“S are as follows: Firstly, I was told during the course of the evidence that the…”
Dated 26 Jul 2019, from the coroner for Milton Keynes. 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 20 Sep 2019. 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 dated26 Jul 2019
- Deadline20 Sep 2019
- Published on judiciary.uk9 Sep 2019
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| South Central Ambulance Service NHS Foundation TrustNamed in the report as “South Central Ambulance Services” | 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. |
| HMP Woodhill | 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. |
Some responses were published as scans, so their text was read automatically. Check the wording against the original before you quote it.
The coroner’s concerns
S are as follows: Firstly, I was told during the course of the evidence that the ambulance crew who attended the prison in response to the emergency call, do not have access to the radio system of SCAS. The ambulance which attended is operated by Jigsaw Medical Services which is denied access to the system. I believe this policy should be reviewed urgently and consideration given to ensure that all ambulance crews have access to the radio system. Secondly I am concerned that the first response did not include a “paramedic”. I believe that consideration should be given to a review to ensure that the first responder to an emergency at the prison should always include a fully qualified paramedic. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) 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 19th September 2019. 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, 2019-0255
- 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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