have sufficient concern about wider issues which warrant the writing of this Prevent Future Death Report (CJA 2009, Schedule 5, Paragraph 7; Regulation 28 Coroners (Investigations) Regulations 2013) to be sent more centrally _ This is: This inquest has raised two matters which would like to highlight to the Prison Service _ are not matters , in Mr 0'Meara's case, which were necessarily causative of the death, but they are live issues very relevant to the current challenging times Prison Officers are facing in busy and short-staffed prisons: Activation of Code Blue/Red The sad facts leading up to the death of John Kevin 0'MEARA have not been the first set of facts where have heard about a death where the activation of codes has not been immediate They am concerned that Prison Officers are not strictly following the Code Blue/Red system which is meaning there is a delay in the London Ambulance being called . Whilst can see in many cases that, by the time the prisoner has been found, there may be nothing that can be done to resuscitate them with the number of deaths happening relating to opiate use, the prompt administration of Naloxone is important to give the deceased the best chance; and this is only one resuscitative measure_ gather the current way that Officers are trained is by the use of Notices and Pocket-sized Cards. The Officer finding Mr 0 'Meara, even after questioning by myself and the Counsel for Interested Persons, left the witness stand still not understanding that by not immediately calling a Code Blue, and despite prison medical staff coming quickly , an ambulance would not have been called. Even presumably having reflected on the case, she did not appear to understand the reason why a Code is called am asking for more consideration to be given to ensure the right message is getting across and that Prison Officers understand the importance of and reasons for the use of the codes Passive Dog Use The Prison GP expert in this inquest was emphatic that Novel Psychoactive Substance played a part in the death. understand that these drugs can be brought into the prison in a number of ways and one is NPS contaminated paper or even childrens photographs, arriving into Prisons in the post: appreciate how challenging it is to control the use of Novel Psychoactive Substances in prisons So, the use of trained passive dogs is particularly helpful In fact it appears to be one of the only failsafe ways to controlling NPS use in prisons. There are only two at HMP Wormwood Scrubs whereas HMP Highdown has eight. Although dogs can be 'borrowed' from other London prisons when handlers are away_ wish to put on record my support for funding for more of these dogs at this current challenging time.