George Emmett
PFD Report
Partially Responded
Ref: 2025-0345
Coroner's Concerns (AI summary)
An HMPPS staff member lacked familiarity with emergency medical response policies, potentially compromising timely, life-saving actions for prisoners in critical health situations.
View full coroner's concerns
During the evidence in person of Operational Support Grade (OSG) , he discussed his actions at the time of and after first seeing George on the floor in his cell. He was taken to sections of the national HMPPS Medical Emergency Response Codes policy which include: 5.2: Local Procedures must ensure that staff understand they should not delay summoning emergency assistance. For example, it must not be a requirement for a member of the prison healthcare team or a Duty Manager to attend the scene before emergency services are called; 5.3 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; 5.4: A representative NHS Ambulance guide for use in the community states that an ambulance should be called when there are signs of chest pain, difficulty in breathing, unconsciousness, severe blood loss, severe burns or scalds, choking, fitting or concussion, severe allergic reactions or a suspected stroke. This must also be the case for prisoners and therefore, in these situations when the medical emergency is called over the radio network, an ambulance must be called immediately; Paragraph 5.7 indicates a number of minimum requirements for local protocols, including to inform staff that if they are in any doubt about the nature of the injury, they must call an ambulance. It is better to act with caution and request an ambulance that can be cancelled if it is later assessed as not required. The policy also describes the circumstances in which a "Code Blue" should be called including a prisoner who is unconscious. Evidence at the inquest demonstrated a Code Blue should be called over the radio from the cell location where a situation such as that in which George was found has arisen. The evidence of OSG did not appear to demonstrate familiarity with the processes set out in this policy at the time of George's death, nor any greater familiarity during evidence given, some two years after George's death. It is understood OSG holds a similar role at HMP Woodhill. There is a continuing concern that optimum reaction to an emergency situation involving the health of a prisoner may be compromised if OSG were to react in a manner which was not in accordance with any local protocols reflective of this HMPPS Medical Emergency Response Codes policy. The circumstances anticipated by this policy include situations where a prisoner's death may be prevented with appropriate application of an emergency response.
Responses
Action Taken
HMP Aylesbury is reissuing Governor's Notices, providing staff briefings, issuing prompt cards, and using a colleague mentor program to reinforce emergency response protocols; HMP Woodhill provided one-to-one briefings, introduced a sign-off sheet for night OSGs, and issued a staff information notice to remind staff of medical emergency procedures and national guidance. (AI summary)
HMP Aylesbury is reissuing Governor's Notices, providing staff briefings, issuing prompt cards, and using a colleague mentor program to reinforce emergency response protocols; HMP Woodhill provided one-to-one briefings, introduced a sign-off sheet for night OSGs, and issued a staff information notice to remind staff of medical emergency procedures and national guidance. (AI summary)
View full response
Dear Mr Butler,
Thank you for your Regulation 28 report of 4 July 2025 following the inquest into the death of George Emmett at HMP Aylesbury on 25 May 2023. I am responding on behalf of His Majesty’s Prison and Probation Service (HMPPS) as the Director General of Operations.
I know that you will share a copy of this response with Mr Emmett’s family, and I would first 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 expressed concerns regarding staff awareness of emergency response procedures.
HMP Aylesbury
HMP Aylesbury continue to take steps to ensure that staff can confidently take effective action in the event of a medical emergency and in particular in the calling of emergency codes. A Governor’s Notice is reissued every six months reminding staff of the emergency response protocols to embed this awareness as much as possible. Additionally, full staff briefings are regularly used to reinforce procedures.
Staff have also been issued with quick reference Code Red/Code Blue prompt cards which can be carried on the person and act as an immediately accessible reminder of the circumstances in which a Code Red or Code Blue should be called. This information is also provided on posters as an additional visual aid.
The prison has a colleague mentor programme whereby newly trained officers are assigned a mentor to provide support, advice and guidance throughout their initial training and full probation period. An induction ‘passport’ is used to provide assurance that the individual is competent in their role before they become fully operational. The mentors play an active role in training and testing new staff, this includes the use of radios and emergency
response procedures. The importance of calling response codes has also been incorporated into the local radio communication training.
HMP Woodhill
HMP Woodhill have advised me that the Operational Support Grade (OSG) who you reference in your report has now received one-to-one briefing on night procedures and the Local Security Strategy. As a further training aid and audit tool, a sign-off sheet was introduced whereby all routine expectations of a night OSG had been listed, such as the use of the radio and the use of emergency codes, the expectation being that this record be discussed by the OSG and the Night Orderly Officer and signed to confirm understanding. The support of the establishment care team has also been offered to the OSG.
On 20 June 2025 a staff information notice was issued to all HMP Woodhill staff reminding them of the policy around medical emergency response procedures and the national guidance on the appropriate use of calling a Code Red or Code Blue during an emergency. Additionally, the establishment have also issued take-along, quick reference, Code Red/Code Blue prompt cards to staff, and control room staff have been reminded of the importance of following the national protocol for calling emergency services for all incidents where a Code Red or Code Blue has been called.
Furthermore, a full briefing is given to night staff when starting their shift, and night operating procedures regarding patrolling during night state and the welfare of prisoners is routinely discussed. Should the need for further training of individuals be identified then upskilling sessions will be provided.
I hope the measures outlined above provide you with reassurance that appropriate action has been taken to address the issues identified in your report arising from Mr Emmett’s death.
Thank you for your Regulation 28 report of 4 July 2025 following the inquest into the death of George Emmett at HMP Aylesbury on 25 May 2023. I am responding on behalf of His Majesty’s Prison and Probation Service (HMPPS) as the Director General of Operations.
I know that you will share a copy of this response with Mr Emmett’s family, and I would first 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 expressed concerns regarding staff awareness of emergency response procedures.
HMP Aylesbury
HMP Aylesbury continue to take steps to ensure that staff can confidently take effective action in the event of a medical emergency and in particular in the calling of emergency codes. A Governor’s Notice is reissued every six months reminding staff of the emergency response protocols to embed this awareness as much as possible. Additionally, full staff briefings are regularly used to reinforce procedures.
Staff have also been issued with quick reference Code Red/Code Blue prompt cards which can be carried on the person and act as an immediately accessible reminder of the circumstances in which a Code Red or Code Blue should be called. This information is also provided on posters as an additional visual aid.
The prison has a colleague mentor programme whereby newly trained officers are assigned a mentor to provide support, advice and guidance throughout their initial training and full probation period. An induction ‘passport’ is used to provide assurance that the individual is competent in their role before they become fully operational. The mentors play an active role in training and testing new staff, this includes the use of radios and emergency
response procedures. The importance of calling response codes has also been incorporated into the local radio communication training.
HMP Woodhill
HMP Woodhill have advised me that the Operational Support Grade (OSG) who you reference in your report has now received one-to-one briefing on night procedures and the Local Security Strategy. As a further training aid and audit tool, a sign-off sheet was introduced whereby all routine expectations of a night OSG had been listed, such as the use of the radio and the use of emergency codes, the expectation being that this record be discussed by the OSG and the Night Orderly Officer and signed to confirm understanding. The support of the establishment care team has also been offered to the OSG.
On 20 June 2025 a staff information notice was issued to all HMP Woodhill staff reminding them of the policy around medical emergency response procedures and the national guidance on the appropriate use of calling a Code Red or Code Blue during an emergency. Additionally, the establishment have also issued take-along, quick reference, Code Red/Code Blue prompt cards to staff, and control room staff have been reminded of the importance of following the national protocol for calling emergency services for all incidents where a Code Red or Code Blue has been called.
Furthermore, a full briefing is given to night staff when starting their shift, and night operating procedures regarding patrolling during night state and the welfare of prisoners is routinely discussed. Should the need for further training of individuals be identified then upskilling sessions will be provided.
I hope the measures outlined above provide you with reassurance that appropriate action has been taken to address the issues identified in your report arising from Mr Emmett’s death.
Sent To
- HM Prison & Probation Service
- HMP Woodhill
- Ministry of Justice
Response Status
Linked responses
1 of 3
56-Day Deadline
2 Sep 2025
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 06 June 2023 I commenced an investigation into the death of George EMMETT aged 25. The investigation concluded at the end of the inquest on 26 June 2025. The conclusion of the inquest was that recorded by the jury was that George's death was drug-related. The Medical Cause of Death Was: 1a) Toxic Effects of Synthetic Cannabinoid II) Coronary Artery Atheroma
Circumstances of the Death
The jury recorded in relation to when, where, how and in what circumstances George came by his death: Mr George Emmett died after taking synthetic cannabinoid in G-Wing at HMP Aylesbury on 25th May 2023. The death was verified by attending paramedics at 21.38 on that day. On 25th May 2023, George was last observed alive in his cell at 18.17. There was a 12 minute period between being observed unresponsive at 20.34 on the floor of his cell and unlocking his cell at 20.46, after which resuscitation attempts followed, and an ambulance was dispatched at 20.48 Paragraphs 5.2 and 5.3 of the applicable Medical Emergency Response Codes, which relate to the summoning of emergency assistance, were only acted upon at 20.47. Due to the ongoing effects of synthetic cannabinoid, it is not possible to ascertain the optimal time at which CPR would have been successful. Therefore, there is insufficient evidence that this lapse of time contributed to George's death.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.