PFD report

William VICKERS · Prevention of Future Deaths report

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Issued 26 Jul 2019•Milton Keynes

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.

View original report
Concerns
4

Raised in this report

Recipients
2

Named on the report

Responses found
3

Of 2 recipients

Stated actions
22

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

Select any concern, action or position to view the source wording.

Concerns raised4

  1. Lack of ambulance crew access to the SCAS radio system
  2. Failure to ensure unobstructed ambulance access through all security gates
    Part of recurring concern: Failure to ensure timely ambulance access to care and emergency treatment premisesPart of recurring concern: Unreliable emergency access arrangements for responders
  3. Failure to include a fully qualified paramedic in the first response to prison emergencies
    Part of recurring concern: Unreliable on-site emergency medical and first-aid response arrangements
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.18

  1. Action

    Provide all Custodial Managers an opportunity to participate in a live test of emergency vehicle receipt arrangements.

    Stated by HM Prison and Probation ServiceStated plannedThe respondent said that this action was planned when they made their response on 9 September 2019.
  2. Action

    Update emergency vehicle contingency plans with immediate ambulance notification, gate staffing, additional OSG support, proportionate searching, and information sharing to prevent access delays.

    Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 9 September 2019.
  3. Action

    Deliver establishment-based training for OSGs on emergency vehicle receipt arrangements, with completion required for all OSGs by the end of 2019.

    Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 9 September 2019.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    Permanent Airwave access for private providers requires them to obtain their own licence and radio equipment.

    Stated by South Central Ambulance Service NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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

Lack of ambulance crew access to the SCAS radio system

Wider context from the report

“Firstly, I was told during the course of the evidence that the ambulance crew who attended the prison in response to the emergency call, did not have access to the radio system of SCAS. The ambulance which attended is operated by Jigsaw Medical Services which is denied access to the system. I believe this policy should be reviewed urgently and consideration given to ensure that all ambulance crews have access to the radio system. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

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 unobstructed ambulance access through all security gates

Wider context from the report

“During the course of the evidence I was concerned that once the ambulance was admitted through the main gate it then took 11 minutes for the ambulance to be escorted through 5 sets of gates to the incident. Consideration must be given to a robust system of ensuring that all gates are opened and manned by security staff so that the ambulance is not in any way hindered in getting to their patient. The present system in my view puts prisoners’ lives at risk. ”

Is this part of a recurring concern?

Yes — Failure to ensure timely ambulance access to care and emergency treatment premises; Unreliable emergency access arrangements for responders.

Open source report

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 include a fully qualified paramedic in the first response to prison emergencies

Wider context from the report

“Secondly I am concerned that the first response did not include a “paramedic”. I believe that consideration should be given to a review to ensure that the first responder to an emergency at the prison should always include a fully qualified paramedic. ”

Is this part of a recurring concern?

Yes — Unreliable on-site emergency medical and first-aid response arrangements.

Open source report

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

Lack of staff confidence in using AEDs within the prison

Wider context from the report

“During the course of the evidence I was concerned that not all staff within the prison, including those within healthcare, were confident in using the AED (Automatic External Defibrillator) and believe that the training of all staff should be reviewed so all are both familiar and confident in its use. ”

Is this part of a recurring concern?

Yes — Inadequate staff training and familiarisation in defibrillator use.

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

Provide all Custodial Managers an opportunity to participate in a live test of emergency vehicle receipt arrangements.

Verbatim wording from the response

“All Custodial Managers will have had the opportunity to take part in a live test of the arrangements for the receipt of emergency vehicles. Training for OSGs is being delivered on the establishment’s bi-monthly training afternoons, and all will have completed it before the end of 2019.”

Source location

2019-0255-Response-by-HM-Prison-and-Probation-Service
Page 2 · response
Published 9 September 2019

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

Update emergency vehicle contingency plans with immediate ambulance notification, gate staffing, additional OSG support, proportionate searching, and information sharing to prevent access delays.

