(1) Evidence was adduced in the course of this Inquest to the effect that in 2010,2011 and 2012 inmates were having social get togethers on C at HMP Wealstun, in particular at a weekend, during which time drugs were taken and hooch was drunk; Evidence was also heard that this is occurring at the present time at this said prison establishment In the circumstances, there should be much greater and effective vigilance by staff and Prison Service employees at HMP Wealstun in relation to such get togethers on the periods of association; {2) The Deceased was not subjected t0 a breathalyser test at any time during the 18"h September 2010. A proportion of, but not all; staff are trained in the use of such breathalyser equipment Had the Deceased been s0 breathalysed, more likely than not; it would have been apparent he was not suffering from the effects of alcohol. In the circumstances all staff should be trained in the use of such breathalyser equipment; (3) The Deceased's behaviour and presentation on the 18" September 2010 was not recorded by any member of staff in the C Wing Observation Book_ Evidence was adduced in the course of the Inquest as to the importance of recording all relevant information in the said Observation Book; thereby apprising all members 0f Wing staff on all shifts of all material facts and matters. In the circumstances, all relevant information in relation t9, for example; an inmate' s behaviour and general presentation should be brought to the attention of all staff and should be done so via an appropriate entrylentries in the Observation Book All Wing staff Managers, Prison Officers and Operational Support Grades) should be made aware of the importance of such; and should ensure information is recorded accordingly; (4) The members of staff who observed the Deceased at around 5.45am on the 19th September 2010 did not out" a Code Blue. It was explained in the course of the Inquest that Codes Blue and Red are basic emergency codes which have been in existence for very many years. Despite the fact that; in this instance; the failure to call a Code Blue would not have affected the outcome, it Is not inconceivable that to omit to use such emergency codes could, in certain circumstances, jeopardise an inmate'$ chances of survival In the circumstances, all Prison staff should be fully acquainted with the use of such Codes and should use them accordingly; (5) Paramedic assistance was not called within a reasonable time and no explanation for the delay was provided in the course of the Inquest: Whilst the failure to summons outside medical assistance sooner would not have affected outcome in this instance it is not inconceivable that to omit to call for such assistance as soon as possible could, in certain circumstances, jeopardise an inmate S chances of survival. Consequently, emergency services should be summoned at the very first available opportunity, and all Prison staff should be instructed as to the importance of so doing: