Wayne Bayley

OFFICIAL

Director General Operations 
HM Prison and Probation Service 
8th Floor Ministry of Justice 
102 Petty France 
London  
SW1H 9AJ 

3 February 2025 

Coroner ME Hassell  
Senior Coroner Inner North London  
St Pancras Coroner’s Court  
Camley Street  
London  
N1C 4PP 

Dear Ms Hassell, 

Thank you for your Regulation 28 report of 31 October 2024, addressed to the Minister of 
State for Prisons, Probation and Reducing Reoffending, following the inquest into the death 
of Wayne Anthony Bayley who died at HMP Pentonville on 17 May 2022. I am responding 
as Director General of Operations for His Majesty’s Prison and Probation Service (HMPPS). 
I am grateful to you for granting an extension for our response. 

I know that you will share a copy of this response with Mr Bayley’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. 

Following evidence heard at the inquest, you have sought reassurance that important 
learning and positive action which has taken locally at HMP Pentonville following Mr 
Bayley’s death be shared more widely across the prison estate.  

I would like to assure you that HMPPS’ approach to investigations following a death in 
custody is to ensure that all learning is identified and used to improve our practices across 
the prison estate. This includes working with healthcare partners whenever there is relevant 
multi-disciplinary action to be taken. I am aware that NHS England are responding to you 
separately, and I do not wish to duplicate their response, however, I can assure you of our 
commitment to working collaboratively with healthcare providers and NHS England to 
facilitate effective delivery of healthcare services. HMPPS is fully supportive of the work 
being led by NHS England to improve awareness of sickle cell disease and other long-term 
conditions amongst all staff working in prison settings and will continue to work alongside 
them to deliver improvements.   

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

Yours sincerely 

OFFICIAL

 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 OFFICIAL

    Director General Operations 

OFFICIAL

Ms M E Hassell 
HM Senior Coroner  
Inner North London  
St Pancras Coroners Court 
Camley Street London 
N1C 4PP 

Dear Coroner, 

National Medical Director  
NHS England  
Wellington House 
133-155 Waterloo Road  
London 
SE1 8UG 

18 December 2024  

Re: Regulation 28 Report to Prevent Future Deaths – Wayne Anthony Bayley 
who died on 17 May 2022  

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated  31 
October 2024 concerning the death of Wayne Anthony Bayley on 17 May 2022. In 
advance of responding to the specific concerns raised in your Report, I would like to 
express  my  deep condolences to Wayne’s family and loved ones. NHS England is 
keen to assure the family and the Coroner that the concerns raised about Wayne’s 
care have been listened to and reflected upon. 

I  note  you  reference  in  your  Report  the  extensive  work  that  has  already  been 
undertaken  by  Practice  Plus  Group  (PPG)  at  HMP  Pentonville  following  this  sad 
death, and I am reassured by this that lessons have been learnt.  

I am pleased to note the collaborative working between healthcare providers and the 
prison with a focus on assessment, treatment, and medication of all prisoners, from 
healthcare planning on arrival into prison, through control and restraint, and entering 
a  cell  in  an  emergency.  As  you  reference,  this  is  particularly  in  the  context  of 
underlying health conditions and includes (but is not limited to) ensuring staff have a 
proper understanding of the identification of and risks associated with an acute sickle 
cell crisis.  

Following  Wayne’s  death,  NHS  England’s  regional  Health  and  Justice  Team 
conducted  a  period  of  engagement  with  staff  and  prison  colleagues  (2023),  the 
findings from which resulted in liaison with the Sickle Cell Society who committed to 
providing training and development with prison staff across the London Health and 
Justice region, where there is a higher incidence of sickle cell.  

This will include three elements: 

1.  Training and upskilling of healthcare staff 
2.  Training and upskilling of prison staff 
3.  Patient engagement  

There will be an evaluation of this programme of training at the end of year one, but 
there is already a commitment to deliver the training for a period of three years. 

Additionally, NHS England’s regional Health and Justice team is working with NHS 

                                                                                                                       
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 England’s Regional Nursing Directorate in London to pilot the ‘ACT NOW’1 sickle cell 
acronym in HMP Pentonville, with a view to rolling this out across other prisons in the 
London region. The ‘ACT NOW’ approach by the NHS is about supporting better care 
for  patients  across  England,  by  encouraging  clinicians  to  ‘ACT  NOW’  whenever  a 
patient  attends  hospital  in  a  sickle  cell  crisis.  Co-developed  by  clinicians,  experts, 
people with sickle cell and their families, this approach supports a rapid and effective 
response to a sickle cell crisis in patients attending any hospital. 

In relation to the matter of concern you direct towards NHS England nationally, that 
it is unclear whether the work identified as having been undertaken by PPG and HMP 
Pentonville has been replicated nationally, with improvements and learnings shared, 
I respond to this below.  

NHS England is in the process of reviewing all current service specifications and I 
can  assure  you  that  the  learning  from  this  case  will  be  used  to  strengthen  this  in 
relation to requirements around assessment and management of not only sickle cell 
anaemia, but all long-term conditions.  

Additionally, a Health Needs Assessment (HNA) is undertaken annually in English 
prisons which reflects the diverse health needs of the population, including those with 
a long-term health condition, and informs local healthcare delivery plans.  

Finally, Wayne’s case will be presented to the Health and Justice Oversight Delivery 
Group (HJDOG) and shared with NHS England’s regional commissioners. The action 
taken by the London region will also be shared with the HJDOG. HJDOG is the senior 
leadership  forum,  which  holds  responsibility  for  the  oversight  of  delivery  and 
continuous improvement in Health and Justice commissioned services, through both 
the  national  and  regional  teams,  with  a  focus  on  improving  health  outcomes  and 
reducing variation across England. 

I  would  also  like  to  provide  further  assurances  on  the  national  NHS  England  work 
taking  place around  the  Reports  to  Prevent Future  Deaths.  All  reports  received  are 
discussed  by  the  Regulation  28  Working  Group,  comprising  Regional  Medical 
Directors,  and  other  clinical  and  quality  colleagues  from  across  the  regions.  This 
ensures  that  key  learnings  and  insights  around  events,  such  as  the  sad  death  of 
Wayne, are shared across the NHS at both a national and regional level and helps us 
to  pay  close  attention  to  any  emerging  trends  that  may  require  further  review  and 
action.   

Thank you for bringing these important patient safety issues to my attention and please 
do not hesitate to contact me should you need any further information.  

Yours sincerely,  

1 https://www.england.nhs.uk/london/a-c-t-n-o-w-sickle-cell-acronym-pilot/  

 
 
 
 
  
  
  
 
 National Medical Director