Dear Sir/Madam,

Regulation 28 Report to Prevent Future Deaths – Inquest touching the death of Mr Azroy Dawes-Clarke

Thank you for your regulation 28 report to prevent future deaths dated 29th July 2025 following the inquest into the death of Mr Azroy Dawes-Clarke which concluded on 3rd July
2025.

In advance of responding to the specific concerns raised in your report, I would like to express my deep condolences to Mr Dawes-Clarke’s family and loved ones. Oxleas NHS Trust is keen to assure the family and the coroner that the concerns raised about Mr Dawes-Clarke’s care have been listened to and acted upon.  I appreciate that responses to Coroner Reports may constitute an important part of process through which family and friends come to terms with the passing of their loved one, and that this will have been an incredibly difficult time for them.

In section 5 of your letter, you raised concerns in relation to the care provided to Mr Dawes- Clarke namely:

(1) Despite the severity of the incident which occurred in this case, there had been little (if any) dialogue between leaders of the various parties involved. Formal complaint processes, safeguarding processes and risk reporting mechanisms had been used, but there was no discussion about how to learn from this specific case or how to avoid a reoccurrence. During prevention of future death evidence, responses were inconsistent as to how to avoid other difficulties during a major medical emergency in a prison setting. One suggestion made was that paramedics may not enter custodial settings in future but it was unclear how prison healthcare could replicate the skills had by the ambulance service (in particular, in the use of intraosseous access during initial resuscitation, or the skill sets of a critical care Private & Confidential

HM Senior Coroner Mid Kent and Medway Mid Kent and Medway Coroners’ Service Oakwood House Oakwood Park Maidstone Kent ME16 8AE

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paramedic or an advance trauma team which may be delivered by a helicopter emergency medical service).

(2) Despite the severity of the incident which occurred in this case, it appeared that there still remains confusion as to which public body would have primacy in an acute medical emergency in a custodial setting.

Following the inquest, senior leaders from Oxleas NHS Foundation Trust have considered these helpful observations and have responded to each of your concerns as follows:

(1) Despite the severity of the incident which occurred in this case, there had been little (if any) dialogue between leaders of the various parties involved. Formal complaint processes, safeguarding processes and risk reporting mechanisms had been used, but there was no discussion about how to learn from this specific case or how to avoid a reoccurrence. During prevention of future death evidence, responses were inconsistent as to how to avoid other difficulties during a major medical emergency in a prison setting. One suggestion made was that paramedics may not enter custodial settings in future but it was unclear how prison healthcare could replicate the skills had by the ambulance service (in particular, in the use of intraosseous access during initial resuscitation, or the skill sets of a critical care paramedic or an advance trauma team which may be delivered by a helicopter emergency medical service).

The concerns regarding dialogue and partnership working have been addressed. Since 2024, Oxleas, SECAmbs, and HMPPS have established a regular partnership meeting, bringing together leaders from agencies across Medway and Swale on a quarterly basis. The primary objectives of this collaboration are to review joint learning opportunities, share training resources, assess the impact of community NHS resources within the prison environment, and coordinate efforts to prepare for potential major incidents. The suggestion that prison healthcare staff could undertake the role of the ambulance service was not supported as this model is not in line with national commissioning policy however the underlying concerns regarding difficulties related to medical emergencies has been central to the partnership working and collaboration that has taken place.

As part of this collaboration, bronze, silver, and gold command training is being incorporated into the Oxleas service and is currently in the process of being sourced appropriately. Additionally, a memorandum of understanding is being jointly drafted by HMPPS, Kent Fire and Rescue, Oxleas, and SECAmbs to outline each agency's responsibilities and to facilitate coordinated joint working during major incidents.

A student paramedic placement has been initiated, with SECAmb seconded student paramedics spending one day at Sheppey prisons to become familiar with the environment. Insights shared during partnership meetings indicated that SECAmb personnel often find the prison setting challenging. Paramedic recruitment is ongoing at HMP Swaleside, and the initial one-day placement will be developed into comprehensive placements for student paramedics.

