Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0312, written 21 May 2026. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 21 May 2026 |
|---|---|
| Reference | 2026-0312 |
| Deceased | George Haldenby |
| Coroner | Rachael Griffin |
| Coroner area | Dorset |
| Organisation named | Oxleas NHS Foundation Trust |
| Source | judiciary.uk record |
| Responses published | 4 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REPORT TO PREVENT FUTURE DEATHS REGULATION 28 OF THE CORONERS (INVESTIGATIONS) REGULATIONS 2013 Please do not include any living persons’ names in this document, in accordance with the Chief Coroner’s PFD Publication Policy (2026). 1. CORONER I am Rachael Clare Griffin, Senior Coroner, for the Coroner Area of Dorset. 2. DATE OF REPORT 21st May 2026 3. CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3. THIS REPORT IS BEING SENT TO 1. Minister of State for Prisons, Probation and Reducing Reoffending 2. Minister of State for Health and Social Care 3. Governor of HMP The Verne 4. Chief Executive of Oxleas NHS Foundation Trust You are under a duty to respond to this report within 56 days of the date of this report, namely by 17th July 2026. I, the coroner, may extend the period if an appropriate application is made. 4. YOUR RESPONSE Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. I have a duty to send a copy of your response to the Chief Coroner. representations In accordance with the Chief Coroner’s Publication Policy, you should send me response. These any representations should be made at the same time as the response is provided. I will pass any representations received to the Chief Coroner for a decision. regarding publication of your Please note any links to webpages included in the response will not be checked for sensitive information prior to publication, as the information is already online. The names of those who do not respond to PFD reports are regularly published on the Chief Coroner’s webpages Non-responses to Prevention of Future Death (PFD) reports - Courts and Tribunals Judiciary. 5. SUMMARY OF CORONER’S CONCERN Matters of National Concern 1. The lack of regular refresher first aid and CPR training that Prison Staff receive after their induction training. 2. The lack of process in place in prisons without 24 hour healthcare provision to ensure hospital prescribed medication is available when prescribed out of working hours especially over weekends and bank holiday periods. Matters of local concern at HMP the Verne 3. The lack of local policy or process so that the prison and healthcare staff have an understanding of how to deal with the situation arising at 2 above to ensure a prisoner receives necessary medications without delay. 6. ACTION SHOULD BE TAKEN In my opinion unless action is taken to address the above concerns then there is a significant risk of future deaths and I believe each of you have the power to take such action. 7. INVESTIGATION AND INQUEST On 7th February 2022, I commenced an investigation into the death of George Edward James Haldenby, aged 56 years born on 24th March 1965. The Inquest concluded before a jury on the 13th May 2026. The medical cause of death was: Ia Congestive Cardiac Failure Ib Hypertensive and Ischaemic Heart Disease How, when and where George came by his death was recorded by the jury as: George Edward James Haldenby died on 29th of January 2022 at Dorset County Hospital, Dorset, following a collapse at HMP the Verne. The impact of George’s medication regime and the impact of George’s move from Wing B2 to the Care and Separation Unit (CSU) on 29th January 2022, these probably caused or contributed more than minimally to his death. The following three matters cannot be said to be causal or contributory in George's death but are recorded for completeness. 1. George was located in a cell which was not in a flat location 2. George was not under secondary care for his cardiac health whilst at HMP the Verne and follow up referrals to cardiology and social care were not made 3. Primary survey following George’s collapse was not completed The conclusion recorded by the jury was a narrative conclusion as follows: George Edward James Haldenby died as a consequence of a combination of naturally occurring disease and the effects of an act of self harm in March 2020, in circumstances where George did not have adequate medication for his heart disease and he experienced exertion on the day of his death which hastened his death. 