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recurance

Thomas Moffett

22 Jan 2022 · Coroner Nicholas Rheinberg · Lancashire and Blackburn with Darwen

The coroner's concerns

  1. 1. lack of communication between healthcare personnel and ambulance control

    “The evidence disclosed the need for healthcare and the prison to devise a better means of communication between healthcare personnel at the scene of a medical emergency and the prison control room / ambulance control”
  2. 2. delayed provision of essential information to ambulance control

    “Similar communication difficulties have already been reported in relation to the inquest into the death of [name redacted] who died at HMP Lancaster Farms and the Prison and Probation Ombudsman has highlighted a delay in the provision of essential 1 information to Ambulance Control in the case of at HMP Garth who died on 9th December 2020”
  3. 3. potential national communication failure between healthcare and ambulance service

    “The fact that communication difficulties have arisen between healthcare and the ambulance service in three recent cases involving prisons in Lancashire may indicate a potentially national problem”

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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