George Emmett

1. 1. delayed emergency assistance

   “Local Procedures must ensure that staff understand they should not delay summoning emergency assistance”

2. 2. failure to call ambulance

   “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”

3. 3. inadequate emergency response criteria

   “A representative NHS Ambulance guide for use in the community states that an ambulance should be called when there are signs of chest pain, difficulty in breathing, unconsciousness, severe blood loss, severe burns or scalds, choking, fitting or concussion, severe allergic reactions or a suspected stroke”

4. 4. lack of clear staff guidance

   “Paragraph 5.7 indicates a number of minimum requirements for local protocols, including to inform staff that if they are in any doubt about the nature of the injury, they must call an ambulance”

5. 5. insufficient staff training on emergency protocols

   “The evidence of OSG [REDACTED] did not appear to demonstrate familiarity with the processes set out in this policy at the time of [the deceased]'s death”

6. 6. preventable death due to protocol failure

   “The circumstances anticipated by this policy include situations where a prisoner's death may be prevented with appropriate application of an emergency response”

Linked reports