8. CIRCUMSTANCES OF DEATH George was a serving prisoner at HMP The Verne having arrived there on the 18th May 2021. Following an incident of self harm in March 2020 he developed severe heart failure on an already pre existing background of ischaemic heart disease. He was prescribed various medications to manage his heart disease, however there had been a history of varied compliance. Between the 10th January and the 26th January 2022 George was not prescribed his Furosemide mediation by the prison healthcare. On Friday 21st January 2022 George was taken to Dorset County Hospital, Dorchester having presented to the prison GP with deteriorating heart failure. Following assessment at the hospital his diuretic mediation, Furosemide, was increased from 20mg a day to 80mg a day. This was prescribed by the hospital after 6pm on a FP10 form. The hospital pharmacy closes at 6pm on a Friday and so it could not be dispensed to take back to the prison as “To Take Out” (TTO) medication. The prescription was therefore taken back to the Prison. The healthcare team at the prison, at the time operated between 7.30am to 6pm daily, however on weekends and bank holidays the team was only staffed by 2 nursing staff and 2 support workers. The GP working hours at the prison were, and still are, Monday to Friday. The prescription from the hospital was not actioned until the next GP review on Wednesday 26th January 2022 and the medication was taken by George at the increased dose on Thursday 27th January and Friday 28th January 2022. On the evening of the 28th January 2022 George defecated in his cell, Cell 23 on Wing B2. On the morning of the 29th January 2022 a decision was made to move him to the Care and Separation Unit (CSU) so he could be showered and an assessment of him take place. This move was assisted by a number of prison officers. George struggled to move to the CSU and just after he arrived in the shower area he collapsed. Healthcare staff, who were at that time on the CSU, were called for and attended. They undertook a visual check of George and believed he was faking the collapse. They instructed the officers to sit him up and they left the shower room. Once sat up the officers were concerned and so placed George in the recovery position. They could not feel a pulse or identify George breathing and so healthcare were requested again and when they arrived a code blue emergency call was made and CPR commenced. This was approximately 9 minutes after George first collapsed. He was taken to Dorset County Hospital where he died that day. Evidence was given by the Home Office Registered Forensic Pathologist, the treating doctor who issued the prescription at the hospital and a Consultant Cardiologist that lack of medication played a part in George’s death. 9. CORONER’S CONCERNS During the course of the inquest I heard evidence giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: After prison officers and prison staff carry out their induction training which covers basic first aid training including the delivery of cardio pulmonary resuscitation (CPR), there is no further mandatory refresher training on first aid or CPR. During the evidence, a Custodial Manager at HMP the Verne stated that the last time he had first aid or CPR training was in 1991, 35 years ago, when he started as a prison officer. Whilst there is a requirement to have a duty first aider on site 24 hours a day, without all staff being suitably and regularly trained in signs of collapse and administering CPR, there could be a delay in delivering effective CPR as it may take time for the duty first aider to get to the prisoner, and a future death could occur. In prisons without 24 hour healthcare provision, if a prisoner receives treatment at a hospital and is issued with a medication prescription on a FP10 form, this cannot be processed at the prison in the absence of a doctor or prescribing nurse, and pharmacies in hospitals are not always open 24 hours a day for it to be dispensed as TTO medication. This means there will be a delay in prisoners receiving necessary and lifesaving medication over a weekend or bank holiday period until staff are in the prison who can action the prescription. Whilst at HMP The Verne there is now a duty Doctor who can be called upon out of hours to progress such prescriptions, there is a lack of local policy or process to ensure the prison and healthcare staff have an understanding of how to deal with the situation should a FP10 be issued outside of hours when a prescribing health professional is not available in the prison to ensure a prisoner receives necessary medications without delay. Although critical medications are held at the prison in a locked cabinet, not all medication are included and Furosemide, which was critical in George’s care, is one of those that is not held by the prison as a critical medicine. 10. COPIES AND PUBLICATION OF THIS REPORT I have a duty to send a copy of my report to every Interested Person who in my opinion should receive it. I also may send a copy of the report to any other person who I believe may find it useful or of interest. I can confirm I have sent the report to: 1. George’s family 2. Practice Plus Group 3. Dorset County Hospital 4. NHS England 5. Prison and Probation Ombudsman 6. Governor of HMP Guys Marsh 7. Governor of HMP Portland I also have a duty to send a copy of the report to the Chief Coroner. You may make representations to me, the coroner, about the publication of the contents of this report in line with Chief Coroner’s PFD Publication Policy (2026). Any representations will be sent to the Chief Coroner alongside the report. Please refer to box 4 above for additional information relating to the publication of reports and responses. SIGNATURE
