Robert Ellery · Prevention of Future Deaths report

A Coronial investigation was commenced on 8th November 2016 into the death of Robert Ellery. The investigation concluded at the end of an inquest which I conducted with a jury on 8th – 18th November 2021. The conclusion of the jury was that Mr Ellery died as the result of ████████ in circumstances where his intentions could not be ascertained. The medical cause of death was ████████

These were recorded as :-

“Robert Ellery was found ████████ in his cell on 31st October 2016. Robert had recently self harmed, An ACCT was not opened, zopiclone was prescribed but not administered to him. In addition, there was 19 minutes between the first 999 call and the ambulance service being informed that Mr Ellery had been found ████████. It cannot be concluded that such issues caused or contributed to Robert’s death.”

(1) The prison control room was not able to provide the Welsh Ambulance Service with any specific information as to the reason why an ambulance was required for 19 minutes after Mr Ellery was found ████████ in his cell. This delayed the ability of the ambulance service to despatch a response. While this was not, on the evidence heard by the jury, causative of Mr Ellery’s death, it gives rise to a concern that a risk that other deaths will occur.

(2) There was no method of communication to allow the Ambulance Service call centre staff to communicate directly with the nurse and officers who were providing basic life support to Mr Ellery. This delayed the relaying of specific information with respect to Mr Ellery’s condition by the prison to the Welsh Ambulance Service. It also impeded the ability of the ambulance service operator to provide guidance to those attempting to resuscitate Mr Ellery. This may affect the use of a defibrillator. In circumstances where not all prison staff are trained in the provision of CPR, it might also prevent the ambulance service operator providing instruction to first responders, or reduce the effectiveness of the same.