11 Mar 2025 NICHOLAS OLIVER JAMES GEDGE · Prevention of Future Deaths report West Yorkshire Eastern
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Concerns raised 5 Failure to coordinate detention and medical staff roles during a medical emergency View source Failure to appreciate the importance of early CPR View source Delays in commencing CPR during a medical emergency in a cell View source Failure of communication between detention and medical staff to facilitate prompt CPR commencement View source Lack of protocols defining detention and medical staff roles during a medical emergency in a cell View source See 2 more concerns
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AI-generated summary
NICHOLAS OLIVER JAMES GEDGE · 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
Nicholas Oliver James Gedge was found unresponsive in a police station cell on 14 November 2022 and was pronounced deceased at hospital later that day. The principal concerns were the delay in commencing CPR, the lack of a shared understanding and coordinated roles among detention and medical staff, and uncertainty about protocols for responding to medical emergencies in cells.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Leeds Community Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to coordinate detention and medical staff roles during a medical emergency
Wider context from the report “(1) From the point when the Detention Officer first entered Nicholas' cell to when CPR was commenced, 8 minutes and 12 seconds elapsed without CPR being given. Within that timeframe, two Detention Officers and a nurse were present in the cell after 75 seconds had passed.
(2) On the evidence, there did not appear to be any shared understanding between the three people in the cell with Nicholas of the urgency of starting CPR on an unresponsive person . There did not appear to be a co-ordinated approach to assisting Nicholas , with the Detention Officers and the nurse not appearing to have defined roles which they understood and undertook .
(3) It was not clear whether there were any protocols in place to define the respective roles of detention staff and medical staff attending a medical emergency in a cell. The passage of time before CPR was commenced gives rise to a concern either that the importance of early CPR was not appreciated, or that the communication between detention and medical staff did not facilitate its prompt commencement.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Leeds Community Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to appreciate the importance of early CPR
Wider context from the report “(1) From the point when the Detention Officer first entered Nicholas' cell to when CPR was commenced, 8 minutes and 12 seconds elapsed without CPR being given. Within that timeframe, two Detention Officers and a nurse were present in the cell after 75 seconds had passed.
(2) On the evidence, there did not appear to be any shared understanding between the three people in the cell with Nicholas of the urgency of starting CPR on an unresponsive person. There did not appear to be a co-ordinated approach to assisting Nicholas, with the Detention Officers and the nurse not appearing to have defined roles which they understood and undertook.
(3) It was not clear whether there were any protocols in place to define the respective roles of detention staff and medical staff attending a medical emergency in a cell. The passage of time before CPR was commenced gives rise to a concern either that the importance of early CPR was not appreciated , or that the communication between detention and medical staff did not facilitate its prompt commencement.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Leeds Community Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in commencing CPR during a medical emergency in a cell
Wider context from the report “(1) From the point when the Detention Officer first entered Nicholas' cell to when CPR was commenced, 8 minutes and 12 seconds elapsed without CPR being given. Within that timeframe, two Detention Officers and a nurse were present in the cell after 75 seconds had passed.
(2) On the evidence, there did not appear to be any shared understanding between the three people in the cell with Nicholas of the urgency of starting CPR on an unresponsive person. There did not appear to be a co-ordinated approach to assisting Nicholas, with the Detention Officers and the nurse not appearing to have defined roles which they understood and undertook.
(3) It was not clear whether there were any protocols in place to define the respective roles of detention staff and medical staff attending a medical emergency in a cell. The passage of time before CPR was commenced gives rise to a concern either that the importance of early CPR was not appreciated, or that the communication between detention and medical staff did not facilitate its prompt commencement.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Leeds Community Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of communication between detention and medical staff to facilitate prompt CPR commencement
Wider context from the report “(1) From the point when the Detention Officer first entered Nicholas' cell to when CPR was commenced, 8 minutes and 12 seconds elapsed without CPR being given. Within that timeframe, two Detention Officers and a nurse were present in the cell after 75 seconds had passed.
(2) On the evidence, there did not appear to be any shared understanding between the three people in the cell with Nicholas of the urgency of starting CPR on an unresponsive person. There did not appear to be a co-ordinated approach to assisting Nicholas, with the Detention Officers and the nurse not appearing to have defined roles which they understood and undertook.
(3) It was not clear whether there were any protocols in place to define the respective roles of detention staff and medical staff attending a medical emergency in a cell. The passage of time before CPR was commenced gives rise to a concern either that the importance of early CPR was not appreciated, or that the communication between detention and medical staff did not facilitate its prompt commencement .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Leeds Community Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of protocols defining detention and medical staff roles during a medical emergency in a cell
Wider context from the report “(1) From the point when the Detention Officer first entered Nicholas' cell to when CPR was commenced, 8 minutes and 12 seconds elapsed without CPR being given. Within that timeframe, two Detention Officers and a nurse were present in the cell after 75 seconds had passed.
