“Despite the severity of the incident which occurred in this case, there had been little…”
Dated 29 Jul 2025, from the coroner for Kent and Medway. Sent to 3 organisations or people.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
Deadline passedReplies were due by 23 Sep 2025. A reply may have been sent and not yet published.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk.
- Report dated29 Jul 2025
- Deadline23 Sep 2025
- Published on judiciary.uk30 Jul 2025
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| HMP Elmley | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
| South East Coast Ambulance Service NHS Foundation TrustNamed in the report as “South East Coast Ambulance Service” | Response publishedPublished on judiciary.uk in July 2025. |
| Oxleas NHS Foundation Trust | Response publishedPublished on judiciary.uk in July 2025. |
The coroner’s concerns
– (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 di iculties 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). (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. (3) 6. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you as the Chief Executives of South East Coast Ambulance Service, Oxleas NHS Foundation Trust and the Governing Governor of HMP Elmley have the power to take such action. 7. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 23 September 2025. I, the coroner, may extend the period.
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports, 2025-0389
- Added to Minute Book
- 8 Oct 2026
- Reuse
- We show short extracts and link to the original. We don’t host the full report.
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
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