Recurring concern

Inadequate staff competence to provide first aid

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First reported 30 Oct 2013•Latest report 15 Jun 2026

Definition

What this concern includes

Includes deficiencies in first-aid or basic-life-support training, currency, refresher provision, competence assessment, practical skill, emergency recognition or ability to provide CPR and other appropriate first aid where these concern staff expected or likely to respond to emergencies.

Not included

  • Excludes failures concerning unrelated professional, clinical or record-keeping competence where first aid is not the safety issue.
  • Excludes missing or inadequate first-aid equipment, facilities or emergency procedures unless the assertion also directly concerns staff competence to use them.
  • Excludes delays or failures by emergency services or other responders that are not attributed to staff first-aid competence.
  • Excludes generic workforce training deficiencies without a direct first-aid or basic-life-support component.
Reports
95

Distinct published reports

Individual concerns
111

A report can raise multiple concerns

Date range
2013–2026

First to latest report issue date

Stated actions
176

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

HM Prison and Probation Service18
Department of Health and Social Care10
Care Quality Commission9
Ministry of Justice9
NHS England7
Pentonville Prison6
Department for Education5
Practice Plus Group4
Care UK3
Department for Transport3
London Ambulance Service NHS Trust3
College of Policing2
Health and Safety Executive2
Metropolitan Police Service2
North West Ambulance Service NHS Trust2

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. Inner North London

    AI-generated summary

    Cristofaro PRIOLO · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Cristofaro Priolo, an 80-year-old man with progressive Alzheimer’s dementia who lived in a nursing home, choked on cauliflower cheese on 25 November 2020 and died. The report identifies concerns that his food was not prepared or fed in accordance with his assessed needs, and that staff failed to provide appropriate first aid, recognise cardiac arrest, and attempt effective CPR.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of frequent appropriate emergency resuscitation training

    Wider context from the report

    “A BUPA internal investigation has already taken place and identified some learning points. However, there are matters outstanding around training and audit. Obviously, the cauliflower for Mr Priolo should have been prepared properly for him by the catering staff, but quite apart from that, Mr Priolo’s carers were never assessed when they were feeding him. Whilst the carer who was feeding him when he choked knew that he needed small, soft mouthfuls that he should be allowed to swallow completely before offering the next, that is not what happened. He was fed a large quantity of cauliflower cheese, it seems relatively quickly, that was undercooked to the point of being almost raw, making it much too hard for him to swallow safely. Staff, including qualified nursing staff, then failed to give appropriate first aid. Even 18 months after the event when they were giving evidence in court this week – the inquest had been delayed to allow a police investigation – some staff were unable to describe the correct treatment for choking. Most significantly, nursing staff failed to recognise that Mr Priolo had suffered a cardiac arrest. They then failed to attempt CPR. After the arrival of paramedics, one member of nursing staff did attempt to give chest compressions, but these were ineffective. That is likely to be the result of panic and distress. These are common feelings in an emergency situation, but the risk of them overwhelming resuscitation efforts may be reduced by frequent appropriate training. ”

    Source location

    Cristofaro PRIOLO · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to provide appropriate first aid for choking

    Wider context from the report

    “A BUPA internal investigation has already taken place and identified some learning points. However, there are matters outstanding around training and audit. Obviously, the cauliflower for Mr Priolo should have been prepared properly for him by the catering staff, but quite apart from that, Mr Priolo’s carers were never assessed when they were feeding him. Whilst the carer who was feeding him when he choked knew that he needed small, soft mouthfuls that he should be allowed to swallow completely before offering the next, that is not what happened. He was fed a large quantity of cauliflower cheese, it seems relatively quickly, that was undercooked to the point of being almost raw, making it much too hard for him to swallow safely. Staff, including qualified nursing staff, then failed to give appropriate first aid. Even 18 months after the event when they were giving evidence in court this week – the inquest had been delayed to allow a police investigation – some staff were unable to describe the correct treatment for choking. Most significantly, nursing staff failed to recognise that Mr Priolo had suffered a cardiac arrest. They then failed to attempt CPR. After the arrival of paramedics, one member of nursing staff did attempt to give chest compressions, but these were ineffective. That is likely to be the result of panic and distress. These are common feelings in an emergency situation, but the risk of them overwhelming resuscitation efforts may be reduced by frequent appropriate training. ”

    Source location

    Cristofaro PRIOLO · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Provide and competency-assess Basic Life Support and DNACPR training, including practical choking and CPR assessment.

    Verbatim wording from the response

    “• Training around Basic Life Support (“BLS” – the content of which includes addressing and dealing with choking incidents and CPR) and DNACPRs. This training involved an online/classroom based training session, as well as a practical session, where learners are practically assessed, and are not deemed competent until the trainer is satisfied that a learner is competent. We are mindful of your on-going concerns in relation to those nurses who gave evidence during the inquest, and we have said more on this point below – see “concerns 3, 4 & 5”, below.”