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(2) Despite the severity of the incident which occurred in this case, it appeared that there still remains confusion as to which public body would have primacy in an acute medical emergency in a custodial setting.

It is recognised that in this very sad incident there may have been confusion regarding primacy in a medical emergency. This incident pre-dates Oxleas NHS Foundation Trust’s delivery of healthcare services at HMP Elmley. The Trust is clear that, as the primary healthcare provider at HMP Elmley, Oxleas NHS Foundation Trust retains responsibility for the care and treatment of prisoners until their departure from custody, regardless of whether this occurs via ambulance or other means, including primacy in an acute medical emergency. There is an inpatient healthcare team at HMP Elmley and staff attend and lead healthcare emergencies as normal practice. Where paramedic support is required, our staff work with paramedics to ensure that their skills are deployed in partnership with the Oxleas staff during the incident.

To promote comprehensive understanding of policies, a new Practice Development Nurse (PDN) joined our team in September 2024 to ensure that all healthcare staff remain current with relevant training and guidance.

The Quality Manager has recently conducted a comprehensive review of all policies, ensured they are updated to the latest versions, and communicated their locations to all staff members. The Practice Development Nurse (PDN) is responsible for ensuring that the healthcare team is informed about all relevant policies, comprehends their content and significance, and that these policies are consistently shared and discussed during teaching sessions, handovers, and supervision meetings. Training records will be maintained as evidence of compliance and understanding.

I hope that this letter reassures you that Oxleas has been highly attentive to the findings of your investigation, and that concerted remedial action has been taken on all the areas you identified to prevent any similar future deaths.

Please do not hesitate to contact me if any clarification or further assurance is required.

Dear Mr Brownhill

Re: Regulation 28 Report to Prevent Future Deaths – Azroy Dawes-Clark who died on 10 November 2021

I write in response to your Report to Prevent Future Deaths (hereafter ‘report’) dated 29 July 2025 concerning the death of Azroy Dawes-Clark on 10 November 2021. In advance of responding to the concerns raised in your report, I would like to express my deep condolences to Azroy’s family and loved ones. SECAmb are keen to assure the family and the coroner that the concerns raised about Mr Dawes-Clark’s care have been listened to and reflected upon.

I note that the report includes HMP Elmley and Oxleas NHS Foundation Trust and that the concerns relate to a failure on all parts to communicate effectively, inconsistent responses from all providers at the inquest on how to prevent an incident such as this occurring again and the ongoing confusion as to which public body would have primacy in an acute medical emergency in a custodial setting. It is also acknowledged and accepted that it was inappropriate for the paramedics who attended Mr Dawes-Clark to approve for prison officers to handcuff him.

For the sake of clarity, primacy of care within a prison environment rests with commissioned prison healthcare services as each prison will have its own safe systems of work and identified procedures for the provision of emergency care. Ambulance Service staff responding to emergencies within a prison will work in liaison and in conjunction with healthcare leads from that facility in line with their scope of practice and in accordance with SECAmb policies and procedures and will assume responsibility for patient care at the point of handover and departure from that facility. This is particularly important as prison healthcare staff will undertake a lead role in risk assessment processes undertaken in facilities prior to transportation. Primacy of care residing with prison healthcare does not, of course, limit the level of care the Ambulance Service is able to provide in the context of an emergency.

At the time of Mr Dawes-Clark’s death, three internal incident reports were completed on the Trust Incident Reporting system, one in relation to equipment failure by the attending crew, one in relation to dispatch and the delay in this due to

communication issues completed by control room staff and the third related to the care provided by prison healthcare raised by the critical care paramedic who attended the scene.

All the incidents were reviewed by the Trust’s Serious Incident Group (SIG) on the 24 November 2021 which at the time, followed the national Serious Incident Framework. A review of all information did not indicate that any acts or omissions of care from SECAmb contributed to serious harm or death in this case, which was, at the time, the determining factor on whether a serious incident investigation should be commissioned or not. The level of harm concluded by SIG on review of all information was low harm. As such, the individual issues relating to the code blue, equipment failure and staff behaviours were individually investigated.

