Azroy Dawes-Clarke

Dear Mr Brownhill, Thank you for the Regulation 28 report of 29 July 2025 sent to the Secretary of State about the death of Azroy Dawes-Clarke. I am replying as the Minister with responsibility for mental health and offender health. Firstly, I would like to say how saddened I was to read of the circumstances of Mr Dawes- Clarke’s death, and I offer my sincere condolences to his family and loved ones. The circumstances your report describes are very concerning and I am grateful to you for bringing these matters to my attention. I understand the concerns your report raises about the communication and confusion between prison staff, healthcare professionals and paramedics as to who should have command and control of the medical emergency, and the lack of clarity as to how such a situation could be avoided if a medical emergency happened in a custodial setting again. In preparing this response, my officials have made enquiries with NHS England to ensure we adequately address the issues highlighted in your report. Good communications are vital during a medical emergency, and it is important that all professionals concerned understand their roles and responsibilities. I can confirm that HM Prison and Probation Service is the public body which takes primacy for the leadership, command and control of an emergency situation in prison, including a medical emergency. Healthcare staff within a prison should respond to and provide any emergency medical treatment, such as CPR, until a paramedic arrives on scene. In light of the circumstances surrounding Mr Dawes-Clarke’s death, I would like to add that the Care Quality Commission has issued guidance about reducing harm in mental health

settings which recognises the risk of non-anchored ligatures. This is available here:

I understand that you have issued a separate Regulation 28 report to the Director General Chief Executive of HM Prison and Probation Service; and one to the Governor at HMP Elmley, Oxleas NHS Foundation Trust and the South East Coast Ambulance Service. I would expect the Ambulance Service to provide more detail about the role of paramedics in medical emergencies within the prison estate. More broadly, as signatories to the National Partnership Agreement for Health and Social Care for England, the Department of Health and Social Care and NHS England are committed to working with partners to reduce health inequalities for people in prison and improving services to ensure that people have access to timely and effective healthcare whilst in prison. I would like to inform you that the Chief Medical Officer for England’s report on health in prisons is due to be published this year and will provide recommendations for further action. I hope this response is helpful. Thank you for bringing these concerns to my attention.