George Haldenby

Dear Ms Griffin, Interim Director General of Prisons HM Prison and Probation Service 8th Floor Ministry of Justice 102 Petty France London SW1H 9AJ REGULATION 28 REPORT TO PREVENT FUTURE DEATHS: MR GEORGE EDWARD JAMES HALDENBY Thank you for your Regulation 28 report of 21 May 2026, following the inquest into the death of George Edward James Haldenby at Dorset County Hospital on 29 January 2022 whilst a prisoner at HMP The Verne. I am responding as the Interim Director General of Prisons, HMPPS, on behalf of the Minister of State for Prisons, Probation and Reducing Reoffending and the Governor of HMP The Verne I know that you will share a copy of this response with Mr Haldenby’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 raised concerns over the lack of regular refresher first aid and cardiopulmonary resuscitation (CPR) training that Prison Staff receive after their initial training. You also mentioned the lack of process in place in prisons without 24-hour healthcare provision to ensure hospital prescribed medication is available when prescribed out of working hours especially over weekends and bank holiday periods and that there is a lack of local policy or

process at HMP The Verne, to direct prison and healthcare staff understanding of how to obtain medication without delay. You will be aware that all new prison officers receive mandatory Emergency First Aid and CPR training as part of their foundation programme. This training remains valid for three years and is subject to requalification. In addition, the HMPPS First Aid Policy Framework (re-issued in August 2023) requires Governors to maintain sufficient first aid provision based on a local First Aid Needs Assessment. To support staff capability, HMPPS provides ongoing refresher resources and learning materials to maintain and enhance first aid knowledge and skills. For example, HMPPS has worked with St John Ambulance to develop bespoke “first-on-scene” video resources for prison officers and frontline staff, offering practical guidance on responding to a range of emergency situations prior to the arrival of healthcare professionals. HMP The Verne is undertaking a comprehensive Training Needs Analysis to inform the development of a structured First Aid training plan. From July 2026, the prison intends to deliver monthly three-day First Aid at Work training programmes. These sessions will be jointly led by the Head of Business Assurance and supported by the Health and Safety Manager. The programme is designed to increase the number of staff trained to a recognised First Aid at Work standard and strengthen the prison’s emergency response capability. Increasing the number of staff trained in First Aid at Work will enable the implementation of a 24-hour, seven-day nominated staff rota, to ensure a coordinated and timely response to emergencies. The initial rollout of training will prioritise key staff groups, including Custodial Managers, Supervising Officers, Care and Separation Unit staff, and Induction Wing staff. A forward-planned training schedule will be maintained throughout the year, incorporating both initial training and refresher courses to ensure ongoing compliance and competency. Although your concerns about the lack of policy/process for healthcare staff around accessing out of hours or hospital prescribed medication has been referred to Oxleas NHS Foundation Trust for their separate consideration and response, HMPPS has also considered whether there is any supportive action that it can take. Oxleas NHS Foundation Trust has confirmed that a formal process and guidance for healthcare teams regarding the management of medicines outside normal operating hours was implemented in September
2024. This is supported by a Standard Operating Procedure, which provides clear direction on the sourcing and provision of prescribed medication during evenings, weekends, and bank holidays. Further collaborative work is being undertaken between prison and healthcare managers to establish a clear and robust local process incorporating defined escalation routes, roles and accountability measures. This will ensure that staff have the necessary clarity and confidence to respond appropriately when out-of-hours medication issues arise, supporting timely access to essential treatment and continuity of care.

I hope the measures outlined above reassure you that appropriate training is in place and that the opportunity to identify learning and address the issues raised has been taken from the circumstances of Mr Haldenby’s death.

Dear Ms Griffin Pinewood House Pinewood Place Dartford Kent DA2 7WG Regulation 28 Report to Prevent Future Deaths - Inquest touching the death of Mr George Edward James Haldenby. Thank you for your regulation 28 report to prevent future deaths dated 2l5t May 2026 following the inquest into the death of Mr George Edward James Haldenby, which concluded on 13thMay 2026. In advance of responding to the specific concerns raised in your report, I would like to express my deep condolences to Mr George Edward James Haldenby's family and loved ones. Oxleas NHS Trust is keen to assure the family and the coroner that the concerns raised about Mr George Edward James Haldenby's care have been listened to and acted upon. I appreciate that responses to Coroner Reports may constitute an important part of process through which family and friends come to terms with the passing of their loved one, and that this will have been an incredibly difficult time for them. In your letter you raised matters of National Concern:
1. The lack of regular refresher first aid and CPR training that Prison Staff receive after their induction training.
2. The lack of process in place in prisons without 24 hour healthcare provision to ensure hospital prescribed medication is available when prescribed out of working hours especially over weekends and bank holiday periods.

And matters of local concern for HMP The Verne (3) The lack of local policy or process so that the prison and healthcare staff understand how to deal with the situation arising at 2 above to ensure a prisoner receives necessary medications without delay. Following a review of these concerns, we can confirm that a formal process has been in place across the Southwest region since September 2024 through the implementation of the Southwest Out of Hours Standard Operating Procedure (SOP)- (Appendices 1). This SOP was circulated to all relevant healthcare teams upon implementation and remains accessible through the organisational document management systems, including the Ox and the SystmOne Pharmacy Document Library. The SOP provides clear guidance to healthcare teams regarding the management of medicines required outside normal operating hours, including arrangements for sourcing and obtaining prescribed medications during evenings, weekends, and bank holidays. The issues identified within the Prevention of Future Deaths report are therefore addressed within the existing governance framework and operational guidance. Upon reflection of the coroner's investigation, it is recognised that the Southwest Out of Hours SOP was not requested or submitted as part of the evidence considered during the investigation process. Had this documentation been provided, it may have assisted in demonstrating the existence of established governance arrangements and operational procedures relevant to the concerns raised. In response to the learning identified through this process, we will strengthen governance arrangements by ensuring that, following any Death in Custody (DIC) investigation where additional evidence is requested, or where medicines management issues are identified, Regional Pharmacists or the Head of Medicines Management are consulted directly. This will help ensure that all relevant SOPs, policies, and supporting governance documentation are identified and submitted as part of future investigations. In addition, this incident has provided an opportunity to further reinforce awareness of existing medicines management policies and SOPs. The Southwest Out of Hours SOP and associated guidance will be recirculated to all healthcare teams, and ongoing training sessions will continue to reinforce staff understanding and compliance. The Medicines Management SOP Log will also be redistributed to all Heads of Healthcare to improve visibility of current medicines-related procedures, alongside signposting staff to the centrally maintained document repository where the most up-to-date versions are held. Whilst these SOPs and policies are developed and maintained centrally, responsibility for local implementation rests with Heads of Healthcare, supported by local Medicines Management teams. They are responsible for ensuring that all relevant staff are familiar with, acknowledge, and adhere to the requirements set out within the SOPs and associated policies. Compliance is monitored through established governance processes, and where individuals are identified as persistently deviating from approved procedures, they will be supported and managed in accordance with the Trust's capability and performance management policies. This may

include additional training, supervision, monitoring, and, where necessary, formal capability procedures. We are therefore satisfied that appropriate policies and procedures are in place to support the timely provision of clinically necessary medication outside normal working hours and have taken further steps to strengthen awareness, oversight, and assurance regarding their implementation across all sites. I hope that this letter reassures you that Oxleas has been highly attentive to the findings of your investigation, and that concerted action has been taken on all the areas you identified to prevent any similar future deaths. Please do not hesitate to contact me if any clarification or further assurance is required.