Robert Ellery

“The prison control room was not able to provide the Welsh Ambulance Service with any specific information as to the reason why an ambulance was required for 19 minutes after Mr [name redacted] was found in his cell. This delayed the ability of the ambulance service to despatch a response. While this was not, on the evidence heard by the jury, causative of Mr [name redacted] death, it gives rise to a concern that a risk that other deaths will occur.”