The report by the Health Services Safety Investigations Body (HSSIB), external found that prisons often encouraged a “low-risk response” when inmates were injured or fell ill.
Some prison control rooms were told to call 999 immediately and then wait for an on-site nurse to examine the patient, and then stand down the ambulance if it was not needed.
High turnover and a lack of training meant that prison staff first on the scene of a medical emergency tended to be inexperienced.
Some staff told the watchdog they were afraid of having to attend a coroner’s court or being blamed for making a wrong decision if they did not call 999.
“You end up with a system that doesn’t work for anybody,” said the HSSIB’s senior investigator Dave Fassam.
“It’s putting pressure on prison staff who are very busy… and paramedics who don’t want to be called to a scenario that doesn’t warrant them being there.”
The watchdog was told that the volume of emergency calls from prisons was now having a knock-on effect on the wider community, with paramedics and call handlers left frustrated after ambulances were diverted from other jobs unnecessarily.
It said communication between prison staff and the emergency services needed to improve significantly, with crews sometimes dispatched to a prison with the wrong information.
In one case, paramedics had been told they were going to treat a patient in his 90s with a twisted ankle. When they arrived they found a man in his 30s with several stab wounds.
