PFD report

Guy Clifton Paget · Prevention of Future Deaths report

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Issued 23 Apr 2021•West Yorkshire Eastern

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
2

Raised in this report

Recipients
2

Named on the report

Responses found
1

Of 2 recipients

Stated actions
1

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 raised2

  1. Failure to communicate the urgent need for ambulance-exit authorisation and have the authorisation prepared
    Part of recurring concern: Failure to provide timely emergency hospital conveyancePart of recurring concern: Unreliable emergency access to hospital care
  2. Lack of an effective and tested system for admitting emergency ambulance vehicles and facilitating their exit with prisoners
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 the HMP Leeds Local Security Strategy to specify manual override procedures for emergency vehicle entry and exit during mechanical failure.

    Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 23 April 2021.

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

  1. Position

    Existing local security strategies, manual overrides, staff training and regular testing are considered sufficient to facilitate ambulance entry and exit.

    Stated by HM Prison and Probation ServiceExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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 communicate the urgent need for ambulance-exit authorisation and have the authorisation prepared

Wider context from the report

“1. The prison should have effective systems to facilitate the exit of an emergency ambulance from the prison. 2. In this case a decision was made shortly after 13:00 that Mr Paget needed to be taken to hospital. It should have been made clear to the prison managers that the necessary authorisation to exit needed to be prepared as a matter of urgency. At approximately 15:00 hours, however, this was not in place. 3. It is foreseeable that prisons nationally will need to admit paramedics and ambulance vehicles to attend to prisoners at times of emergency – and may then need to leave with the prisoner in the ambulance. An efficient and tested system to manage this process is essential, in order that serving prisoners are provided with an equivalent level of care to that which they could expect in the community. ”

Is this part of a recurring concern?

Yes — Failure to provide timely emergency hospital conveyance; Unreliable emergency access to hospital care.

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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. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of an effective and tested system for admitting emergency ambulance vehicles and facilitating their exit with prisoners

Wider context from the report

“1. The prison should have effective systems to facilitate the exit of an emergency ambulance from the prison. 2. In this case a decision was made shortly after 13:00 that Mr Paget needed to be taken to hospital. It should have been made clear to the prison managers that the necessary authorisation to exit needed to be prepared as a matter of urgency. At approximately 15:00 hours, however, this was not in place. 3. It is foreseeable that prisons nationally will need to admit paramedics and ambulance vehicles to attend to prisoners at times of emergency – and may then need to leave with the prisoner in the ambulance. An efficient and tested system to manage this process is essential, in order that serving prisoners are provided with an equivalent level of care to that which they could expect in the community. ”

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

Revise the HMP Leeds Local Security Strategy to specify manual override procedures for emergency vehicle entry and exit during mechanical failure.

Verbatim wording from the response

“There was then an issue with the time taken to open the gate because it required a manual override. The Local Security Strategy (LSS) at HMP Leeds has been revised and now clearly outlines the system that allows staff to utilise a manual override to facilitate emergency vehicle entry or exit in the event of any mechanical failure. This is necessarily a somewhat slower process, but still allows entry or exit within a reasonable time period. This is in accordance with the National Security Framework, which is clear that each prison must”

Source location

2021-0118-Response-from-HMPPS_Published
Page 1 · response
Published 23 April 2021

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

Existing local security strategies, manual overrides, staff training and regular testing are considered sufficient to facilitate ambulance entry and exit.

Verbatim wording from the response

“There was then an issue with the time taken to open the gate because it required a manual override. The Local Security Strategy (LSS) at HMP Leeds has been revised and now clearly outlines the system that allows staff to utilise a manual override to facilitate emergency vehicle entry or exit in the event of any mechanical failure. This is necessarily a somewhat slower process, but still allows entry or exit within a reasonable time period. This is in accordance with the National Security Framework, which is clear that each prison must”

Source location

2021-0118-Response-from-HMPPS_Published
Page 1 · response
Published 23 April 2021

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

Records indicate the hospital-transfer authorisation was generated immediately after the emergency code was called, rather than being delayed.

Verbatim wording from the response

“With regard to the paperwork needed to authorise Mr Paget’s move to hospital, our records do not indicate that there was a delay: it was generated as soon as the emergency code was called and was in the possession of the escorting officer, who was at the healthcare centre before the ambulance.”

Source location

2021-0118-Response-from-HMPPS_Published
Page 2 · response
Published 23 April 2021

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