    Source location

    Response from BUPA Care Services
    Page 1 · response
    Published 12 May 2022

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Have the Internal Lead Inspector attend Basic Life Support training to assess its quality and efficacy.

    Verbatim wording from the response

    “9. Our Internal Lead Inspector will attend training in Basic Life Support (BLS) to assess the quality and efficacy of the training provided internally by Bupa. To reassure you, our BLS and Emergency First Aid at Work trainers are all qualified and trained by external training providers. During this training our staff are evaluated and leave the classroom assessed as competent. This includes a practical assessment of delivery of chest compressions.”

    Source location

    Response from BUPA Care Services
    Page 4 · response
    Published 12 May 2022

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Retrain remaining Highgate staff and ensure they are competent and confident to manage future choking, cardiac arrest and CPR incidents.

    Verbatim wording from the response

    “10. Given the concerns raised at inquest regarding the competence of some of The Highgate staff, we will ensure that those who remain within The Highgate are retrained, competent and confident to manage any further incidents in the future.”

    Source location

    Response from BUPA Care Services
    Page 4 · response
    Published 12 May 2022

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Consider implementing more frequent competency checks or opportunities to practise chest compressions.

    Verbatim wording from the response

    “We will, however, consider whether or not to implement more frequent competency checks, or opportunities to practice chest compressions. It should be kept in mind though that nurses have a professional obligation to take responsibility and ensure that they feel confident to carry out their role and maintain their competencies in line with NMC requirements.”

    Source location

    Response from BUPA Care Services
    Page 4 · response
    Published 12 May 2022

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Existing evidence indicates Highgate BLS delegates passed competency assessments, disputing that training competence was absent.

    Verbatim wording from the response

    “We did, however, make enquiries with our Learning and Development team as to the training provided to staff at Highgate, including some of those who gave evidence at the inquest. We wanted to be sure that there had been no issue with their engagement or competency checks. The feedback from our trainer on the BLS training delivered at Highgate was that all delegates (which would include some of those who gave evidence during the inquest) had all passed first time and had a completed competency assessment on file, which confirmed, amongst other things, competent to deliver CPR and how to respond to a choking incident. However, the relevant staff will attend further training to ensure competency.”

    Source location

    Response from BUPA Care Services
    Page 4 · response
    Published 12 May 2022

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Annual BLS training frequency is not out of step with other social care providers.

    Verbatim wording from the response

    “11. We also note your comments in relation to the frequency of training. At present, BLS is scheduled on an annual basis, although during the pandemic, there was a time during which practical assessments by trainers could not take place, due to measures put in place to comply with government guidance and infection prevention control measures. To the best of our knowledge, the frequency of our training is not out of step with other social care providers and our focus will be as outlined above, which is ensuring the quality and competency of our trainers, the content of our training and the competency checks, to ensure staff leave training confident and competent.”

    Source location

    Response from BUPA Care Services
    Page 4 · response
    Published 12 May 2022

    Open published response

  2. Leicester City and South Leicestershire

    AI-generated summary

    Jane Louise SHILTON · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Jane Louise Shilton, who had severe and enduring mental health difficulties and lived in a residential care home, was found unresponsive in her bedroom and was pronounced dead at the scene. The report raises concerns about the failure to check on her after missed medication, dinner and cigarettes, the absence of overnight proactive checks, and the staff’s response to the medical emergency, including not checking breathing or pulse and not attempting CPR. It also raises concerns about the quality and frequency of first-aid training.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Inadequacy of online first aid training

    Wider context from the report

    “I was told during the inquest that Hamilton House First Aid Training was outdate at the point Jane died and I have since been provided with the First Aid Training Certificates which evidence that First Aid Training was provided to staff once every 3 years, and this was in 2018 and staff had received updated training in 2021, within the 3 year time frame. I remain concerned and that concern is heightened when having heard the evidence of the support workers on shift that evening to learn that updated first aid training was only undertaken 5 days prior to this incident. I understand that the first aid training in 2021 was delivered online given the Cv19 restrictions. I further understand that whilst yearly first aid refresher training can be undertaken Hamilton House have not required staff to undergo such training. As I have found in this inquest sadly for Jane the failure to attempt to deliver any first aid would not have made any difference in her case as she had been sadly passed away for some time. However, the way in which the incident was handled which is evident from the 999 call which gave rise to a safeguarding alert does deeply trouble me especially in the context of learning that refresher training had been received by the individuals engaged with the incident only 5 days prior. This causes me to question quality of that training in the context of an online setting given the pandemic. I am further concerned that first aid training is only undertaken at the minimum requirement of every 3 years, given that Hamilton House is charged with the responsibility of looking after some of society’s most vulnerable individuals who I am told have co-existing difficulties of both mental health but also substance misuse. ”

    Source location

    Jane Louise SHILTON · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to provide first aid refresher training more frequently than every three years