Verbatim wording from the response

“Since Mr Vickers’ inquest the contingency plans at HMP Woodhill have been updated to ensure that there are no delays to the process of receipt of any emergency vehicle, including ambulances during night state. When a code red or blue is called, the control room contacts South Central Ambulance Service (SCAS) immediately. When this occurs during night state, members of staff report to the prison gate to await the arrival of the ambulance, and to assist the responding dog handler with opening the gates to the units.”

Source location

2019-0255-Response-by-HM-Prison-and-Probation-Service
Page 1 · response
Published 9 September 2019

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

Deliver establishment-based training for OSGs on emergency vehicle receipt arrangements, with completion required for all OSGs by the end of 2019.

Verbatim wording from the response

“All Custodial Managers will have had the opportunity to take part in a live test of the arrangements for the receipt of emergency vehicles. Training for OSGs is being delivered on the establishment’s bi-monthly training afternoons, and all will have completed it before the end of 2019.”

Source location

2019-0255-Response-by-HM-Prison-and-Probation-Service
Page 2 · response
Published 9 September 2019

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 monthly local AED and emergency-equipment refreshers, quarterly clinical attendance, attendance monitoring and signed competence statements.

Verbatim wording from the response

“We have, with immediate effect, ensured that all Offender Care Services including Woodhill will have:”

Source location

2019-0255-Response-by-CNWL-NHS-Trust
Page 2 · response
Published 9 September 2019

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

Commission an independent external review of emergency-response practice in Offender Care to inform recommendations for policy, practice and training.

Verbatim wording from the response

“An external independent review has been commissioned to review the practice of emergency response within Offender Care and make recommendations for policy, practice and training. The findings will form the basis of a detailed action plan to ensure staff are equipped by the training provided and equipment available to respond to a medical emergency according to their role and expertise. These actions are expected to improve patient safety and outcomes.”

Source location

2019-0255-Response-by-CNWL-NHS-Trust
Page 3 · response
Published 9 September 2019

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 new HMP Woodhill CNWL staff with local induction covering emergency-equipment locations and use.

Verbatim wording from the response

“All new CNWL staff at HMP Woodhill complete a detailed local induction which includes location of emergency equipment and its use.”

Source location

2019-0255-Response-by-CNWL-NHS-Trust
Page 3 · response
Published 9 September 2019

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

Display “Know your AED” posters and distribute a “How to use the AED” guide for refresher training.

Verbatim wording from the response

“‘Know your AED’ posters have been developed and are displayed throughout HMP Woodhill to maintain familiarisation with it.”

Source location

2019-0255-Response-by-CNWL-NHS-Trust
Page 2 · response
Published 9 September 2019

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

Add AED verbal-instruction meanings, including “shock cancelled”, to emergency response training.

Verbatim wording from the response

“The Trust Resuscitation Lead has confirmed that all emergency response training (BLS, ELS, ILS) includes information on the verbal instructions (and their meaning) that is given by an AED. The meaning of the wording ‘shock cancelled’ has been added with immediate effect to the training delivered.”

Source location

2019-0255-Response-by-CNWL-NHS-Trust
Page 2 · response
Published 9 September 2019

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

Establish a Resuscitation Review Group to share best practice, standardise emergency equipment and response, and review staff training needs.

Verbatim wording from the response

“In December 2018, the Offender Care Directorate established a Resuscitation Review Group with the purpose of sharing best practice, standardising emergency equipment and response and to review the training needs of staff. The review group is led by the Lead Nurse for Offender Care and includes senior clinicians from services and the Trust Resuscitation Lead.”

Source location

2019-0255-Response-by-CNWL-NHS-Trust
Page 3 · response
Published 9 September 2019

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

Complete Train the Trainer preparation for the HMP Woodhill Primary Care Lead to deliver regular local emergency-response and refresher training.

Verbatim wording from the response

“On 27 June 2019, the CNWL Primary Care Lead at HMP Woodhill, who is a senior paramedic, completed a ‘Train the Trainer’ course which will enable local emergency response and refresher training detailed above to be carried out on a regular basis within the Woodhill Team.”