Separately, a complaint was also received on 15 November 2021 from the prison deputy governor expressing concerns regarding crew behaviour and professionalism, particularly in terms of their actions relating to the recognition of the deteriorating condition of Mr Dawes-Clark, as well as an equipment issue. This was fully investigated by an Operational Manager and a response was provided on 21 December 2021. The outcome of the complaint was partially upheld due to the issue with the equipment, but the level of harm was recorded as none.

In January 2024, the Trust, in line with national guidance, moved from the Serious Incident framework to use of the Patient Safety Incident Response Framework (PSIRF). The shift to PSIRF has driven quite a significant change in how patient safety incidents are categorised and managed. There has been a shift to a learning focused approach, understanding how incidents happen and learning from them whilst engaging with those directly affected rather than simply a focus on the level of harm.

The Trust has identified an opportunity to improve triangulation between complaints and patient safety incidents reported. The Trust is in the process of implementing organisational change to restructure teams aligned to a divisional model aligned to five divisions including Kent, Surrey, Sussex, Integrated Care, and Resilience & Specialist Operations (which includes the Hazardous Area Response Team, Special Operations Response Teams and the emergency preparedness, resilience and response team). Currently the Trust operates centrally, and we know that neighbourhood, place-based care is widely advocated to deliver efficient, equitable and person-centred care. The aim of the Trust is to operate through clinical service divisions that enable closer working with key partners in each of the integrated care systems and devolve leadership and responsibility to colleagues working closer to the front line. The restructuring of teams aligned to this approach will allow for more effective triangulation of information from incidents, complaints and compliments supporting learning and continuous improvement. Additionally, previously centralised teams such as Patient Safety, Incident and PALS teams will be enabled to integrate with local clinical and operational teams, sharing information, learning and advocating for quality to be at the centre of everything we do. This will support delivery of a whole quality management system (QMS).

In April 2025, the Trust completed a review of the use of code red/ code blue terminology. In 2013 and again in September 2021, the Ministry of Justice published a Standard Operating Procedure (SOP) highlighting the use of Code Red/ Blue within the prison setting. The SOP identified that the internal terminology used within a prison to request medical assistance from 999 (code red/ blue) was not appropriate for use outside of the prison service and declared that this should cease being used.

However, there is evidence that this terminology continues to be used by prisons when calling 999 within the SECAmb area. In July 2024, HSSIB conducted their own investigation regarding the Healthcare Provision in Prisons across the UK. The investigation focused on access to 999 emergency services and ambulance responses, whereby it concluded that security restrictions and the prison environment complicated emergency care, which in turn, impacted on patient health outcomes. The report concluded that the use of code blue and code red calls in prisons, while intended to ensure timely and effective responses to medical emergencies, had several issues and should not be utilised.

The Trust recognised the challenge in implementing this change and added this as a risk on the Trust risk register. A meeting was held on 3 April 2025 with key stakeholders, and it was agreed that the Trust would communicate with prisons a six- month grace period, after which the terminology would not be utilised. The Trust Emergency Preparedness, Resilience and Response (EPRR) team has held discussions about this with all prisons within SECAmb’s geographical footprint as part of the development of ‘Site Specific Plans’, which articulate the specific approach and challenges to operating in specific locations and environments around the Trust geography.

Further, a letter was sent from SECAmb’s Chief Nursing Officer to the Ministry of Justice, local prison Governors and identified contacts in the local Health & Justice commissioning team to advise them of the proposed plan that after six months, SECAmb will no longer recognise the code red/ code blue terminology.

The Trust provide training on multiagency response in relation to major incidents as part of our annual statutory mandatory training. These are largely based on the JESIP (Joint Emergency Services Interoperability Principles) principles which are Co-locate, Communicate, Co-ordinate, Jointly Understand Risk, and Shared Situational Awareness. These principles aim to improve the way emergency services work together during major incidents.