(2) On the evidence, there did not appear to be any shared understanding between the three people in the cell with Nicholas of the urgency of starting CPR on an unresponsive person. There did not appear to be a co-ordinated approach to assisting Nicholas, with the Detention Officers and the nurse not appearing to have defined roles which they understood and undertook.
(3) It was not clear whether there were any protocols in place to define the respective roles of detention staff and medical staff attending a medical emergency in a cell. The passage of time before CPR was commenced gives rise to a concern either that the importance of early CPR was not appreciated, or that the communication between detention and medical staff did not facilitate its prompt commencement.
” Open source report
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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 Review the Death in Custody procedure through a clinical working group and strengthen joint reflection with colleagues involved in incidents.
Verbatim wording from the response “• A working group consisting of LCH HCP’s, led by a clinical team manager, has commenced to review the Death in Custody (DIC) procedure.” Source location Response from Leeds Community Healthcare NHS Trust
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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 Expand life-support training with custody-suite simulations and joint scenarios to improve coordination between healthcare professionals and detention officers.
Verbatim wording from the response “• In addition to the organisational mandatory bespoke life support training, LCH will expand the scenario aspect of training to include simulation exercises in the custody suite environment with the aim of improving the co-ordination between LCH staff and detention officers in the event of emergency scenarios.” Source location Response from Leeds Community Healthcare NHS Trust
Open published response
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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 Include coordination of response in investigations of life-threatening incidents and deaths in custody.
Verbatim wording from the response “• The service will ensure that they include ‘coordination of response’ in the investigation process of incidents where there has been a life-threatening response or a DIC.” Source location Response from Leeds Community Healthcare NHS Trust
Open published response
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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 Incorporate recommendations from reflective discussions with incident staff into CPR training.
Verbatim wording from the response “• LCH has conducted a reflective conversation with the staff involved in the incident and has incorporated their recommendations and suggestions for improvements into the CPR training.” Source location Response from Leeds Community Healthcare NHS Trust
Open published response
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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 Agree the reviewed procedure with police to define robust coordination of responses in life-threatening situations.
Verbatim wording from the response “• The procedure will be agreed with the police to ensure the coordination of response in life threatening situations is robust.” Source location Response from Leeds Community Healthcare NHS Trust
Open published response
17 Nov 2014 Mrs Gladys Smith · Prevention of Future Deaths report West Yorkshire (East)
View report summary
Concerns raised 16 Failure to fully record wound dimensions and presenting features on each District Nurse visit View source Failure to regularly and fully record residents' weights View source Lack of Care Home staff knowledge of dementia care View source Lack of comprehensive national guidance on prevention and treatment of impact-injury wounds and ulcers View source Delays in District Nurse referrals to the Tissue Viability Nurse Service View source Failure to regularly monitor residents' weights View source Failure to body map residents' bruises View source Failure to complete turning and repositioning charts View source Omission of guidance on when District Nurses should refer patients to the Tissue Viability Nurse Service View source Failure to implement nutrition charts for residents with significant weight loss View source Failure to proactively seek medical practitioners' care advice for residents with recognised medical conditions View source Failure to undertake regular falls assessments for residents View source Delays in seeking medical advice after apparent impact injury bruising View source Failure to implement medical practitioners' advice and instruction on resident turning and repositioning View source Failure to consider the appropriate location of residents' rooms View source Delays in seeking medical advice after significant resident weight loss View source See 13 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Mrs Gladys Smith · 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
Mrs Gladys Smith died while resident at a care home; the supplied text does not provide further circumstances of her death. The concerns included failures in repositioning, bruise and wound monitoring, falls assessment, weight and nutrition monitoring, dementia care, and delays or gaps in district nursing wound documentation and referral. The report also identified a lack of comprehensive national guidance on wounds and ulcers caused by impact injuries.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Leeds Community Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to fully record wound dimensions and presenting features on each District Nurse visit
Wider context from the report “(a) Members of the District Nursing Team who attended upon Mrs Smith did not, upon each visit, fully record and document the dimensions and presenting features of the wound . In the circumstances, the Trust should ensure District Nurses do record and document all bruises and/or wounds, in particular the dimensions of the same together with a detailed description as to all presenting features;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Leeds Community Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to regularly and fully record residents' weights
Wider context from the report “(e) Between January and June 2012 Mrs Smith lost a total of 28lbs in weight. Mrs Smith's weight was neither regularly monitored nor regularly and fully recorded . In the circumstances, Care Home staff should ensure that there is regular monitoring and appropriate recording of residents' weights';
