Jamie Funnell

Practice Plus Group 
Building 1330, 
Arlington Business Park, 
Theale, 
Reading, 
RG7 4SA 

practiceplusgroup.com 

Ms Rachel Redman 
H.M. Assistant Coroner for East Sussex Coroner’s Service 

27 November 2025 

Dear Madam, 

Regulation 28: Prevention of Future Deaths Report – Jamie Funnell 

I write in response to your Regulation 28 Prevention of Future Deaths Report issued to Practice 

Plus Group ("PPG") on 13 October 2025 following the inquest touching upon the death of Jamie 

Funnell at HMP Lewes. Practice Plus Group would like to express its sincere condolences to 

Jamie’s family and friends. 

This response addresses the matters of concern as it relates to Practice Plus Group. 

Matters of Concern:  

1.  The  Standard  Operating  Procedure  for  Assessment  and  Management  of  Alcohol 

Dependence  expired  in  March  2024.  I  heard  evidence  that  it  will  be  replaced  by  an 

updated Policy on 9.10.25. I asked for a copy of the draft Policy to determine whether 

issuing  a  PFD  could  be  avoided  when  hearing  evidence  about  PFD  matters  but  was 

advised by the PPG’s legal representative that this was not possible, without a reason 

why being offered. I consider that action should be taken to prevent a failure to update 

before their expiry all PPG’s Standard Operating Procedures including this one which 

the  Clinical  Reviewer  found  to  be  potentially  unclear.  His  findings  were  published  on 

19.4.24,  a  month  after  the  Standard  Operating  Procedure  had  expired,  and  yet  it 

continues to remain out of date, almost 18 months later. PPG could have reasonably 

expected it would be subject to scrutiny in this inquest and update it accordingly and in 

Practice Plus Group Health and Rehabilitation Services Ltd. Registered in England No 10498997 
Registered Office: Hawker House, 5-6 Napier Court, Napier Road, Reading, Berkshire RG1 8BW 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 a  timely  manner.  Their  failure  to  do  so  indicates  a  cavalier  attitude  to  reviewing  and 

updating important Policies and action should be taken to address this.  

2.  I heard evidence describing the care given to Jamie Funnell after his collapse as chaotic, 

with faulty equipment and incorrect CPR technique. The Ambulance crews witnessed 

the healthcare members carrying out CPR before taking over. After Jamie’s death was 

confirmed,  a  crew  member  raised  concerns  with  the  Duty  Governor  about  the  CPR 

attempts she had witnessed. I have heard evidence that although 32 eligible healthcare 

staff have now completed life support training, I have not heard any evidence regarding 

the level of this training and remain concerned, especially in light of the unsatisfactory 

response  by  PPG  in  its  Action  Plan  for  the  PPO  Report  dated  September  2024  that 

adequate training of staff and monitoring of equipment to prevent faults in its operation 

have been undertaken to prevent a fatality occurring in similar circumstances. 

Standard Operating Procedure for Assessment and Management of Alcohol Dependence 

Please  find  the  enclosed  clinical  guidance  document  for  ‘Assessment  and  Management  of 

Alcohol  Dependence’.  We  can  confirm  that  this  was  ratified  at  a  Governance  meeting  on  9 

October 2025.  

The enclosed document has turned the previous SOP into clinical guidance, allowing for a best 

practice benchmark and more patient centred care rather than the constraints of an SOP. The 

guidance has now been changed to become more user friendly for staff and breaks the guidance 

into  smaller  sections.  It  has  also  added  a  contents  page  to  help  staff  navigate  the  guidance 

documents more easily and makes reference to the SMS template hub, for capturing prescribing 

interventions, monitoring requirements and monitoring results. 

As well as the above, the guidance ensures clearer responsibilities regarding those patients that 

require  overnight  monitoring.  Previously,  the  policy  indicated  that  increased  face  to  face 

monitoring through the night with the cell door open would need to be considered for high-risk 

patients or those displaying signs of severe withdrawal. The new guidance document outlines 

that  if,  based  on  a  risk  assessment  of  the  individual,  the  prescriber  deems  that  additional 

monitoring through the night is required, they need to clearly outline the specific management 

plan in the notes (e.g. what monitoring is required (CIWA-Ar), how often that should take place, 

escalation plans and the indication for additional medication). The requirement to open the door 

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 for any additional assessments still stands. The requirement for a management plan ensures 

that measures to protect the welfare of the patient are documented so that all staff are clear 

about the expectations, allowing for greater continuity of care. 

The  revised  operating  procedure  acknowledges  that  since  moving  towards  integrated  care 

pathways, the EDiC (Early Days in Custody) team have a responsibility to consider whether the 

minimum  monitoring  requirements  (or  additional  monitoring  requirements  outlined  by  the 

prescriber) are appropriate at their daily MDT (Multi-Disciplinary Team meeting). In addition, the 

EDiC team is also required to consider whether any further action needs to be taken based on 

recent assessments. This provides an additional 'safety net' for new patients entering the prison 

to ensure the correct treatment regime is implemented without delay, a service which was not 

available when Mr Funnell arrived at HMP Lewes.   

