strongly reinforced to the nursing staff. Training sessions have taken place for all the staff and attendance sheets have been collected. Posters re-affirming the criteria of Code Red and Code Blue were displayed in clinical areas in December 2016. Furthermore, Safer Custody have been requested to re-order 250 of the aide-memoire cards for distribution across the establishment.”

    Source location

    2016-0437-Response-by-Care-UK.pdf
    Page 3 · response
    Published 6 December 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

    Request 250 additional emergency-response aide-memoire cards for distribution across the establishment.

    Verbatim wording from the response

    “The use and meaning of Code Red and Code Blue has again been strongly reinforced to the nursing staff. Training sessions have taken place for all the staff and attendance sheets have been collected. Posters re-affirming the criteria of Code Red and Code Blue were displayed in clinical areas in December 2016. Furthermore, Safer Custody have been requested to re-order 250 of the aide-memoire cards for distribution across the establishment.”

    Source location

    2016-0437-Response-by-Care-UK.pdf
    Page 3 · response
    Published 6 December 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

    Develop and circulate a standard operating procedure for emergency response.

    Verbatim wording from the response

    “In addition to this, the healthcare team plan to discuss issues relating to resuscitation and use of emergency bags regularly in their Friday afternoon training sessions. A SOP for emergency response is in development by the national team and is due for circulation shortly.”

    Source location

    2016-0437-Response-by-Care-UK.pdf
    Page 3 · response
    Published 6 December 2016

    Open published response

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