Skip to content
recurance

Delayed ambulance call for medical distress

Closely relatedConfidence 0.90 · high2 reports · 2014–2025 One-page brief (print or PDF)

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.

2
reports
2
different coroners
2014–2025
years
0.90
lowest link confidence

The story, report by report

Spacing grows with the time between reports.

  1. First warning

    Garry Gilbey↗

    10 Dec 2014 · Karen Harrold · Portsmouth & South East Hampshire

    “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

  2. 10 years 7 months later

    Raised again · 1st time

    George Emmett↗

    8 Jul 2025 · Crispin Butler · Buckinghamshire

    Closely 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) ↗

  3. All reports to Ministry of Justice

Next

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.

  • Built with
  • NVIDIA Nemotron Nano, Super and Ultra
  • Nebius Token Factory inference
  • Qwen3 Embedding 8B on Token Factory
  • Tavily follow-up web search
  • Postgres and pgvector search
  • Next.js site

Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person. Methodology and responsible use · Report an error