4 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
(cid:127)Department of Health & Social Care HM Coroner Rachael Clare Griffin Dorset Minister of State for Health (Secondary Care) 39 Victoria Street London SW1H0EU 05 June 2026 Dear Rachael Griffin, Thank you for the Regulation 28 report of 21 May 2026 about the death of George Edward James Haldenby. I am replying as the Minister with responsibility for system commissioning and provider oversight, including health and justice. Firstly, I would like to say how saddened I was to read of the circumstances of Mr Haldenby's death, and I offer my sincere condolences to his family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention. The report raises concerns about the lack of process in place in prisons without 24-hour healthcare provision, to ensure that hospital prescribed medication is available when prescribed out of hours, and over weekends and bank holiday periods. In considering your report, officials within the Department of Health and Social Care have made enquiries with NHS England and concluded that these concerns are more appropriately addressed by NHS England directly. I am advised that NHS England will therefore provide you with a full and comprehensive response on the concerns you have raised. I hope this response is helpful. Kind regards, MINISTER OF STATE FOR HEALTH
Interim Director General of Prisons HM Prison and Probation Service 8th Floor Ministry of Justice 102 Petty France London SW1H 9AJ Rachael Clare Griffin Senior Coroner for Dorset The Coroner's Office for the County of Dorset Civic Centre Bourne Avenue Bournemouth BH2 6DY 6 August 2026 Dear Ms Griffin, REGULATION 28 REPORT TO PREVENT FUTURE DEATHS: MR GEORGE EDWARD JAMES HALDENBY Thank you for your Regulation 28 report of 21 May 2026, following the inquest into the death of George Edward James Haldenby at Dorset County Hospital on 29 January 2022 whilst a prisoner at HMP The Verne. I am responding as the Interim Director General of Prisons, HMPPS, on behalf of the Minister of State for Prisons, Probation and Reducing Reoffending and the Governor of HMP The Verne I know that you will share a copy of this response with Mr Haldenby’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. You have raised concerns over the lack of regular refresher first aid and cardiopulmonary resuscitation (CPR) training that Prison Staff receive after their initial training. You also mentioned the lack of process in place in prisons without 24-hour healthcare provision to ensure hospital prescribed medication is available when prescribed out of working hours especially over weekends and bank holiday periods and that there is a lack of local policy or process at HMP The Verne, to direct prison and healthcare staff understanding of how to obtain medication without delay. You will be aware that all new prison officers receive mandatory Emergency First Aid and CPR training as part of their foundation programme. This training remains valid for three years and is subject to requalification. In addition, the HMPPS First Aid Policy Framework (re-issued in August 2023) requires Governors to maintain sufficient first aid provision based on a local First Aid Needs Assessment. To support staff capability, HMPPS provides ongoing refresher resources and learning materials to maintain and enhance first aid knowledge and skills. For example, HMPPS has worked with St John Ambulance to develop bespoke “first-on-scene” video resources for prison officers and frontline staff, offering practical guidance on responding to a range of emergency situations prior to the arrival of healthcare professionals. HMP The Verne is undertaking a comprehensive Training Needs Analysis to inform the development of a structured First Aid training plan. From July 2026, the prison intends to deliver monthly three-day First Aid at Work training programmes. These sessions will be jointly led by the Head of Business Assurance and supported by the Health and Safety Manager. The programme is designed to increase the number of staff trained to a recognised First Aid at Work standard and strengthen the prison’s emergency response capability. Increasing the number of staff trained in First Aid at Work will enable the implementation of a 24-hour, seven-day nominated staff rota, to ensure a coordinated and timely response to emergencies. The initial rollout of training will prioritise key staff groups, including Custodial Managers, Supervising Officers, Care and Separation Unit staff, and Induction Wing staff. A forward-planned training schedule will be maintained throughout the