Source location

2019-0255-Response-by-CNWL-NHS-Trust
Page 3 · response
Published 9 September 2019

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

Hold AED training sessions for CNWL Offender staff to develop competence and confidence in AED use.

Verbatim wording from the response

“In July 2019, with the introduction of the new AEDs there have been a number of training sessions held to ensure CNWL Offender staff are competent and confident in their use.”

Source location

2019-0255-Response-by-CNWL-NHS-Trust
Page 2 · response
Published 9 September 2019

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

Require role-appropriate annual e-learning and biennial face-to-face emergency response training for all CNWL Offender Care staff.

Verbatim wording from the response

“In addition to the above, all CNWL Offender Care staff are required to complete mandatory emergency response training (e-learning annually and face to face bi-annually) at a level appropriate to their role.”

Source location

2019-0255-Response-by-CNWL-NHS-Trust
Page 2 · response
Published 9 September 2019

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

Offer AED training to HMP Woodhill officers through scheduled monthly refresher sessions.

Verbatim wording from the response

“It has been agreed with the Governor that CNWL will offer AED training sessions to officers at HMP Woodhill. Officers will be able to attend the refresher sessions scheduled each month.”

Source location

2019-0255-Response-by-CNWL-NHS-Trust
Page 2 · response
Published 9 September 2019

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

Establish a joint process allowing ambulance staff to retain operational radios and work mobile telephones when attending prisoners.

Verbatim wording from the response

“3. Operational radios and mobile telephones”

Source location

2019-0255-South-Central-Ambulance-Service-NHS-Trust
Page 4 · response
Published 9 September 2019

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

Establish a joint prison access process to provide ambulance crews with timely access to patients and identify expected emergency resources.

Verbatim wording from the response

“2. Access to the prisoner (patient).”

Source location

2019-0255-South-Central-Ambulance-Service-NHS-Trust
Page 4 · response
Published 9 September 2019

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

Complete a prison call-triage process requiring callers to provide accurate information about the patient’s condition.

Verbatim wording from the response

“As part of the review we are undertaking with our local prisons, we are facilitating a fixed process regarding call triaging, access to the prison and retention of our personnel’s operational radios and mobile telephones. I will detail each point separately below.”

Source location

2019-0255-South-Central-Ambulance-Service-NHS-Trust
Page 4 · response
Published 9 September 2019

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

Inform private provider firms that they can pursue their own Airwave licence and radio equipment for permanent radio access.

Verbatim wording from the response

“For private provider crews to have permanent access to the radio system, they must apply for a licence for their own organisation and procure the radio equipment. Following receipt of your report, we will ensure that the private provider firms that we work with are aware of this option so they can consider whether it is an option they would like to pursue.”

Source location

2019-0255-South-Central-Ambulance-Service-NHS-Trust
Page 2 · response
Published 9 September 2019

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

Maintain a specification requiring paramedic backup for immediately life-threatening incidents, including cardiac or respiratory arrest.

Verbatim wording from the response

“To offer you assurance that a Paramedic will always be dispatched to attend immediately life-threatening incidents, within our standard operating procedures, there is already a specification for a paramedic crew to be sent to all patients who are in cardiac or respiratory arrest (see below).”

Source location

2019-0255-South-Central-Ambulance-Service-NHS-Trust
Page 2 · response
Published 9 September 2019

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Permanent Airwave access for private providers requires them to obtain their own licence and radio equipment.

Verbatim wording from the response

“The airwave radio system used by SCAS, and NHS Ambulance Trusts nationally, is governed by strict licence conditions. I have included a copy of the ‘Airwave Code of Practice – NHS Ambulance Service Profile’ with this letter. The licence terms (copied below) dictate that any private provider using the radio system must have their own licence.”

Source location

2019-0255-South-Central-Ambulance-Service-NHS-Trust
Page 1 · response
Published 9 September 2019

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Paramedic shortages make it infeasible to guarantee that every ambulance crew includes a paramedic.

Verbatim wording from the response

“As you will be aware, there are a number of different operational job roles within the prehospital environment. These include Specialist Paramedics, Paramedics, Ambulance Technicians and Emergency Care Assistants. Nationally there is a shortage of Paramedics which means that it is not feasible for us to guarantee a Paramedic is part of a crew on every resource.”

Source location

2019-0255-South-Central-Ambulance-Service-NHS-Trust
Page 2 · response
Published 9 September 2019

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.4

  1. 1

    Install AEDs with data cards at HMP Woodhill to record incident duration, shocks, first-shock timing and presenting ECG.

    Stated by Central and North West London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 September 2019.
  2. 2

    Introduce medical-emergency audit forms and review completed forms through the Resuscitation Review Group, with concerns monitored by senior management.

    Stated by Central and North West London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 September 2019.
  3. 3

    Share emergency-care learning across services through Care Quality Meetings, Learning Lessons Circulars and local quality and team meetings.

    Stated by Central and North West London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 September 2019.
  4. 4

    Produce a memorandum of understanding covering private provider colleagues undertaking work on the Trust’s behalf.

    Stated by South Central Ambulance Service NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 9 September 2019.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    Prison location alone does not justify a different response; triage must be based on the patient's clinical condition.

    Stated by South Central Ambulance Service NHS Foundation TrustNo action considered necessaryThe respondent said that no further action was needed.

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

Install AEDs with data cards at HMP Woodhill to record incident duration, shocks, first-shock timing and presenting ECG.

Verbatim wording from the response

“New AED’s with data cards are now in place at HMP Woodhill, which record activity during its use. This data will include the following:”

Source location

2019-0255-Response-by-CNWL-NHS-Trust
Page 1 · response
Published 9 September 2019

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

Introduce medical-emergency audit forms and review completed forms through the Resuscitation Review Group, with concerns monitored by senior management.

Verbatim wording from the response

“A ‘resuscitation/medical emergency’ audit form has been introduced to enable a review of care delivered during a medical emergency. These audit forms are reviewed at the Offender Care Resuscitation Review Group and any learning shared across services in their local Care Quality Meetings. Any concerns are reported and monitored by the monthly Business and Performance Meeting by the Offender Care Senior Management Team. Any learning is shared through Learning Lessons Circulars which are disseminated to staff and discussed in local quality and team meetings.”

Source location

2019-0255-Response-by-CNWL-NHS-Trust
Page 3 · response
Published 9 September 2019

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

Share emergency-care learning across services through Care Quality Meetings, Learning Lessons Circulars and local quality and team meetings.

Verbatim wording from the response

“A ‘resuscitation/medical emergency’ audit form has been introduced to enable a review of care delivered during a medical emergency. These audit forms are reviewed at the Offender Care Resuscitation Review Group and any learning shared across services in their local Care Quality Meetings. Any concerns are reported and monitored by the monthly Business and Performance Meeting by the Offender Care Senior Management Team. Any learning is shared through Learning Lessons Circulars which are disseminated to staff and discussed in local quality and team meetings.”

Source location

2019-0255-Response-by-CNWL-NHS-Trust
Page 3 · response
Published 9 September 2019

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

Produce a memorandum of understanding covering private provider colleagues undertaking work on the Trust’s behalf.

Verbatim wording from the response

“We will ensure that the memorandum of understanding produced will apply to our private provider colleagues undertaking work on our behalf.”

Source location

2019-0255-South-Central-Ambulance-Service-NHS-Trust
Page 5 · response
Published 9 September 2019

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Prison location alone does not justify a different response; triage must be based on the patient's clinical condition.

Verbatim wording from the response

“When we receive an emergency call, it is really important that we receive accurate information regarding the patient’s condition to ensure that we are able to triage the call appropriately. This is something which will be expanded on further below in the section on the work we are undertaking with our local prison services. It is not appropriate for the location of the incident to be included as part of the triage; the focus must be on the clinical condition of the patient. Therefore, we are unable to provide a different response to a call for help just because the location is a prison.”

Source location

2019-0255-South-Central-Ambulance-Service-NHS-Trust
Page 2 · response
Published 9 September 2019

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