An additional section is also included in respect of the location of patients and transfer. This 

highlights that patients in alcohol withdrawal should be in a safe area of the prison and should 

not be routinely transferred to another prison or attending court for the duration of their alcohol 

detox. 

A  section  on  omitted  doses  is  also  included to  highlight  that  diazepam  for  alcohol  detox  is  a 

critical medication and a single missed dose should be followed up with the patient. Pabrinex is 

also no longer available and has been amended to generic vitamin B&C IM injections. We also 

added in a link to the SPS (Specialist Pharmacy Service) guidelines around prescribing thiamine 

in alcohol dependence. 

In respect of embedding this guidance at HMP Lewes and other PPG sites across the country, 

we have taken a number of steps. Following the ratification of the guidance this has been added 

to the PPG intranet for all staff to be able to access. A Green Alert (a notification to staff relating 

to clinical updates) was sent to all Heads of Healthcare on 17 November 2025 to notify them of 

the updated guidance and a webinar about it and the changes took place on 20 November 2025.  

At  HMP  Lewes  specifically  the  guidance  was  shared  with  the  senior  leadership  team  on  13 

November  2025  to  share  with  their  staff  through  the  weekly  team  meetings.  In  addition,  the 

guidance  was  shared  via  the  weekly  staff  bulletin  sent  to  all  staff  on  14  November  2025.  A 

clinical training session with all staff has been arranged for the week commencing 1 December 

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 2025 to share the updated guidance and focus on the key principles. Furthermore, the service 

ran a refresher training session for all staff on 6 November 2025 on the CIWA scoring tool and 

its use in managing those detoxing from alcohol. 

Emergency Response 

The service at HMP Lewes has placed significant focus on emergency response and recognise 

the  importance  of  having  the  right  equipment  available,  competent  staff  to  manage  these 

complex situations and robust governance processes in place to ensure quality of care.  

At HMP Lewes, all of our substantive and bank nursing staff, GP staff and health care assistants 

receive  annual  Immediate  Life  Support  training  which  is  accredited  with  the  Resuscitation 

Council UK.  Agency staff receive annual training through their employing agency and are not 

able to work at Practice Plus Group sites without having an in-date certificate of completion. 

Current  compliance  figures  for  Immediate  Life  Support  training  are  96%  which  is  monitored 

monthly so that timely courses can be booked to ensure staff remain up to date.  

Following  successful  recruitment,  the  service  now  has  minimal  requirement  for  temporary 

agency  staff  which  means  that  the  team  is  more  cohesive  and  consistent,  enabling  better 

working relationships which are key when dealing with emergency situations.        

We recognise that attending to emergency situations can be challenging in a prison environment 

and therefore to address this we introduced a number of training initiatives in July 2025 which 

includes: 

•  All  staff  “back  to  basics”  training  covering  emergency  bags,  where  bags  are  located 

across the site, what is in each of the emergency bags, and the importance of bag check 

audits. 

•  All staff scenario-based emergency response training. This training involves the team 

walking  through  an  emergency  response  -  what  happened,  what  the  immediate 

response was, what worked well, what didn’t work well, and any learning taken from the 

incident. The purpose of this training is to provide staff with a “real life” scenario to build 

confidence across the whole team to lead an emergency response if needed.  

The above training sessions are scheduled to occur quarterly and currently include healthcare 

staff only but we plan to include our HMPPS colleagues to enable learning as a wider team.           

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 Emergency bag equipment is checked every 2 weeks by the team to ensure that they contain 

the correct equipment, that the equipment works and that emergency drugs are in date.  After 

each check, the bags are resealed and the seals are checked daily on site to ensure they remain 

intact.  The emergency bag check process is audited monthly as per the Practice Plus Group 

annual  audit  schedule  and  in  line  with  the  Emergency  Response  Policy  for  Healthcare 

Professionals  within  Health  in  Justice  sites  (ratified  January  2024  and  due  for  review  March 

2026). In addition to the regular bag checks, we have also implemented bimonthly dip tests of 

the emergency response bags to provide further reassurance.  

We recognise that the emergency response on 16th December 2023 fell short of the standards 

we  expect  of  our  healthcare  team.  Sadly,  whilst  any  concerns  raised  are  unlikely  to  have 

changed the outcome in this case, PPG has taken significant steps to address the concerns 

raised during the Inquest. Armed with the training described above, the healthcare team's ability 

to respond in a timely and appropriate manner to a patient in cardio-pulmonary arrest were put 

to the test in a similar emergency in October 2025. We are pleased to confirm that the same 

governor who gave evidence at the inquest described the healthcare response in October 2025 

as “exemplary”. She specially commended the two emergency response nurses who were first 

on scene and who undoubtedly saved the individual's life.   

I am confident that with these measures in place, supported by the new guidance document, 

the staff at HMP Lewes will continue to provide the safe, effective and high quality care that we 

expect from any of our Practice Plus Group sites.            

I hope that the above response provides assurance that Practice Plus Group are committed to 

providing  a  high-quality  healthcare  service  at  HMP  Lewes,  and  its  other  sites,  and  trust  this 

response addresses the concerns you had. 

Yours sincerely, 

National Medical Director, Health in Justice Practice Plus Group 

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