year, incorporating both initial training and refresher courses to ensure ongoing compliance and competency. Although your concerns about the lack of policy/process for healthcare staff around accessing out of hours or hospital prescribed medication has been referred to Oxleas NHS Foundation Trust for their separate consideration and response, HMPPS has also considered whether there is any supportive action that it can take. Oxleas NHS Foundation Trust has confirmed that a formal process and guidance for healthcare teams regarding the management of medicines outside normal operating hours was implemented in September 2024. This is supported by a Standard Operating Procedure, which provides clear direction on the sourcing and provision of prescribed medication during evenings, weekends, and bank holidays. Further collaborative work is being undertaken between prison and healthcare managers to establish a clear and robust local process incorporating defined escalation routes, roles and accountability measures. This will ensure that staff have the necessary clarity and confidence to respond appropriately when out-of-hours medication issues arise, supporting timely access to essential treatment and continuity of care. I hope the measures outlined above reassure you that appropriate training is in place and that the opportunity to identify learning and address the issues raised has been taken from the circumstances of Mr Haldenby’s death. Yours sincerely, Interim Director General of Prisons
Ms. Rachael Clare Griffin Senior Coroner for Dorset Coroner's Office for the County of Dorset BCP Civic Centre Bourne Avenue Bournemouth BH26DY NHS England National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG 13th July 2026 Dear Ms. Griffin, Re: Regulation 28 Report to Prevent Future Deaths - George Edward James Haldenby who died on 29th January 2022. Thank you for your Report to Prevent Future Deaths (hereafter "Report") dated 21st May 2026 concerning the death of George Edward James Haldenby on 29th January 2022. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to George's family and loved ones. NHS England is keen to assure the family and yourself that the concerns raised about George's care have been listened to and reflected upon. Your Report raises concerns the following concerns: 1. There is a lack of regular refresher first aid and CPR training for Prison Staff after their induction training. 2. There is a lack of a process in place for patients to receive hospital prescribed medications in prisons out of hours, particularly over weekends and bank holiday periods. 1. Lack of refresher training The issue of training for prison officers is the responsibility of HM Prison and Probation Service, so NHS England is unable to answer this concern. We note that the Coroner has also addressed the Report to the Minister for Prisons, Probation and Reducing Reoffending, who will be best placed to answer this. 2. Out of hours healthcare in prisons The national health and justice service specification details core service delivery and standards that providers are expected to prioritise which, in the primary care specification, includes out of hours (OOH) action in establishments without 24-hour healthcare. Not all prisons provide 24-hour healthcare. Delivery against this specification is usually managed locally under contract management. HMP The Verne is a category C establishment which is defined as a training and resettlement prison. As such the healthcare services available should mirror those provided in the wider community, but delivered within a secure custodial environment In the event of there being serious concerns about an individual's health, it is expected that a 999 call is made to request an ambulance in the same way an ambulance would be called for a person in their own home; this is described as 'urgent referrals'. Under the pharmacy and medicines optimisation section of the specification, it sets out that the provider is required to arrange and use a process for the dispensing of urgent medication from local pharmacies, or other urgent care or OOH primary care services, outside of core hours (including public holidays). This should be available on request although pick up/delivery of the medicines must be arranged by the prison teams. All national health and justice service specifications are under review at present and it is expected this review will be completed by Autumn 2026. Of note, the healthcare provider has changed at HMP The Verne since George's death. 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 George, 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, National Medical Director NHS England
