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recurance

Lack of knowledge about emergency response codes and delayed staff training on

Closely relatedConfidence 0.90 · high2 reports · 2017–2024No published response to an earlier report One-page brief (print or PDF)

His Majesty's Prison and Probation Service received 2 coroners' reports about this hazard between 28 Mar 2017 and 16 May 2024.

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 0 specific actions.

2
reports
2
different coroners
2017–2024
years
0.90
lowest link confidence

The story, report by report

Spacing grows with the time between reports.

  1. First warning

    John Williams↗

    28 Mar 2017 · ME Hassell · London Inner (North)

    “The issue of the difference between a code blue and a code red is one about which | have written before.”
    Original on judiciary.uk ↗

    His Majesty's Prison and Probation Service responded.Response (PDF) ↗

  2. 7 years 2 months later

    Raised again · 1st time

    Luke Pearce↗

    16 May 2024 · Kelly Dixon · Staffordshire and Stoke on Trent

    Closely relatedConfidence 0.90 · higha different coroner
    “relevant training and guidance to equip staff to understand when and how to enter a cell in a medical emergency, and the appropriate use of Code Blue and Code Red communications in a medical emergency”
    Original on judiciary.uk ↗

    Repeated from the earlier report:CodeBlue

    His Majesty's Prison and Probation Service responded.Response (PDF) ↗

  3. All reports to His Majesty's Prison and Probation Service

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.

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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