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recurance

John Henderson

17 Jan 2023 · Coroner Ian Brownhill · Mid Kent and Medway

The coroner's concerns

  1. 1. lack of close monitoring of prisoners with seizure activity

    “During the course of evidence, I also established that [the deceased] was not being monitored any more closely than other prisoners due to his seizure activity. That was confirmed by [REDACTED] in the course of their evidence. They indicated to me that sometimes they will be asked to monitor prisoners more closely but this had not been applied to [the deceased].”
  2. 2. absence of clear information sharing process for medical conditions

    “I asked additional questions of witnesses and asked to have sight of policies and procedures in respect of information sharing protocols and procedures in respect of prisoners with chronic conditions, (be is seizure activity, diabetes, cardiac issues). My concern being that there did not appear to be a clear process for prisoners to consent to disclosure of medical information to front line officers so that they could be made aware that a particular prisoner may be prone to sudden or unexpected”
  3. 3. staff unawareness of sudden medical episodes

    “My concern was that a prisoner could have a sudden (but perhaps predictable) acute medical episode and front line prison staff may not be made aware of what was causing the issue or how to respond thereto.”

Responses

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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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