Recurance · prevention of future deaths reports
Pre-inquest brief
Delay in ambulance response for prisoners
The earlier warning
Sharon Butcher · 31 Mar 2015 · Andrew Tweddle, County Durham & Darlington
“There was a 10 minute delay and the prisons local protocol for summoning an ambulance was not followed.”
judiciary.uk/prevention-of-future-death-reports/sharon-butcher
What was promised
A published response was found, but no specific action could be extracted with a verified quote.
What recurred
- 8 Jul 2025 · George Emmett · Crispin Butler · Identical hazard · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Sharon Butcher · 31 Mar 2015
“There was a 10 minute delay and the prisons local protocol for summoning an ambulance was not followed.”
Later · 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”
What happened next
No web check of the stated actions has been published for this chain.