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Leeds Community Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of Care Home staff knowledge of dementia care
Wider context from the report “(g) Mrs Smith suffered from vascular dementia and had done so since the commencement of her residency at the Care Home. A number of other residents suffer from dementia. Care Assistants at the said Care Home have little or no knowledge of dementia and, consequently, how to care for residents suffering from such a condition . In the circumstances, all Care Home staff should undergo more indepth training in relation to dementia;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Leeds Community Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of comprehensive national guidance on prevention and treatment of impact-injury wounds and ulcers
Wider context from the report “(a) There are no NICE guidelines which provide any comprehensive guidance to Medical Practitioners in relation to the prevention and treatment of wounds and ulcers caused by impact injuries . Clinical Guideline 29 – The prevention and treatment of pressure ulcers, does not give guidance in respect of wounds/ulcers caused by impact injuries . In the circumstances there should be national guidelines which deal with such
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Leeds Community Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in District Nurse referrals to the Tissue Viability Nurse Service
Wider context from the report “(b) Mrs Smith was referred to the Tissue Viability Nurse Service on or around 25 June 2012, some 12 days after a referral ought to have been made according to expert evidence adduced in the course of the Inquest. In the circumstances, the Trust should ensure District Nurses make referrals to the Tissue Viability Nurse Service timeously;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Leeds Community Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to regularly monitor residents' weights
Wider context from the report “(e) Between January and June 2012 Mrs Smith lost a total of 28lbs in weight. Mrs Smith's weight was neither regularly monitored nor regularly and fully recorded. In the circumstances, Care Home staff should ensure that there is regular monitoring and appropriate recording of residents' weights';
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Leeds Community Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to body map residents' bruises
Wider context from the report “(b) None of the bruises sustained by Mrs Smith, in particular the one which was noticed on the 25 May 2012, were body mapped by Care Home staff. In the circumstances, staff should ensure that all bruises sustained by residents are carefully body mapped at the first available opportunity;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Leeds Community Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete turning and repositioning charts
Wider context from the report “(a) Advice and instruction given to Care Home staff as to the turning and repositioning of Mrs Smith was not followed and repositioning charts were not completed . In the circumstances, all Care Home staff should ensure that all advice and instruction given by medical practitioners, that is to say by General Practitioners and District Nurses, in relation to residents is appropriately implemented and that turning/repositioning charts are completed;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Leeds Community Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Omission of guidance on when District Nurses should refer patients to the Tissue Viability Nurse Service
Wider context from the report “(c) The Trusts Clinical Guidelines for Wound Management in Adults and Children omits to provide guidance as to when District Nurses should refer patients to the Tissue Viability Nurse Service . In the circumstances, the Trust should amend the said Clinical Guidelines in order to provide comprehensive guidance as to when such a referral to the said Service should be made
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Leeds Community Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to implement nutrition charts for residents with significant weight loss
Wider context from the report “(f) Despite the aforesaid weight loss experienced by Mrs Smith, at no time was a nutrition chart implemented in order to monitor Mrs Smith's nutritional intake . Moreover, medical advice in relation to Mrs Smith's weight loss was only sought a number of weeks after the commencement of the said weight loss. In the circumstances, Care Home staff should ensure nutrition charts are completed in respect of any resident whose weight falls significantly and should ensure appropriate medical advice is sought at the first available opportunity following such a fall in weight;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Leeds Community Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to proactively seek medical practitioners' care advice for residents with recognised medical conditions
Wider context from the report “(h) Care Home staff do not proactively enquire of medical practitioners as to how to care for residents with certain medical conditions – for example, hiatus hernias, dementia. In the circumstances, Care Home staff should ensure proactive enquiries are made of relevant medical practitioners at the earliest opportunity as to the appropriate care for residents suffering from recognised medical conditions.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Leeds Community Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake regular falls assessments for residents
Wider context from the report “(d) Falls assessments in respect of Mrs Smith whilst a resident at the Care Home were not regularly undertaken and no consideration was at any time given by Care Home staff as to the most appropriate location for Mrs Smith's room within the Care Home. In the circumstances, falls assessments should be regularly undertaken in respect of all residents and regular consideration should be given as to the appropriate location of residents' rooms within the Care Home;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Leeds Community Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in seeking medical advice after apparent impact injury bruising
