“~ The Deceased was medically assessed whilst an inmate of HMP Albany (now part of HMP…”
Dated 13 Apr 2015, from the coroner for Exeter and Greater Devon. Sent to 2 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 8 Jun 2015. 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 dated13 Apr 2015
- Deadline8 Jun 2015
- Published on judiciary.uk13 Apr 2015
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Dorset Healthcare University NHS Foundation Trust | Response publishedPublished on judiciary.uk in April 2015. |
| NHS England | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 8 Jun 2015. A reply may have been sent and not yet published. |
The coroner’s concerns
This report was published as a scan, so its text was read automatically. Check the wording against the original before you quote it.
~ The Deceased was medically assessed whilst an inmate of HMP Albany (now part of HMP Isle of Wight) on 28 September 2006 and known to have extensive and well documented history of high cholesterol, ischaemic heart disease with episodic angina, two previous myocardial infarctions, blood pressure 220/100. But after arrival at HMP Dartmoor on 15 March 2013, (1) there was no record that his blood pressure was monitored: or (2) that he had been informed of a screening test for aortic aneurysm. He died on 6" January 2014 from a ruptured aortic aneurysm at HMP Dartmoor. (3) There was a delay in calling an emergency ambulance because HMP Dartmoor did not have an emergency code (unlike HMP Exeter) protocol. There was insufficient evidence to say the above were causative of Mr NORTON’s death but there would have been an awareness of possible problems to come.
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, 2015-0137
- Added to Minute Book
- 8 Oct 2026
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- 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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