Whilst this incident was not deemed to be a major incident, when multiple agencies are involved in a situation, for effective co-ordination, one agency generally needs to take a lead role. To decide who the lead agency should be, factors such as the phase of the incident, the need for specialist capabilities and investigation, during both the response and recovery phases should be considered. There is specific guidance for some types of incidents, highlighting which agency should take the lead role. The decision on who takes the lead role should be documented and the lead agency may change as the incident develops. However, as noted within the report, this was not explicit within this incident and confusion remained as to which organisation takes primacy. Ensuring clarity around primacy of care in the context of

patients within secure settings like a prison is a key action for the Trust, both in terms of engaging with prison healthcare providers and ensuring that our staff understand where primacy sits.

Following Mr Dawes-Clark’s inquest, the Trust’s Head of Resilience has liaised with JESIP regarding this incident and been advised that they are preparing to release a Joint Organisational Learning (JOL) report related to a different recent prison incident (not within our region). While JESIP has limited engagement with the prison sector and the JESIP principles are not yet deeply embedded within prison operations. JESIP has committed to address the matter of primacy when developing further national guidance around working with prisons as part of a multi-agency response.

To support this work and increase understanding of each other’s roles with an aim of improving integrated working, the Trust has undertaken several actions alongside the prisons within the Sheppey cluster (HMP Elmley, HMP Swaleside and HMP Stanford Hill). Specifically, SECAmb staff provided training to 7 Prison Nurses who supply a first response in the prisons in October 2024. Each participant obtained the Future Quals Level 3 Award for First Responders On scene: Ambulance Service Community First Responder qualification.

This development was initially a proof of concept for prison healthcare staff to complete the SECAmb Community First Responder (CFR) training to improve their knowledge regarding the first person on scene. This is now continuing through the prison organising private First Response Emergency Care (FREC) training.

We feel this endeavour builds on the HSSIB recommendation made in relation to prison officers receiving first aid at work training, which was a commitment made by HM Prison and Probation Service on the 3rd of December, 2024.

More widely, SECAmb have invited prison colleagues to observe ambulance shifts and in return, local SECAmb staff have been invited by the prisons in the Sheppey cluster to complete shadow shifts within the prison. Further, tours of all prison sites have been completed by the local leadership team except for Swaleside which is in the process of being arranged.

Importantly, the SECAmb Resilience Team have now completed the development of Site Specific Response Plans (SSRP) for all prison sites within our region, which has included discussion around the use of ‘Code Red and Code Blue’ terminology. These SSRPs provide a predefined attendance protocol for complex prison incidents, including the deployment of a structured command presence at the scene. They are accessible to both the Emergency Operations Centre (EOC) and frontline crews, and offer pre-agreed access, egress, and rendezvous point (RVP) information, along with site-specific risk details that must be considered to ensure a coordinated and informed response to these challenging locations. More broadly, a memorandum of understanding (MOU) is being written between SECAmb, HMP Elmley and Oxleas to articulate roles and responsibilities when attending prisons incidents. The first draft of this has been shared with SECAmb and comments are currently being prepared to return to Oxleas who are the lead authors of this document. It expected that the

document will be finalised and ratified in Q4 of 2025/26.

Practically, training around a system of triage known as ‘Ten Second Triage’ has been delivered by the local Operations team for all three prisons. The sessions have been attended by HMP and Oxleas colleagues and provided a general introduction to the NHS England Ten Second Triage Tool and how SECAmb would respond to a major incident within secure estate. This training was completed on 18 August 2025.

Regionally, the SECAmb Medway Operating Unit Leadership team meet with the prison’s healthcare team and governors every quarter and review any incidents or escalations with a view to learning and improving. Building on this, the Medway operating unit team have been invited to CPD events at the prison, and they have offered to provide restraint continuing professional development for the Trust following Azroy’s inquest which will be explored in relation to ongoing education and development programs for SECAmb staff. At an organisational level, a new section has been added to SECAmb’s Incident Response Plan which provides a comprehensive command-and-control framework for responding to incidents within HM Prison establishments.

The national United Kingdon Ambulance Services EPRR Delivery Group have also updated the national HM Prison Response Framework in April 2025. This provides strategic and operational guidance for all UK NHS Ambulance Services responding to incidents in HM Prisons and Immigration Removal Centres.

