Inmate at HMP Forest Bank has cardiac arrest and dies after prisoner turns off emergency cell alarm

The incident has prompted a coroner to issue a "prevention of future deaths" report, highlighting serious flaws in the prison's cell bell system.

Assistant Coroner Bronia Hartley criticised the current setup, which allowed a non-vulnerable prisoner to deactivate the emergency alarm.

The non-vulnerable prisoner, referred to as 'Prisoner A', who was outside the cell, deactivated the alarm before resuming a conversation with other inmates.

This action resulted in a one-minute delay before Prisoner A alerted staff at the wing office.

The action potentially delayed Deavall receiving crucial medical assistance.

The coroner's report revealed that both Deavall and his cellmate were "believed to be at risk from other prisoners and were classed as vulnerable prisoners (VPs) accordingly".

In her report, Coroner Hartley expressed grave concerns about the cell bell system at Forest Bank.

She stated that staff became aware of the medical emergency "more by accident than design", criticising the ease with which alarms can be deactivated by other prisoners.

The coroner emphasised that responses to medical emergencies are "generally time critical" and highlighted the recognised risk of non-vulnerable prisoners victimising vulnerable prisoners.

Hartley warned: "There remains a risk that future deaths could occur as it remains the case that emergency cell bells at HMP Forest Bank can be deactivated readily and altogether by other prisoners."

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She added: "In my opinion urgent action should be taken to prevent future deaths."

The report has been sent to Deavall's family, the Ministry of Justice, HM Prison and Probation Service, and Sodexo Justice Services.

In response to the coroner's report, an HMP Forest Bank spokesperson said: "Our thoughts and condolences remain with Mr Deavall's family.

"Following the close of the inquest, we are working with HMPPS and the Ministry of Justice to review the coroner's conclusions and recommendations."