Carl Foot

1. 1. inadequate response to cell bell

   “Between 1.53pm and 2.51pm on the afternoon of his death, Mr [name redacted] rang his cell bell 13 times.”

2. 2. inadequate response to cell bell

   “The jury found that there was an inadequate response by prison officers to the cell bells, and that this was a contributory factor in [the deceased]'s death.”

3. 3. lack of post-incident review of cell bell logs

   “In terms of learning lessons for the future, which may include learning by individual officers as well as on a systemic basis, there was no exploration immediately after [the deceased]'s death of the cell bell log and all those who heard/answered his bell that afternoon.”

No published response was found on judiciary.uk.