Recurance · prevention of future deaths reports
Pre-inquest brief
Delayed ambulance call for medical distress
The earlier warning
Garry Gilbey · 10 Dec 2014 · Karen Harrold, Portsmouth & South East Hampshire
“The Prison did not have a set policy about when an ambulance should be called.”
judiciary.uk/prevention-of-future-death-reports/garry-gilbey
What was promised
Stated action 1 · response to Garry Gilbey (10 Dec 2014) · stated timescale: 2013/03
“Since Mr [name redacted] death Prison Service Instruction 2013/03 Emergency Response Codes has been issued. The PSI reminds staff who can call a medical emergency, and provides guidance on the use of the correct medical emergency codes, and what information should be communicated to the control room from the scene of the incident. It also states that all Governors must have a Medical Emergency Response Code protocol in place that is based on the PSI and that all prison staff must be made aware of and”
What recurred
- 8 Jul 2025 · George Emmett · Crispin Butler · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Garry Gilbey · 10 Dec 2014
“The Prison did not have a set policy about when an ambulance should be called.”
Later · George Emmett · 8 Jul 2025
“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;”
What happened next
No web check of the stated actions has been published for this chain.