Sean Williams

Dear Ms Hassall, Thank you for your Prevention of Future Death Report (‘PFDR’) dated 20 February 2026 following the conclusion of the Inquest into the death of Sean Perry Williams who sadly died in March 2024. As the Managing Director of Serco’s Justice and Immigration business, I am responding on behalf of Serco and , Serco’s Group Chief Executive Officer to matters of concern that you have raised in the PFDR, in so far as they relate to Serco under the Prisoner Escort and Custody Services (PECS) contract. I am aware that you will share a copy of this response with Mr Williams’ family and I would like to express my sincere condolences for their loss. Every death in custody is a tragedy, and the safety of those detained and transported by Serco is our absolute priority. I am grateful to you for bringing the matters of concern to Serco’s attention. Thankfully medical emergencies on our vehicles whilst they are in transit are fairly unusual, when you bear in mind that Serco PECS complete over 250,000 journeys per annum. Mr Williams’ death was the first of only three deaths on a Serco PECS vehicle in the last 10 years. I can provide some assurance that in the vast majority of cases involving a medical emergency on a vehicle staff have acted promptly, professionally, and have followed the correct procedure to keep the prisoner safe and have provided the appropriate care pending the arrival of the emergency services. Serco recognises that any death in custody or during transport is a matter of the utmost seriousness, regardless of how infrequently such events occur. The circumstances of Mr Williams’ death have prompted detailed reflection on our policies, training, and operational guidance, with the aim of reducing the risk of any recurrence. Indeed, our health and safety management is always under review as we seek to continuously improve. Following an incident, we review the risk factors involved and whether we have sufficient and effective controls in place to ensure compliance with our obligations to keep the often-vulnerable individuals in our custody safe and well. Serco does not hesitate to implement enhancements to its processes where these are appropriate. As with existing procedures any changes are subject to approval by the MOJ before implementation Since the death of Mr Williams we have revised Standard Operating Procedure (SOP) 038 Prisoner Welfare on a Vehicle, SOP 009 Duties of a Vehicle Escort Officer and SOP 047 Death or attempted suicide of a prisoner in custody, to improve the clarity of the steps to be taken where a medical emergency is suspected and I understand copies of the updated SOPs have been provided to you. The changes have also been reflected in other SOPs and training documents to ensure consistency. However, I note the jury’s findings and your concerns in relation to the apparent lack of urgency on the part of the staff involved with Mr Williams, their competencies, and the contents of the relevant training and guidance provided to staff in relation to first aid and dealing with a medical emergency on a vehicle. Serco Justice & Immigration Serco House, 16 Bartley Wood Business Park, Bartley Way, Hook, Hampshire, RG27 9UY United Kingdom T: +44 (0)1256 745 900 | F: +44 (0)1256 744 112 | www.serco.com Serco Group Plc, a company registered in England and Wales No. 2048608 Registered Office: Serco House, 16 Bartley Wood Business Park, Bartley Way, Hook, Hampshire RG27 9UY, United Kingdom

[Page 2] Adequacy of training – First Aid issues As you will be aware from the evidence at the Inquest, all Serco escort staff undergo an extensive five and a half week initial training course (ITC), the contents of which are regularly reviewed and updated in order that improvements can be implemented. The ITC is followed by a comprehensive assessment of staff competencies before any member of staff is passed on the course and are permitted to work within the PECS contract. I believe that you have been provided with the slides which form the basis of the two modules of the ITC most relevant to Mr Williams’ death, being vehicle emergencies and First Aid, and that the slides were included in the Inquest bundle. However, the contents of the slides are merely the basis of the training, with each slide being expanded upon by the trainer responsible for delivering the training, in accordance with policy and procedures set out in our Standard Operating Procedures. The resulting qualification meets the Health and Safety Executive (HSE) requirements. In addition, the Highfield Level 3 Award in First Aid at Work is regulated by Ofqual. In light of the concerns raised, we have undertaken additional steps to review our ITC provision and our annual training programme to ensure that any further opportunities to strengthen our approach are given full and proper consideration I note the jury’s findings and that one particular concern related to seizures. As you will note the First Aid slides include a whole section on seizures (slides 118-122). Nevertheless, while seizure recognition and response forms part of existing first‑aid training, this finding has prompted Serco to consider whether additional measures are required to strengthen staff confidence and recognition with respect to this issue in practice. Similarly, the findings relating to use of the recovery position have informed a focused review of how this aspect of training is emphasised and reinforced. That said, once again, you will have noted that there is a whole section on the recovery position within the training slides (slides 49-57). I can also confirm that aspects of both of these sections are included in the assessment of staff when the training is concluded. The Use of Force training provided annually to all staff also references training on the recovery position. The jury’s findings indicate that further consideration needs to be given to strengthening recall, urgency and confidence when staff are required to respond to medical emergencies under operational pressure. This issue is likely to be compounded by the fact that it is fairly rare for staff to be faced with a medical emergency let alone a seizure, or an occasion when it would be appropriate to place a casualty in the recovery position. That said, Serco accepts that training must continue to evolve to address this risk. However, the difficulty faced by staff in recalling their medical emergency training in an emergency (referred to by in his evidence as fright, flight or freeze) is covered during the use of force training and during the medical emergencies on a cellular vehicle training during the ITC. It is also covered in the annual staff refresher to assist staff. To further improve retention of the instruction provided during training, as confirmed by our Training Partner during his evidence at the Inquest, since March 2026 the training on medical emergencies on a cellular vehicle and first aid principles have been included in the PECS internal annual refresher within Serco’s internal Learning Management System (LMS). Serco Justice & Immigration Serco House, 16 Bartley Wood Business Park, Bartley Way, Hook, Hampshire, RG27 9UY United Kingdom T: +44 (0)1256 745 900 | F: +44 (0)1256 744 112 | www.serco.com Serco Group Plc, a company registered in England and Wales No. 2048608 Registered Office: Serco House, 16 Bartley Wood Business Park, Bartley Way, Hook, Hampshire RG27 9UY, United Kingdom

[Page 3] We are also in the process of reviewing the training provided with the awarding organisation, Highfield, to explore the possibility of including a video of a seizure in the training, to assist staff in identifying a seizure, and in retaining the instruction provided on how to deal with a seizure should they encounter one. A review of the adequacy of the training on the recovery position is also being undertaken to ensure that any possible improvements are implemented. We are also reviewing whether it would be appropriate to include additional and new training on the recovery position within the training module on vehicle emergencies, to emphasise its importance, and to assist in retention of this very importance aspect of the training. Adequacy of training – process issues I note the jury’s findings and the particular concerns in relation to guidance provided to staff on the use of the emergency buttons installed on all Serco vehicles for use in emergency situations, and the potential conflicting information provided in relation to who to contact and where to take the prisoner to, in order to provide prompt and efficient assistance to a prisoner during a medical emergency. As you are aware the process to be followed if staff encounter a medical emergency on a vehicle is covered in the ITC, and I can confirm that it is also included in the annual refreshers that all operational staff in PECS undertake. In addition, in order to remind staff of the required process and aid their retention of the information provided during the training, in March 2025 we created a new online course on Serco’s LMS. This is a mandatory course for all staff members and includes what to do in an emergency medical incident, basic life support, self-harm incidents, vehicle breakdown, fire and anything deemed a vehicle emergency. The content provides a refresher of the training covered in the ITC course, to reinforce learning and gives additional prominence by being a separate module and links together the concepts that staff have learned during their Highfield First Aid training. This new medical emergency on a cellular vehicle training course also reinforces that staff must conduct CPR if a prisoner is unresponsive and summon medical attention, and that CPR must continue until the prisoner is breathing, a medical professional arrives, or they are otherwise directed to stop by a medical professional or emergency call-handler. There is an exam at the end of the course with a pass rate of 80%. If they fail this test employees must take it again until they have achieved the required pass mark. The action that staff should take in the event of a medical emergency will inevitably be fact specific.In such circumstances the staff on scene must carry out a dynamic risk assessment specific to the case in hand, to identify what steps must be taken to keep the prisoner safe and to provide prompt assistance. Following the death of Mr Williams, Serco has taken steps to assist staff to recall their training on who to contact and where to take the casualty to, to ensure they receive prompt medical attention. Having said that, there does need to be some degree of flexibility in the process, so that if part of the process cannot be followed, for whatever reason, the staff feel confident to take further appropriate steps to keep the prisoner safe. I am aware that in Mr Williams’ case, the staff on the vehicle contacted the emergency services promptly to request an ambulance, but that there were considerable difficulties in communicating their location to ensure that the ambulance attended at the correct location. Although the particular communication difficulties encountered by staff in this case were not anticipated, it is in part for this reason that the process requires staff to press the emergency button on the vehicle and to call the Operational Control Centre (OCC) to seek assistance. Serco Justice & Immigration Serco House, 16 Bartley Wood Business Park, Bartley Way, Hook, Hampshire, RG27 9UY United Kingdom T: +44 (0)1256 745 900 | F: +44 (0)1256 744 112 | www.serco.com Serco Group Plc, a company registered in England and Wales No. 2048608 Registered Office: Serco House, 16 Bartley Wood Business Park, Bartley Way, Hook, Hampshire RG27 9UY, United Kingdom

[Page 4] As was confirmed by the evidence at the Inquest, all Serco PECS vehicles are tracked by the OCC. Activation of the emergency button enables the OCC to prioritise the call from that vehicle and to communicate the vehicle’s location directly to the emergency services, thereby reducing the risk of location‑related delay. Not only are the resources available to staff at the OCC more readily available, but the staff member at the OCC is able to assist the staff on scene in assessing the situation and ensuring that appropriate assistance is provided promptly. As outlined by Serco’s Head of Professional Standards and Security in his evidence, and to support staff on scene in following the correct process, Serco has developed a flowchart for escort officers following the death of Mr Williams. A copy appears in the Inquest bundle. This has since been incorporated into training, and laminated copies are now displayed within all escort vehicles in a position visible from the escort seat. The intention is that this readily accessible guide will reinforce existing training, clarify the required steps, and support escort officers in responding with confidence and consistency during suspected medical emergencies. Serco has also developed a corresponding flowchart for the OCC to reflect that provided to PCOs, together with structured prompt questions to assist OCC controllers in identifying the nature of an emergency and providing appropriate support and direction to PCOs when an incident occurs. A copy of the OCC flowchart has also been provided. A laminated version of this flowchart is now attached to each controller’s desk within the OCC with several copies of the list of questions being available on each desk for completion during each incident. It is intended that the standardised response protocol for alarm activations, supported by structured questioning, will help gather sufficient information to ensure an appropriate response. However, we have also reiterated to staff that PCOs should feel confident to take the decision, having activated the alarm, not to wait for direction if life-threatening circumstances exist, including opening the cell door and contacting the emergency services directly. More generally I also note the concern in relation to the adequacy of Serco’s assessment of the first aid knowledge and competence of its staff. Staff competence is assessed through formal testing and practical assessments as part of the Level 3 First Aid at Work qualification, together with instructor-led observation and scenario-based assessment during the Initial Training Course, with staff being required to demonstrate competence before being signed off as operational. In relation to the formal testing, learners must achieve at least 70%. Further oral questioning can be undertaken if learners do not achieve the required pass mark. Practical assessment is completed throughout the course delivery, and requires learners to demonstrate practical first aid skills to an acceptable and competent standard. Finally, since the conclusion of the Inquest a review of the jury’s findings has taken place internally in order to attempt to put additional safety measures in place, to avoid a similar incident in the future. This has resulted in a full review of relevant SOPs, updates to training materials to ensure full consistency with those procedures, and the introduction of clearer, more accessible guidance to support staff during suspected medical emergencies. This work has been supported by a structured internal review, with time-bound actions and supporting analysis to ensure that any changes are evidence-led, proportionate and effectively implemented. Serco Justice & Immigration Serco House, 16 Bartley Wood Business Park, Bartley Way, Hook, Hampshire, RG27 9UY United Kingdom T: +44 (0)1256 745 900 | F: +44 (0)1256 744 112 | www.serco.com Serco Group Plc, a company registered in England and Wales No. 2048608 Registered Office: Serco House, 16 Bartley Wood Business Park, Bartley Way, Hook, Hampshire RG27 9UY, United Kingdom

[Page 5] Thank you again for bringing your concerns to our attention. I hope you are reassured by the response to the issues raised. If I can be of any further assistance, please do not hesitate to contact me.

Dear Ms Hassell Prevention of Future Deaths - Mr Sean Williams We acknowledge receipt of your Regulation 28 report dated 20 February 2026 concerning the inquest into the death of Mr Sean Williams. We extend our sincere condolences to the family and all those affected by this tragic event. In response to the matters of concern you have raised, the Healthcare Director for the Metropolitan Police Service (MPS) Custody has outlined the governance and procedures in place to manage the care of detainees. ' Summary of Concern 1 "TheMPShadalreadyrecognisedbeforeinquestthat, followingMrWilliams'detention, he was notseen bya custodynurse for23 hours." MPS Response - Action Taken MPS Custody Teams (Police Sergeant Custody Officer and Designated Detention Officers) complete a risk assessment and identify detainees who require medical assessment. They inform the Healthcare Practitioner (HCP) on duty (Nurse, Doctor or Paramedic). The communication takes the form of a 'medical request' on the MPS CONNECT' system, in addition, a verbal handover is sometimes included direct to the HCP. In this case, there was a delay in referring the individual to the Custody HCP; consequently, operational reminders have been issued reminding Custody Officers to ensure such requests are made. 1CONNECTcaptures MPS data and detainee records into a single, integrated platform.

[Page 2] A new protocol for 'case finding' was implemented in November 2025, where the HCP on duty runs through the custody whiteboard with the Grip Sergeant2 at around 05:30hrs and checks ì ifthere are anydetainees who may have unmet medical needs (i.e. theydo not have a medical request on CONNECT). The Custody HCP will prioritise cases waiting to be seen and check the CONNECT entry, risk . · assessmentand reason for medical referral. Detainees are seen in the medical room or cell depending on their level of cooperation or risk ofviolence. The HCP will complete an initial assessment and devise a plan ofcare, which may include medication and regular reviews. Detainees who present with medical conditions or potential to withdraw from alcohol and/or drugs, are seen as a minimum every six hours whilst in, custody. Some are seen more often depending on their condition and medication needs. Outcome/Impact The MPS are monitoring compliance with protocols regarding 'case finding' and withdrawal management Individual detainee cases are reviewed monthly, and feedback provided to HCPs who are notfollowing clinical practice guidelines and actively completing the discussion with the Grip Sergeant. Summary of Concern 2 "The custodynurse who reviewedMr Williams on two separate occasions in the twelve hours immediate/y before he attended court, did not on the second occasion take any
• observations of Mr Williams' vital signs before (or after) prescribing dihydrocodeine, and didnotrecordanypart'ofMr Williams' clinicalpicture". MPS Response - Action Taken lt is a requirement that the HCP records a full set of vital signs and other observations (e.g. COWS - Clinical Opiate Withdrawal Scale) prior to medication administration. In April 2024, the new SYSTMOne? templates were created which mandate a setof vital signs (unless the patient refuses) to be recorded at the initial clinical assessment and when reviews take place. The importance of detainee reassessment (including vital signs) each time there is a clinical review cannot be underestimated, and this is communicated to all HCPs during the induction and annual refresher programme (Immediate Life Support and Professional Development Days). Detainees may not have fully disclosed / be aware of or understand all their medical needs - their physical or psychological condition can change during their stay in custody. Grip Sergeants lead theteam on duty and managethe effective and safe management ofa custodysuite. 3SYSTMOne isthe healthcare electronicmedical records system.

[Page 3] Regular checks (minimum hourly) by Designated Detention Officers are also part of the 'recognition ofdeterioration' system in place for all detainees in custody. The Clinical Practice Guidelines followed by HCP in custody highlight this approach to safe care and assessment for detainees. Compliance with guidelines and quality of care delivered is monitored through HCP audits led by the Senior HCPs in each area. Feedback and guidance are provided where the documentation falls below standards or there are learning needs to provide the standard ofcare expected from all HCPs working in MPS Custody Suites. HCPs entermedical records inthe NHS SYSTMOne system, which is separatefrom the Police CONNECT system, this maintains medical confidentiality. The system is template driven and requires HCPs to complete mandatory fields (unless the patient refuses to cooperate with observations/questions). This promotes consistency in practiceand record keeping. The HCP is prompted to record a reason in the case that mandatory fields are not completed. Outcome/Impact Regular monitoring of HCP practice is undertaken bya Senior HCPforeach area, who reviews the clinical documentation. The newtemplate has improved the recording ofvital signs ateach review and decision point for medication administration. Summary of Concern 3 "Despite havingprescribeddihydrocodeine fordrug withdrawal, when giving evidence in court the nurse wasunable to describe the signs andsymptoms ofwithdrawal". MPS Response -Action Taken Annual refresher training is in place for· all custody HCPs. This includes assessment and recognition of drug (and alcohol) dependency and withdrawal. The template for opiate dependency/ withdrawal uses the COWS score and the list of signs and symptoms are on the screen. Clinical practice guidelines have been updated to ensure that detainees who are likely to withdraw can be medicated earlier to prevent this. HCPs can follow the Patient Group Direction to provide medication when the detainee is showing signs of withdrawal, if a prescription is required earlier there are non-medical prescribers on duty 24 hours every day. Qutcome/Impact Review ofclinical notes as part ofthe ongoing auditprogramme has resulted in feedback and additional training for HCPs. This focusses on recognising drug and alcohol withdrawal in the custody setting, medication protocols and recognising when medication is not working or requires review.

[Page 4] Clinical Governance Oversight for monitoring clinical standards of care is managed by the Clinical Governance Committee (CGC) which is chaired by the Healthcare Director. Attendance and scrutiny are provided by an external Senior Medical Advisor and Consultant Pharmacist. The CGC review learning from incidents, investigations, and inquests. The Clinical Standards Group informs the CGC of national reviews, changes to guidance and supports local dissemination of learning. We are committed to ensuring that lessons are learned and that robust measures are in place to prevent similar incidents in the future. We will continue to monitorthe effectiveness ofthese changes and make further improvements where necessary. If you require any additional information or evidence of the actions taken, please do not hesitate to contact us.