NHS Foundation Trust Oxleas Pinewood House Pinewood Place Dartford Kent DA2 7WG 8thJune 2026 Private & Confidential Senior Coroner Rachael Griffin The Coroner's Office for the County of Dorset, Civic Centre, Bourne Avenue, Bournemouth BH2 6DY Dear Ms Griffin Regulation 28 Report to Prevent Future Deaths - Inquest touching the death of Mr George Edward James Haldenby. Thank you for your regulation 28 report to prevent future deaths dated 2l5t May 2026 following the inquest into the death of Mr George Edward James Haldenby, which concluded on 13thMay 2026. In advance of responding to the specific concerns raised in your report, I would like to express my deep condolences to Mr George Edward James Haldenby's family and loved ones. Oxleas NHS Trust is keen to assure the family and the coroner that the concerns raised about Mr George Edward James Haldenby'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 your letter you raised matters of National Concern: 1. The lack of regular refresher first aid and CPR training that Prison Staff receive after their induction training. 2. The lack of process in place in prisons without 24 hour healthcare provision to ensure hospital prescribed medication is available when prescribed out of working hours especially over weekends and bank holiday periods. And matters of local concern for HMP The Verne (3) The lack of local policy or process so that the prison and healthcare staff understand how to deal with the situation arising at 2 above to ensure a prisoner receives necessary medications without delay. Following a review of these concerns, we can confirm that a formal process has been in place across the Southwest region since September 2024 through the implementation of the Southwest Out of Hours Standard Operating Procedure (SOP)- (Appendices 1). This SOP was circulated to all relevant healthcare teams upon implementation and remains accessible through the organisational document management systems, including the Ox and the SystmOne Pharmacy Document Library. The SOP provides clear guidance to healthcare teams regarding the management of medicines required outside normal operating hours, including arrangements for sourcing and obtaining prescribed medications during evenings, weekends, and bank holidays. The issues identified within the Prevention of Future Deaths report are therefore addressed within the existing governance framework and operational guidance. Upon reflection of the coroner's investigation, it is recognised that the Southwest Out of Hours SOP was not requested or submitted as part of the evidence considered during the investigation process. Had this documentation been provided, it may have assisted in demonstrating the existence of established governance arrangements and operational procedures relevant to the concerns raised. In response to the learning identified through this process, we will strengthen governance arrangements by ensuring that, following any Death in Custody (DIC) investigation where additional evidence is requested, or where medicines management issues are identified, Regional Pharmacists or the Head of Medicines Management are consulted directly. This will help ensure that all relevant SOPs, policies, and supporting governance documentation are identified and submitted as part of future investigations. In addition, this incident has provided an opportunity to further reinforce awareness of existing medicines management policies and SOPs. The Southwest Out of Hours SOP and associated guidance will be recirculated to all healthcare teams, and ongoing training sessions will continue to reinforce staff understanding and compliance. The Medicines Management SOP Log will also be redistributed to all Heads of Healthcare to improve visibility of current medicines-related procedures, alongside signposting staff to the centrally maintained document repository where the most up-to-date versions are held. Whilst these SOPs and policies are developed and maintained centrally, responsibility for local implementation rests with Heads of Healthcare, supported by local Medicines Management teams. They are responsible for ensuring that all relevant staff are familiar with, acknowledge, and adhere to the requirements set out within the SOPs and associated policies. Compliance is monitored through established governance processes, and where individuals are identified as persistently deviating from approved procedures, they will be supported and managed in accordance with the Trust's capability and performance management policies. This may include additional training, supervision, monitoring, and, where necessary, formal capability procedures. We are therefore satisfied that appropriate policies and procedures are in place to support the timely provision of clinically necessary medication outside normal working hours and have taken further steps to strengthen awareness, oversight, and assurance regarding their implementation across all sites. I hope that this letter reassures you that Oxleas has been highly attentive to the findings of your investigation, and that concerted 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
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