PFD report

Wayne Wesley Cornlouer · Prevention of Future Deaths report

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Issued 12 Oct 2016•Dorset

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
5

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

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Concerns raised1

  1. Failure to ensure all staff are aware of emergency coding in the Night Orders
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 recipient says it has done, is doing, or plans to do in response to a concern raised.5

  1. Action

    Re-issue the Notice to Staff requiring emergency codes and prompt ambulance requests.

    Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 26 February 2017.
  2. Action

    Update the induction programme for new staff to include local emergency protocol guidance.

    Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 26 February 2017.
  3. Action

    Provide all existing staff with personal briefings from their heads of function.

    Stated by HM Prison and Probation ServiceStated plannedThe respondent said that this action was planned when they made their response on 26 February 2017.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to ensure all staff are aware of emergency coding in the Night Orders

Wider context from the report

“I understand that the coding system for a medical emergency, code red/code blue, was not part of the Night Orders at the time of Mr Cornlouer’s death. However, the Night Orders have since been amended to include this emergency coding. My concern is as to whether or not all staff are aware of the change in the Night Orders. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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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

Re-issue the Notice to Staff requiring emergency codes and prompt ambulance requests.

Verbatim wording from the response

“I can confirm that the relevant Notice to Staff was re-issued on 28 September 2016. This reminds all staff that an emergency code, either Red or Blue, must be called when there are serious concerns about the health of a prisoner, and that on receiving either emergency code the gate staff are required to request an ambulance. The Notice to Staff also confirms the nature of the injuries that should prompt the use of each of the emergency codes, and the further information that it is helpful to pass on to assist the local Ambulance Service. In addition, the local emergency code protocol has been distributed to all areas of the establishment and is displayed in prominent areas for easy reference, including the communications room.”

Source location

2016-0356-Response-by-NOMS
Page 1 · response
Published 26 February 2017

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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 the induction programme for new staff to include local emergency protocol guidance.

Verbatim wording from the response

“In addition to a copy of the emergency code protocol and the Notice to Staff, all existing staff will receive a personal briefing from their head of function. The induction programme for all new staff is being updated to include guidance on the local emergency protocol.”

Source location

2016-0356-Response-by-NOMS
Page 1 · response
Published 26 February 2017

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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

Provide all existing staff with personal briefings from their heads of function.

Verbatim wording from the response

“In addition to a copy of the emergency code protocol and the Notice to Staff, all existing staff will receive a personal briefing from their head of function. The induction programme for all new staff is being updated to include guidance on the local emergency protocol.”

Source location

2016-0356-Response-by-NOMS
Page 1 · response
Published 26 February 2017

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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

Undertake a joint exercise with the South Western Ambulance Service to test understanding and application of the local protocol.

Verbatim wording from the response

“Finally, the prison and the South Western Ambulance Service are intending to undertake a joint exercise in the near future to reassure both organisations that staff understand the local protocol and will follow required procedures in a real emergency.”

Source location

2016-0356-Response-by-NOMS
Page 1 · response
Published 26 February 2017

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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

Distribute and prominently display the local emergency code protocol throughout the establishment.

Verbatim wording from the response

“I can confirm that the relevant Notice to Staff was re-issued on 28 September 2016. This reminds all staff that an emergency code, either Red or Blue, must be called when there are serious concerns about the health of a prisoner, and that on receiving either emergency code the gate staff are required to request an ambulance. The Notice to Staff also confirms the nature of the injuries that should prompt the use of each of the emergency codes, and the further information that it is helpful to pass on to assist the local Ambulance Service. In addition, the local emergency code protocol has been distributed to all areas of the establishment and is displayed in prominent areas for easy reference, including the communications room.”

Source location

2016-0356-Response-by-NOMS
Page 1 · response
Published 26 February 2017

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026