Wider context from the report “(c) On or around 25 May 2012 bruising on the left side of Mrs Smith's bottom cheek was noted by a Care Home staff together with a blister. However, District Nurse attendance in respect of an open area on Mrs Smith's bottom on her left side took place 7 (seven) days later on 11 June 2012. In the circumstances, Care Home staff should ensure appropriate medical advice is sought at the first available opportunity upon noticing a bruise to a resident following an apparent impact injury;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Leeds Community Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to implement medical practitioners' advice and instruction on resident turning and repositioning
Wider context from the report “(a) Advice and instruction given to Care Home staff as to the turning and repositioning of Mrs Smith was not followed and repositioning charts were not completed. In the circumstances, all Care Home staff should ensure that all advice and instruction given by medical practitioners, that is to say by General Practitioners and District Nurses, in relation to residents is appropriately implemented and that turning/repositioning charts are completed;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Leeds Community Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to consider the appropriate location of residents' rooms
Wider context from the report “(d) Falls assessments in respect of Mrs Smith whilst a resident at the Care Home were not regularly undertaken and no consideration was at any time given by Care Home staff as to the most appropriate location for Mrs Smith's room within the Care Home . In the circumstances, falls assessments should be regularly undertaken in respect of all residents and regular consideration should be given as to the appropriate location of residents' rooms within the Care Home;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Leeds Community Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in seeking medical advice after significant resident weight loss
Wider context from the report “(f) Despite the aforesaid weight loss experienced by Mrs Smith, at no time was a nutrition chart implemented in order to monitor Mrs Smith's nutritional intake. Moreover, medical advice in relation to Mrs Smith's weight loss was only sought a number of weeks after the commencement of the said weight loss . In the circumstances, Care Home staff should ensure nutrition charts are completed in respect of any resident whose weight falls significantly and should ensure appropriate medical advice is sought at the first available opportunity following such a fall in weight;
” Open source report
17 Oct 2014 William Thomas Anderson · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 5 Delays in summoning emergency medical services View source Failure to record relevant inmate behaviour and presentation information in the Wing Observation Book View source Incomplete Wing staff training in the use of breathalyser equipment View source Failure to use emergency codes when required View source Inadequate vigilance over inmate social gatherings during periods of association View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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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. The report was sent to Leeds Community Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in summoning emergency medical services
Wider context from the report “(5) Paramedic assistance was not called within a reasonable time and no explanation for the delay was provided in the course of the Inquest. Whilst the failure to summons outside medical assistance sooner would not have affected the outcome in this instance, it is not inconceivable that to omit to call for such assistance as soon as possible could, in certain circumstances, jeopardise an inmate’s chances of survival. Consequently, emergency services should be summoned at the very first available opportunity , and all Prison staff should be instructed as to the importance of so doing.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Leeds Community Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record relevant inmate behaviour and presentation information in the Wing Observation Book
Wider context from the report “(3) The Deceased’s behaviour and presentation on the 18th September 2010 was not recorded by any member of Wing staff in the C Wing Observation Book . Evidence was adduced in the course of the Inquest as to the importance of recording all relevant information in the said Observation Book, thereby apprising all members of Wing staff on all shifts of all material facts and matters. In the circumstances, all relevant information in relation to, for example, an inmate’s behaviour and general presentation should be brought to the attention of all Wing staff and should be done so via an appropriate entry/entries in the Wing Observation Book . All Wing staff (Wing Managers, Prison Officers and Operational Support Grades) should be made aware of the importance of such, and should ensure information is recorded accordingly;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Leeds Community Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Incomplete Wing staff training in the use of breathalyser equipment
Wider context from the report “(2) The Deceased was not subjected to a breathalyser test at any time during the 18th September 2010. A proportion of, but not all, Wing staff are trained in the use of such breathalyser equipment . Had the Deceased been so breathalysed, more likely than not, it would have been apparent he was not suffering from the effects of alcohol. In the circumstances all Wing staff should be trained in the use of such breathalyser equipment;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Leeds Community Healthcare NHS Trust; that does not assign responsibility.
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 ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Leeds Community Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate vigilance over inmate social gatherings during periods of association
Wider context from the report “(1) Evidence was adduced in the course of this Inquest to the effect that in 2010, 2011 and 2012 inmates were having social get togethers on C Wing at HMP Wealstun, in particular at a weekend, during which time drugs were taken and hooch was drunk. Evidence was also heard that this is occurring at the present time at this said prison establishment. In the circumstances, there should be much greater and effective vigilance by Wing staff and Prison Service employees at HMP Wealstun in relation to such get togethers on the Wings during periods of association ;
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations