HM Prison Probation Service
Central Government
Action Taken
HMP Aylesbury is reissuing Governor's Notices, providing staff briefings, issuing prompt cards, and using a colleague mentor program to reinforce emergency response protocols; HMP Woodhill provided one-to-one briefings, introduced a sign-off sheet for night OSGs, and issued a staff information notice to remind staff of medical emergency procedures and national guidance. (AI summary)
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Dear Mr Butler,
Thank you for your Regulation 28 report of 4 July 2025 following the inquest into the death of George Emmett at HMP Aylesbury on 25 May 2023. I am responding on behalf of His Majesty’s Prison and Probation Service (HMPPS) as the Director General of Operations.
I know that you will share a copy of this response with Mr Emmett’s family, and I would first like to express my condolences for their loss. Every death in custody is a tragedy and the safety of those in our care is my absolute priority.
You have expressed concerns regarding staff awareness of emergency response procedures.
HMP Aylesbury
HMP Aylesbury continue to take steps to ensure that staff can confidently take effective action in the event of a medical emergency and in particular in the calling of emergency codes. A Governor’s Notice is reissued every six months reminding staff of the emergency response protocols to embed this awareness as much as possible. Additionally, full staff briefings are regularly used to reinforce procedures.
Staff have also been issued with quick reference Code Red/Code Blue prompt cards which can be carried on the person and act as an immediately accessible reminder of the circumstances in which a Code Red or Code Blue should be called. This information is also provided on posters as an additional visual aid.
The prison has a colleague mentor programme whereby newly trained officers are assigned a mentor to provide support, advice and guidance throughout their initial training and full probation period. An induction ‘passport’ is used to provide assurance that the individual is competent in their role before they become fully operational. The mentors play an active role in training and testing new staff, this includes the use of radios and emergency
response procedures. The importance of calling response codes has also been incorporated into the local radio communication training.
HMP Woodhill
HMP Woodhill have advised me that the Operational Support Grade (OSG) who you reference in your report has now received one-to-one briefing on night procedures and the Local Security Strategy. As a further training aid and audit tool, a sign-off sheet was introduced whereby all routine expectations of a night OSG had been listed, such as the use of the radio and the use of emergency codes, the expectation being that this record be discussed by the OSG and the Night Orderly Officer and signed to confirm understanding. The support of the establishment care team has also been offered to the OSG.
On 20 June 2025 a staff information notice was issued to all HMP Woodhill staff reminding them of the policy around medical emergency response procedures and the national guidance on the appropriate use of calling a Code Red or Code Blue during an emergency. Additionally, the establishment have also issued take-along, quick reference, Code Red/Code Blue prompt cards to staff, and control room staff have been reminded of the importance of following the national protocol for calling emergency services for all incidents where a Code Red or Code Blue has been called.
Furthermore, a full briefing is given to night staff when starting their shift, and night operating procedures regarding patrolling during night state and the welfare of prisoners is routinely discussed. Should the need for further training of individuals be identified then upskilling sessions will be provided.
I hope the measures outlined above provide you with reassurance that appropriate action has been taken to address the issues identified in your report arising from Mr Emmett’s death.
Thank you for your Regulation 28 report of 4 July 2025 following the inquest into the death of George Emmett at HMP Aylesbury on 25 May 2023. I am responding on behalf of His Majesty’s Prison and Probation Service (HMPPS) as the Director General of Operations.
I know that you will share a copy of this response with Mr Emmett’s family, and I would first like to express my condolences for their loss. Every death in custody is a tragedy and the safety of those in our care is my absolute priority.
You have expressed concerns regarding staff awareness of emergency response procedures.
HMP Aylesbury
HMP Aylesbury continue to take steps to ensure that staff can confidently take effective action in the event of a medical emergency and in particular in the calling of emergency codes. A Governor’s Notice is reissued every six months reminding staff of the emergency response protocols to embed this awareness as much as possible. Additionally, full staff briefings are regularly used to reinforce procedures.
Staff have also been issued with quick reference Code Red/Code Blue prompt cards which can be carried on the person and act as an immediately accessible reminder of the circumstances in which a Code Red or Code Blue should be called. This information is also provided on posters as an additional visual aid.
The prison has a colleague mentor programme whereby newly trained officers are assigned a mentor to provide support, advice and guidance throughout their initial training and full probation period. An induction ‘passport’ is used to provide assurance that the individual is competent in their role before they become fully operational. The mentors play an active role in training and testing new staff, this includes the use of radios and emergency
response procedures. The importance of calling response codes has also been incorporated into the local radio communication training.
HMP Woodhill
HMP Woodhill have advised me that the Operational Support Grade (OSG) who you reference in your report has now received one-to-one briefing on night procedures and the Local Security Strategy. As a further training aid and audit tool, a sign-off sheet was introduced whereby all routine expectations of a night OSG had been listed, such as the use of the radio and the use of emergency codes, the expectation being that this record be discussed by the OSG and the Night Orderly Officer and signed to confirm understanding. The support of the establishment care team has also been offered to the OSG.
On 20 June 2025 a staff information notice was issued to all HMP Woodhill staff reminding them of the policy around medical emergency response procedures and the national guidance on the appropriate use of calling a Code Red or Code Blue during an emergency. Additionally, the establishment have also issued take-along, quick reference, Code Red/Code Blue prompt cards to staff, and control room staff have been reminded of the importance of following the national protocol for calling emergency services for all incidents where a Code Red or Code Blue has been called.
Furthermore, a full briefing is given to night staff when starting their shift, and night operating procedures regarding patrolling during night state and the welfare of prisoners is routinely discussed. Should the need for further training of individuals be identified then upskilling sessions will be provided.
I hope the measures outlined above provide you with reassurance that appropriate action has been taken to address the issues identified in your report arising from Mr Emmett’s death.