Azroy Dawes-Clarke

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

Ian Brownhill, Assistant Coroner for Kent, and Medway 
Kent and Medway Coroners' Service 
Oakwood House 
Oakwood Park 
Maidstone 
Kent 
ME16 8AE 

9 February 2026 

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. 

Yours sincerely, 

Interim Director General of Operations

Pinewood House  
Pinewood Place 
Dartford 
Kent  
DA2 7WG 

Private & Confidential 

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

18th September 2025 

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 

1 

 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 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.  

2 

 
 
 
 
 
 
 
 
 (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. 

Yours sincerely, 

Chief Executive Officer 

CC: 

Chief Operation Officer, 
Chief Nursing Officer, 

3

19 September 2025 

Mr Ian Brownhill   
HM Assistant Coroner for Kent and Medway  

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.  

Yours faithfully,  

Chief Executive  

 
 
  
  
 
 
 
 
 
 Summary of Actions and Improvement Plans: 

Anticipated 
Delivery Date  
To be reviewed 
Quarter 2 
(2026/7)  

December, 
2025  

Governance / 
Assurance  
To report 
progress via 
Clinical Quality 
Governance 
Group 

Task and Finish 
Group 
reporting.   

Progress to 
Date  
An initial 
meeting took 
place on 30 July 
2025 with 
further 
discussion on 
the 9th of 
September.  

Site Specific 
Response Plans 
(SSRPs) 
complete for all 
prisons within 
Kent, Surrey & 
Sussex, 
including 
engagement 
around code 
blue/red and 
best practice.   

Each SSRP has 
been reviewed 
in 2025.  

December, 
2025  

Meeting 
minutes, update 
to Task and 
Finish Group 
Reporting.  

Action  

Owner  

Divisional 
Director of 
Resilience and 
Specialist 
Operations 
(Senior 
Responsible 
Officer)  

Divisional 
Resilience 
Managers  

Establish the 
SECAmb ‘Prisons’ 
Task and Finish 
Group to provide a 
coordinated 
approach to the 
work taking place 
across the Trust in 
relation to 
prisons.   
Communicate 
with all Prison 
healthcare 
services to 
reiterate the move 
away from ‘Code 
Red/ Code Blue’ 
terminology.  

SECAmb Chief 
Paramedic (or 
deputy)  

Ensure clarity 
around primacy of 
care in the context 
of patients within 
secure settings. 
Specifically, 
arrange meeting 
with healthcare 
leads from prison 
healthcare 
providers and 
discuss in context 
of MOU drafting 
(as below).   

 
 
  
  
  
  
 Head of 
Education  

SECAmb to 
undertake 
learning needs 
analysis re 
ensuring that staff 
are confident with 
the implications of 
restraint.  

For 2026/7 
education cycle  

SECAmb 
learning 
syllabus.  

Patient 
advocacy a 
central aspect 
of transition to 
practice, 
safeguarding, 
and key skills 
education.   

December, 
2025  

Task and Finish 
Group Reporting  

Head of 
Safeguarding  

Surrey 
Safeguarding 
Adults Board Care 
of Prisoners into 
Acute Hospitals; A 
Guidance 
Pathway to Aid a 
Safe Admission 
and Discharge 
dated 3 July 2025 
to be reviewed 
within Task and 
Finish Group   

Surrey Heartlands 
ICB  learning from 
this work to be 
shared with 
SECAmb for 
inclusion at the 
task and finish 
group.