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recurance

Andrew Crane

22 May 2018 · Coroner Philip Barlow · Northamptonshire

The coroner's concerns

  1. 1. failure to initiate Code Blue for chest pain

    “Mr [name redacted] had complained of chest pain shortly before his cardiac arrest. The prison officer did not consider that he was unwell and so asked the healthcare nurse to attend. According to PSI 3/2013 and the prison's emergency response policy, a complaint of chest pain should result in a Code Blue call. There was a lack of clarity amongst witnesses as to what, if any, discretion should be given in these circumstances to a prison officer who thinks that a complaint of chest pain does not require a”
  2. 2. lack of information sharing after Code Blue activation

    “A Code Blue was called when Mr [name redacted] collapsed, and at this stage an ambulance 1 was called. After this call, it became clear that Mr [name redacted] was not breathing and CPR was commenced, but this further information was not passed to the ambulance service. This information would have changed the priority of the ambulance response”

Responses

No published response was found on judiciary.uk.

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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.

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Andrew Crane · Recurance