Delayed ambulance call for medical distress
Ministry of Justice received 2 coroners' reports about this hazard between 10 Dec 2014 and 8 Jul 2025.
They came from 2 different coroners in 2 coroner areas. A similar concern was raised again 1 time after the first warning.
A published response was found for 1 of the 1 earlier reports, stating 1 specific action.
The story, report by report
Spacing grows with the time between reports.
“The Prison did not have a set policy about when an ambulance should be called.”
Original on judiciary.uk ↗ Ministry of Justice responded, stating 1 specific action.Response (PDF) ↗
“Since Mr [name redacted] death Prison Service Instruction 2013/03 Emergency Response Codes has been issued. The PSI reminds staff who can call a medical emergency, and provides guidance on the use of the correct medical emergency codes, and what information should be communicated to the control room from the scene of the incident. It also states that all Governors must have a Medical Emergency Response Code protocol in place that is based on the PSI and that all prison staff must be made aware of and”
Stated timescale: 2013/03
- 10 years 7 months laterClosely relatedConfidence 0.90 · higha different coroner
“It is essential that an ambulance is called in all cases where there are serious concerns about the health of a prisoner and that access to both the prison and the individual prisoner is not delayed;”
Original on judiciary.uk ↗ Repeated from the earlier report:ambulancecalledprison
Ministry of Justice responded.Response (PDF) ↗
- All reports to Ministry of Justice
Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals.
2014 → 2025George Emmett10 years 7 months after Garry Gilbey · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight problems with the prison’s process for deciding when to summon an ambulance for a prisoner in medical distress. The earlier report notes the absence of a clear policy, while the later report stresses that an ambulance must be called without delay in all serious cases.
Garry Gilbey · 10 Dec 2014
“The Prison did not have a set policy about when an ambulance should be called.”
Original on judiciary.uk ↗ George Emmett · 8 Jul 2025
“It is essential that an ambulance is called in all cases where there are serious concerns about the health of a prisoner and that access to both the prison and the individual prisoner is not delayed;”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“Since Mr [name redacted] death Prison Service Instruction 2013/03 Emergency Response Codes has been issued. The PSI reminds staff who can call a medical emergency, and provides guidance on the use of the correct medical emergency codes, and what information should be communicated to the control room from the scene of the incident. It also states that all Governors must have a Medical Emergency Response Code protocol in place that is based on the PSI and that all prison staff must be made aware of and”
Stated action · timescale: 2013/03
“Since Mr [name redacted] death Prison Service Instruction 2013/03 Emergency Response Codes has been issued. The PSI reminds staff who can call a medical emergency, and provides guidance on the use of the correct medical emergency codes, and what information should be communicated to the control room from the scene of the incident. It also states that all Governors must have a Medical Emergency Response Code protocol in place that is based on the PSI and that all prison staff must be made aware of and”
No specific action could be extracted with a verified quote.
- Each report's concerns were extracted by Nemotron 3 Nano on Nebius Token Factory, each with a quote copied from the report.
- Concerns from reports to Ministry of Justice at least six months apart were compared by meaning (Qwen3 embeddings) and wording (TF-IDF).
- The closest pairs were judged by Nemotron 3 Super with reasoning on. Only identical or closely related, with confidence of at least 0.70, are shown.
- Every quote was checked by code as an exact substring of the original text. Names of staff and family are redacted, and the deceased are named by report title only.
| Link | Meaning | Wording | Judge | Coroner |
|---|---|---|---|---|
| 2014 → 2025 | 0.77 | 0.20 | Closely related · 0.90 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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This shows that a similar concern was raised again after an earlier report. It does not say why, and it is not a finding about any organisation or person. To report an error, see the corrections route.