It complements and reinforces the SECAmb Incident Response Plan update by:

• Standardising response expectations across Trusts, including clinical care, major incident planning, and staff welfare.
• Clarifying multi-agency coordination, especially during high-risk events such as riots, hostage situations, or infectious disease outbreaks.
• Outlining operational safeguards, including escort protocols, control and restraint procedures, and the use of electronic patient records under central authorisation.
• Providing national consistency while allowing for local adaptation based on prison profiles and Trust capabilities.

These changes are reflected in the Site Specific Plans for prisons as well as associated guidance and support resources for leaders, tactical advisors, and others involved in prison incidents.

SECAmb recognises the need to ensure a coordinated approach to all the work that is happening across the Trust in relation to prisons and a task and finish group has been commissioned. An initial meeting took place on 30 July 2025. The ambition is to develop an organisation wide approach recognising appropriate place-based variation, avoid duplication and ensure any gaps are mitigated from a patient safety and care perspective. In addition, this group will seek to identify points of practice requiring further focus in terms of human factors considerations, to ensure staff of all clinical grades are confident in operating within the secure context and in conjunction with other professionals and advocating for patients’ clinical needs effectively.

A final draft of the Surrey Safeguarding Adults Board Care of Prisoners into Acute Hospitals; A Guidance Pathway to Aid a Safe Admission and Discharge dated 3 July 2025 has been shared with SECAmb and Surrey Heartlands ICB have offered to share their learning from this piece of work with SECAmb and contribute to the task and finish group.

In conclusion, there is a significant amount of work that has taken place to improve how we respond to and provide care in prisons and other secure locations and in conjunction with partner organisations providing care at those sites. Equally, we recognise that there is more to do and SECAmb is committed to continuing this work via the task and finish group leading on a co-ordinated Trust wide approach.

If I can be of any further assistance, please do not hesitate to contact me.

Dear Mr. Brownhill,

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS: MR AZROY DAWES- CLARKE

Thank you for your Regulation 28 report of 29 July 2025, addressed to The Secretary of State for Justice and The Secretary of State for Health and Social Care. I am responding as the Interim Director General of Operations for HMPPS.

As with my earlier responses to the other PFDs you issued following this inquest, I know that you will share a copy of this reply with Mr. Dawes-Clarke’s family and again would like to express my condolences for their loss. Every death in custody is a tragedy and the safety of those in our care is my absolute priority.

You have raised a concern about the management of the medical emergencies in prison, including how roles and responsibilities are understood.

It is essential that all staff understand their responsibilities when responding to a medical emergency, including actions relating to resuscitation, the use of restraints, and the removal of ligatures. Local procedures are in place at HMP Elmley to support a coordinated and effective response, and staff have been directed to adhere to these consistently.

HMPPS policy on responding to medical emergencies is set out in Prison Service Instruction 03/2013. Operational staff are responsible for ensuring that appropriate medical support is summoned promptly – whether from on‑site healthcare services or the ambulance service – and for enabling healthcare professionals to access and treat the individual without delay. While prison staff will often be the first on scene, they are not expected to lead medical interventions beyond the scope of first aid or CPR where healthcare professionals or paramedics are present. Their role is to support, facilitate, and assist clinical staff as required.

I am aware that NHS England Health & Justice have issued a Use of Force (UoF) Framework which outlines and provides clarity on roles and responsibilities for healthcare staff where there is planned or unplanned use of force. This includes the requirement that healthcare attend all general alarms when on site and remain in

attendance if a UoF incident is ongoing. To continually monitor the patient throughout the UoF incident and intervene where necessary for any immediate health concerns. The NHS England Health & Justice guidance has been shared with UoF Coordinators across all prisons and will be included in the new HMPPS framework and guidance, which is due to be reviewed and published at the end of the year.

At HMP Elmley, staff have been formally reminded of their obligation to request healthcare assistance immediately during any unplanned restraint, in line with local and national procedures. Similarly, Oxleas staff have been reminded of their contractual requirement to remain with the individual throughout the medical emergency until paramedics have assumed responsibility and the prisoner has been taken to hospital.

Thank you again for bringing your concerns to my attention. I trust that this response provides assurance that action is being taken to address the issues identified.