Dear Madam,

Regulation 28: Prevention of Future Deaths Report – Jamie Funnell

I write in response to your Regulation 28 Prevention of Future Deaths Report issued to Practice Plus Group ("PPG") on 13 October 2025 following the inquest touching upon the death of Jamie Funnell at HMP Lewes. Practice Plus Group would like to express its sincere condolences to Jamie’s family and friends.

This response addresses the matters of concern as it relates to Practice Plus Group.

Matters of Concern:
1. The Standard Operating Procedure for Assessment and Management of Alcohol Dependence expired in March 2024. I heard evidence that it will be replaced by an updated Policy on 9.10.25. I asked for a copy of the draft Policy to determine whether issuing a PFD could be avoided when hearing evidence about PFD matters but was advised by the PPG’s legal representative that this was not possible, without a reason why being offered. I consider that action should be taken to prevent a failure to update before their expiry all PPG’s Standard Operating Procedures including this one which the Clinical Reviewer found to be potentially unclear. His findings were published on
19.4.24, a month after the Standard Operating Procedure had expired, and yet it continues to remain out of date, almost 18 months later. PPG could have reasonably expected it would be subject to scrutiny in this inquest and update it accordingly and in

a timely manner. Their failure to do so indicates a cavalier attitude to reviewing and updating important Policies and action should be taken to address this.

2. I heard evidence describing the care given to Jamie Funnell after his collapse as chaotic, with faulty equipment and incorrect CPR technique. The Ambulance crews witnessed the healthcare members carrying out CPR before taking over. After Jamie’s death was confirmed, a crew member raised concerns with the Duty Governor about the CPR attempts she had witnessed. I have heard evidence that although 32 eligible healthcare staff have now completed life support training, I have not heard any evidence regarding the level of this training and remain concerned, especially in light of the unsatisfactory response by PPG in its Action Plan for the PPO Report dated September 2024 that adequate training of staff and monitoring of equipment to prevent faults in its operation have been undertaken to prevent a fatality occurring in similar circumstances.

Standard Operating Procedure for Assessment and Management of Alcohol Dependence Please find the enclosed clinical guidance document for ‘Assessment and Management of Alcohol Dependence’. We can confirm that this was ratified at a Governance meeting on 9 October 2025.

The enclosed document has turned the previous SOP into clinical guidance, allowing for a best practice benchmark and more patient centred care rather than the constraints of an SOP. The guidance has now been changed to become more user friendly for staff and breaks the guidance into smaller sections. It has also added a contents page to help staff navigate the guidance documents more easily and makes reference to the SMS template hub, for capturing prescribing interventions, monitoring requirements and monitoring results.

As well as the above, the guidance ensures clearer responsibilities regarding those patients that require overnight monitoring. Previously, the policy indicated that increased face to face monitoring through the night with the cell door open would need to be considered for high-risk patients or those displaying signs of severe withdrawal. The new guidance document outlines that if, based on a risk assessment of the individual, the prescriber deems that additional monitoring through the night is required, they need to clearly outline the specific management plan in the notes (e.g. what monitoring is required (CIWA-Ar), how often that should take place, escalation plans and the indication for additional medication). The requirement to open the door

for any additional assessments still stands. The requirement for a management plan ensures that measures to protect the welfare of the patient are documented so that all staff are clear about the expectations, allowing for greater continuity of care.

The revised operating procedure acknowledges that since moving towards integrated care pathways, the EDiC (Early Days in Custody) team have a responsibility to consider whether the minimum monitoring requirements (or additional monitoring requirements outlined by the prescriber) are appropriate at their daily MDT (Multi-Disciplinary Team meeting). In addition, the EDiC team is also required to consider whether any further action needs to be taken based on recent assessments. This provides an additional 'safety net' for new patients entering the prison to ensure the correct treatment regime is implemented without delay, a service which was not available when Mr Funnell arrived at HMP Lewes.

An additional section is also included in respect of the location of patients and transfer. This highlights that patients in alcohol withdrawal should be in a safe area of the prison and should not be routinely transferred to another prison or attending court for the duration of their alcohol detox.

