Dear Ms Brown Regulation 28 Report following the inquest into the death of Mr Ahmedreza Fathi on 13 May 2015 at HMP Gartree Thank you for your Regulation 28 report of 5 May addressed to the Governor of HMP Gartree and the East Midlands Ambulance Service NHS Trust, concerning the recent inquest into the death of Mr Ahmedreza Fathi. Your report has been passed to Equality, Rights and Decency (ERD) Group in NOMS, as we are responsible for sharing learning from deaths in custody. This response has been prepared in consultation with the Governor of HMP Gartree. In your report you repeat the concern that you, the Coroner and the PPO have raised following previous deaths in prisons in the Leicester area about delays by prison staff in calling for an ambulance. You point out that the East Midlands Ambulance Service NHS Trust (EMAS) had advised the court that discussion of a prison emergency response protocol would be welcomed and encourage the prison and EMAS to arrange a meeting to take this forward. You will be aware that PSI 03/2013 Medical Emergency Response Codes sets out the national instruction for calling a medical emergency over the establishment radio network in all prisons and NOMS-operated Immigration Removal Centres HMP Gartree has revised the local contingency plans and re-issued instructions in May 2016 to ensure that all staff understand that they must not delay calling an ambulance in all cases where there are serious concerns about the health of an offender. The local protocols now provide clear guidance to all staff to ensure timely, appropriate and effective responses to medical emergencies In addition HMP Gartree and other prisons in the Leicester area are collaborating with the EMAS to ensure effective Joint working and consistency of approach in all the prisons. Representatives of the prison met with EMAS in April 2016, and there is an expectation that a joint emergency response protocol will be in place by 31 July 2016 Thank you for bringing these matters of concern to our attention. I hope that this letter has been helpful in providing some national context and in giving you assurance that the concerns that you have raised have been, or are being, addressed locally at HMP Gartree and in the other prisons in the Leicester area.

~~GR~~~~~ East Midlands Ambulance Service '' "~ _, %,$r~ Emergency Care ~ Urgent Care (1Ne Care Trust Headquarters 1 Horizon Place Mellors Way Nottingham Business Park Nottingham NG8 6PY Telephone: 0115 884 5000 Fax: 0115 884 5001 Website: www.emas.nhs.uk Our ref: 25 July 2016 Mrs Lydia Brown HM Assistant Coroner. Leicester City and Leicestershire South The Coroner's Court Town Hall Town Hall Square Leicester LE1 9BG I~Z~Tii11
• . ~ Re: Report to Prevent Future Deaths: Ahmedreza Fathi (DECEASED) Thank you for your Regulation 28 Report to Prevent Future Deaths, dated 11 May 2016, bringing to my attention HM Coroner's concerns arising from the Inquest into the death of Ahmedreza Fathi. I would like to re-emphasise our apologies for the failure to respond to the original Regulation 28 Report. An initial investigation has not found evidence of receipt of this report, however our management of Coronial processes is under review to ensure stronger and more robust handling of all cases to avoid such events in the future. would like to reassure you that within the East Midlands Ambulance Service (EMAS) all matters related to patient safety are taken extremely seriously. In particular, any matters arising from Coroner's Inquests from which lessons can be learnt, and this includes any Prevention of Future Deaths notices, are discussed within the Coroners Working Group. The Coroners Working Group, having considered all the relevant issues of concern relating to the particular Inquest at hand, will then develop an appropriate action plan with specified timelines for each action, together with identified individuals to deliver the actions specified. This process has been applied to the Prevention of Future Deaths notice (PFD notice) pertaining to the Inquest into the death of Ahmedreza Fathi.

d~, _- 4a, ~ ~ Y. r =~ ~~, East Midlands Ambulance Service ~ ~` ~;_:- ~~::~'~ ~lHs Trust Emergency Care ~ Urgent Care (1Ne Care The MATTERS OF CONCERN are as follows:
• On previous occasions following deaths in prison locally in Leicester, the Coroner and the PPO have raised concerns regarding delays in requesting 999 emergency assistance. On the night of 12 May 2015 there was a delay in summonsing an ambulance, in breach of PSI 03/13 and the prisons own internal policy. The then serving Head of Safety advised the Court that she "dealt with this problem a lot". There appeared to be a perception from gatehouse staff that calls had to be delayed until further information could be obtained from those officers at the scene.
• EMAS advised the court that 3 protocols already exist between other stakeholders and discussions to consider aprison/emergency response protocol would be welcomed and could be accommodated. I therefore encourage both the prison and EMAS to arrange a meeting to take this matter forward. set out below the actions EMAS has taken and our response to HM Coroner's concerns as detailed in the PFD notice. To address the specific issues identified in relation to Gartree Prison, alongside informing wider regional secure units, an initial meeting has been scheduled for Wednesday 3 August 2016. This meeting will be attended by the (Deputy Medical Director), (Consultant Paramedic Lead) from EMAS, and the Head of Operations .and Senior Operations Team from HMP Gartree. This meeting will aim to set an agenda to address access issues, ambulance activation protocols and partnership working principles. It is planned that this will be the first of a number of meetings and workshops to address the identified issues and available opportunities. EMAS has been proactively working with secure environment teams to develop working practices to create safe and efficient care delivery. This has been led by local management teams based upon locally identified needs. A key example of this working is the provision of SEND cards (Secondary Emergency Notification of Dispatch) for all secure environments for staff issue. These cards identify the core information required by the AMPDS triage system to appropriately triage patients and act as an aide memoire for front line police and public safety officials. In order to provide suitable oversight, leadership and empowerment to change, EMAS has now formed a senior regional group to address issues relating to secure environments such as prisons and secure mental health units etc. This centralised approach will enable a consistent and informed approach to this complex area of healthcare provision. This group has membership of senior team members from the Operations Directorate, Medical Directorate, Emergency Planning and Resilience Directorate and Emergency Operations Centre.

„V iil ~4~a~~~ East Midlands Ambulance Service ~~ .'m ~.z~,~~ `~'-~:'~~~ tVNs Trust Emergency Care ~ Urgent Care (We Care hope that you agree that EMAS have taken initial steps to ensure that the provision of high quality emergency care for secure environments working alongside partner agencies. I can assure you that we are taking the actions identified with a view to ensuring that similar tragic events can be avoided wherever possible in the future and that lessons are learnt. Please do not hesitate to contact me should you require any additional information, or any clarification, in connection with the above.