PFD report

Sharon Louise Suki Butcher · Prevention of Future Deaths report

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Issued 31 Mar 2015•County Durham and Darlington

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
3

Raised in this report

Recipients
2

Named on the report

Responses found
1

Of 2 recipients

Stated actions
3

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 raised3

  1. Delays in summoning ambulances after emergency medical codes are broadcast
    Part of recurring concern: Failure to call an ambulance promptly when emergency assistance is requiredPart of recurring concern: Unreliable on-site emergency medical and first-aid response arrangements
  2. Delays and lack of clarity in control-room responses to medical emergencies
    Part of recurring concern: Ineffective communication during medical emergenciesPart of recurring concern: Unreliable emergency access to hospital care
  3. Failure to use appropriate codes for medical emergencies
    Part of recurring concern: Ineffective communication during medical emergencies
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.1

  1. Action

    Revise local contingency plans and reissue emergency instructions requiring timely ambulance calls and defining medical emergency response codes.

    Stated by Frankland PrisonStated completedThe respondent said that this action was complete when they made their response on 31 March 2015.

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

Delays in summoning ambulances after emergency medical codes are broadcast

Wider context from the report

“The PPO report highlights an issue relating to the delay in calling for an ambulance as soon as an emergency medical code was broadcast. There was a 10 minute delay and the prisons local protocol for summoning an ambulance was not followed. There have been a series of similar failings in dealing with medical emergencies of HMP Frankland and HMP Durham with either staff using wrong or inappropriate codes, or there being delays in the control room and this recurring issue of lack of clarity in response to a medical emergency could well lead to a fatality in the future. ”

Is this part of a recurring concern?

Yes — Failure to call an ambulance promptly when emergency assistance is required; 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

Delays and lack of clarity in control-room responses to medical emergencies

Wider context from the report

“The PPO report highlights an issue relating to the delay in calling for an ambulance as soon as an emergency medical code was broadcast. There was a 10 minute delay and the prisons local protocol for summoning an ambulance was not followed. There have been a series of similar failings in dealing with medical emergencies of HMP Frankland and HMP Durham with either staff using wrong or inappropriate codes, or there being delays in the control room and this recurring issue of lack of clarity in response to a medical emergency could well lead to a fatality in the future. ”

Is this part of a recurring concern?

Yes — Ineffective communication during medical emergencies; Unreliable emergency access to hospital care.

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 use appropriate codes for medical emergencies

Wider context from the report

“The PPO report highlights an issue relating to the delay in calling for an ambulance as soon as an emergency medical code was broadcast. There was a 10 minute delay and the prisons local protocol for summoning an ambulance was not followed. There have been a series of similar failings in dealing with medical emergencies of HMP Frankland and HMP Durham with either staff using wrong or inappropriate codes, or there being delays in the control room and this recurring issue of lack of clarity in response to a medical emergency could well lead to a fatality in the future. ”

Is this part of a recurring concern?

Yes — Ineffective communication during medical emergencies.

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

Revise local contingency plans and reissue emergency instructions requiring timely ambulance calls and defining medical emergency response codes.

Verbatim wording from the response

“HMP Frankland revised their local contingency plans and re-issued instructions following the death of Ms. Sharon Butcher to ensure that all staff understood, that they must not delay in calling an ambulance in all cases where there are serious concerns about the health of an offender.”

Source location

2015-0129-Response-by-NOMS
Page 1 · response
Published 31 March 2015

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.2

  1. 1

    Issue a national learning bulletin on medical emergency response.

    Stated by Frankland PrisonStated completedThe respondent said that this action was complete when they made their response on 31 March 2015.
  2. 2

    Work with the North East Prisons cluster and North East Ambulance Service to ensure consistent joint emergency-response arrangements across establishments.

    Stated by Frankland PrisonStated in progressThe respondent said that this action was in progress when they made their response on 31 March 2015.

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 national learning bulletin on medical emergency response.

Verbatim wording from the response

“In April 2015 an additional learning bulletin was issued nationally by ERDG (please see attached).”

Source location

2015-0129-Response-by-NOMS
Page 1 · response
Published 31 March 2015

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

Work with the North East Prisons cluster and North East Ambulance Service to ensure consistent joint emergency-response arrangements across establishments.

Verbatim wording from the response

“In addition HMP Frankland are also working with the North East Prisons cluster and the North East Ambulance Service to ensure joint working and consistency of approach across all establishments.”

Source location

2015-0129-Response-by-NOMS
Page 1 · response
Published 31 March 2015

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