A section on omitted doses is also included to highlight that diazepam for alcohol detox is a critical medication and a single missed dose should be followed up with the patient. Pabrinex is also no longer available and has been amended to generic vitamin B&C IM injections. We also added in a link to the SPS (Specialist Pharmacy Service) guidelines around prescribing thiamine in alcohol dependence.

In respect of embedding this guidance at HMP Lewes and other PPG sites across the country, we have taken a number of steps. Following the ratification of the guidance this has been added to the PPG intranet for all staff to be able to access. A Green Alert (a notification to staff relating to clinical updates) was sent to all Heads of Healthcare on 17 November 2025 to notify them of the updated guidance and a webinar about it and the changes took place on 20 November 2025.

At HMP Lewes specifically the guidance was shared with the senior leadership team on 13 November 2025 to share with their staff through the weekly team meetings. In addition, the guidance was shared via the weekly staff bulletin sent to all staff on 14 November 2025. A clinical training session with all staff has been arranged for the week commencing 1 December

2025 to share the updated guidance and focus on the key principles. Furthermore, the service ran a refresher training session for all staff on 6 November 2025 on the CIWA scoring tool and its use in managing those detoxing from alcohol.

Emergency Response The service at HMP Lewes has placed significant focus on emergency response and recognise the importance of having the right equipment available, competent staff to manage these complex situations and robust governance processes in place to ensure quality of care.

At HMP Lewes, all of our substantive and bank nursing staff, GP staff and health care assistants receive annual Immediate Life Support training which is accredited with the Resuscitation Council UK. Agency staff receive annual training through their employing agency and are not able to work at Practice Plus Group sites without having an in-date certificate of completion. Current compliance figures for Immediate Life Support training are 96% which is monitored monthly so that timely courses can be booked to ensure staff remain up to date.

Following successful recruitment, the service now has minimal requirement for temporary agency staff which means that the team is more cohesive and consistent, enabling better working relationships which are key when dealing with emergency situations.

We recognise that attending to emergency situations can be challenging in a prison environment and therefore to address this we introduced a number of training initiatives in July 2025 which includes:
• All staff “back to basics” training covering emergency bags, where bags are located across the site, what is in each of the emergency bags, and the importance of bag check audits.
• All staff scenario-based emergency response training. This training involves the team walking through an emergency response - what happened, what the immediate response was, what worked well, what didn’t work well, and any learning taken from the incident. The purpose of this training is to provide staff with a “real life” scenario to build confidence across the whole team to lead an emergency response if needed.

The above training sessions are scheduled to occur quarterly and currently include healthcare staff only but we plan to include our HMPPS colleagues to enable learning as a wider team.

Emergency bag equipment is checked every 2 weeks by the team to ensure that they contain the correct equipment, that the equipment works and that emergency drugs are in date. After each check, the bags are resealed and the seals are checked daily on site to ensure they remain intact. The emergency bag check process is audited monthly as per the Practice Plus Group annual audit schedule and in line with the Emergency Response Policy for Healthcare Professionals within Health in Justice sites (ratified January 2024 and due for review March
2026). In addition to the regular bag checks, we have also implemented bimonthly dip tests of the emergency response bags to provide further reassurance.

We recognise that the emergency response on 16th December 2023 fell short of the standards we expect of our healthcare team. Sadly, whilst any concerns raised are unlikely to have changed the outcome in this case, PPG has taken significant steps to address the concerns raised during the Inquest. Armed with the training described above, the healthcare team's ability to respond in a timely and appropriate manner to a patient in cardio-pulmonary arrest were put to the test in a similar emergency in October 2025. We are pleased to confirm that the same governor who gave evidence at the inquest described the healthcare response in October 2025 as “exemplary”. She specially commended the two emergency response nurses who were first on scene and who undoubtedly saved the individual's life.

I am confident that with these measures in place, supported by the new guidance document, the staff at HMP Lewes will continue to provide the safe, effective and high quality care that we expect from any of our Practice Plus Group sites.

I hope that the above response provides assurance that Practice Plus Group are committed to providing a high-quality healthcare service at HMP Lewes, and its other sites, and trust this response addresses the concerns you had.