“Evidence was adduced in the course of this Inquest to the effect that in 2010, 2011 and…”

The coroner’s concerns

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- (1) Evidence was adduced in the course of this Inquest to the effect that in 2010, 2011 and 2012 inmates were having social get togethers on C Wing at HMP Wealstun, in Particular at a weekend, during which time drugs were taken and hooch was drunk. Evidence was also heard that this is ‘occurring at the present time at this said prison establishment. In the circumstances, there should be much greater and effective vigilance by Wing staff and Prison Service employees at HMP Weaistun in relation to such get togethers on the Wings during periods of association; (2) The Deceased was not subjected to a breathalyser test at any time during the 18” September 2010. A proportion of, but not all, Wing staff are trained in the use of such breathalyser equipment. Had the Deceased been so breathalysed, more likely than not, itwould have been apparent he was not ‘suffering from the effects of alcohol. Im the circumstances all Wing staff should be trained in the use of such breathalyser equipment; (3) The Deceased’s behaviour and presentation on the 18" September 2010 was not recorded by any member of Wing staff in the C Wing Observation Book. Evidence was adduced in the course of the Inquest as to the importance of recording all relevant information in the said Observation Book, thereby apprising all members of Wing staff on all shifts of all material facts and matters. In the circumstances, all relevant information in relation to, for example, an inmate's behaviour and general presentation should be brought to the attention of all Wing staff and should be done so via an appropriate entry/entries in the Wing Observation Book. All Wing staff (Wing Managers, Prison Officers and Operational Support Grades) should be made aware of the importance of ‘such, and should ensure information is recorded accordingly; (4) The members of staff who observed the Deceased at around 5.45am on the 19" ‘September 2010 did not “put out’ a Code Blue. It was explained in the course of the Inquest that Codes Blue and Red are basic emergency codes which have been in existence for very many years. Despite the fact that, in this instance, the failure to call a Code Blue would not have affected the outcome, it is not inconceivable that to omit to Use such emergency codes could, in certain circumstances, jeopardise an inmate's ‘chances of survival. In the circumstances, all Prison Staff should be fully acquainted with the use of such Codes and should use them accordingly; (5) Paramedic assistance was not called within a reasonable time and no explanation for the delay was provided in the course of the Inquest. Whilst the failure to summons. outside medical assistance sooner would not have affected the outcome in this instance, itis nc conceivable that to omit to call for such assistance as soon as possible could, in certain circumstances, jeopardise an inmate's chances of survival. Consequently, emergency services should be summoned at the very first available opportunity, and all Prison staff should be instructed as to the importance of so doing.

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, 2014-0452

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8 Oct 2026

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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