    Wider context from the report

    “I was told during the inquest that Hamilton House First Aid Training was outdate at the point Jane died and I have since been provided with the First Aid Training Certificates which evidence that First Aid Training was provided to staff once every 3 years, and this was in 2018 and staff had received updated training in 2021, within the 3 year time frame. I remain concerned and that concern is heightened when having heard the evidence of the support workers on shift that evening to learn that updated first aid training was only undertaken 5 days prior to this incident. I understand that the first aid training in 2021 was delivered online given the Cv19 restrictions. I further understand that whilst yearly first aid refresher training can be undertaken Hamilton House have not required staff to undergo such training. As I have found in this inquest sadly for Jane the failure to attempt to deliver any first aid would not have made any difference in her case as she had been sadly passed away for some time. However, the way in which the incident was handled which is evident from the 999 call which gave rise to a safeguarding alert does deeply trouble me especially in the context of learning that refresher training had been received by the individuals engaged with the incident only 5 days prior. This causes me to question quality of that training in the context of an online setting given the pandemic. I am further concerned that first aid training is only undertaken at the minimum requirement of every 3 years, given that Hamilton House is charged with the responsibility of looking after some of society’s most vulnerable individuals who I am told have co-existing difficulties of both mental health but also substance misuse. ”

    Source location

    Jane Louise SHILTON · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Arrange face-to-face First Aid training with the training provider.

    Verbatim wording from the response

    “• First Aid training is now mandated annually instead of the previous 3 year requirement and in light of Covid-19 restrictions coming to an end this training will be carried out face-to-face. We are communicating with our training provider to accommodate this training as we can not complete the training in one session. We hope to complete this by the end of April 2022.”

    Source location

    2022-0053-Response-from-Hamilton-Community-Homes-Ltd_Published
    Page 2 · response
    Published 24 February 2022

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Mandate annual First Aid training instead of training every three years.

    Verbatim wording from the response

    “• First Aid training is now mandated annually instead of the previous 3 year requirement and in light of Covid-19 restrictions coming to an end this training will be carried out face-to-face. We are communicating with our training provider to accommodate this training as we can not complete the training in one session. We hope to complete this by the end of April 2022.”

    Source location

    2022-0053-Response-from-Hamilton-Community-Homes-Ltd_Published
    Page 2 · response
    Published 24 February 2022

    Open published response

  3. Surrey

    AI-generated summary

    Henry Edward Hullin Doll · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Henry Edward Hullin Doll, who had a learning disability, Down’s Syndrome and dementia and was at high risk of aspiration and choking, entered the kitchen of his residential care home alone on 21 February 2021, obtained a shortbread biscuit, choked and aspirated on it, and died the following day from aspiration pneumonia. The court found that the risks of him obtaining unsuitable food and eating it unsupervised had not been identified or appropriately prevented. Concerns also related to the way risk assessments were completed and the effectiveness of staff CPR training.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Insufficient staff capability to provide effective CPR

    Wider context from the report

    “2. The court found that the CPR provided by staff to Mr Doll on 21 February 2021 prior to the arrival of the paramedics was ineffective, albeit this did not contribute to his death. The Avenues Groups is invited to consider whether staff have received sufficient practical training so as to ensure that they are confident and capable of carrying out effective CPR. ”

    Source location

    Henry Edward Hullin Doll · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

  4. Manchester South

    AI-generated summary

    Emiel Ariel Malinski · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Emiel Ariel Malinski attended a miniature rifle range on 2 November 2020, where he fired a rifle in the direction of his right temple and later died in hospital. The report recorded that he died as a consequence of suicide and raised concerns about the limited regulation of miniature rifle ranges, including the absence of requirements for supervision, secure weapons, ammunition control and first-aid provision.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to provide first-aid-trained staff and a first-aid kit

    Wider context from the report

    “It is a matter of concern that the continued existence and operation of s11 (4) Firearms Act 1968 enables miniature rifle ranges to operate with no minimal regulation, with attendees able to fire miniature rifles and ammunition not exceeding .23 calibre and air weapons in a largely unregulated environment. In addition, it is a matter of particular concern that the following specific requirements do not currently apply to miniature rifle ranges: 1) Requirement for the user to sign a prohibited person (Section 21) declaration on each and every visit; 2) Requirement for the weapon to be securely tethered so that any projectile discharged from it can only be ‘down range’; 3) Requirement for a competent Range Conducting Officer (“RCO”) to be present on the range at all times to enable effective supervision of the shooter; 4) Requirement for the weapon to be loaded for the customer by the RCO or other member of staff so ammunition may be accounted for; 5) Requirement for the RCO or other member of staff present to be first aid trained with a first aid kit present; 6) Requirement for any weapon or ammunition used on the range to be kept secure, controlled and supervised by a member of staff at all times. ”

    Source location

    Emiel Ariel Malinski · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  5. South Yorkshire (Eastern)

    AI-generated summary

    Darren Adams · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Darren Adams was transferred between prisons and, within 24 hours of arrival, experienced a deterioration in his mental health. He was found ligatured in his cell on 12 November 2017 and was declared dead at hospital on 13 November 2017; the inquest concluded that he died by suicide. Concerns included nursing staff misdiagnosing hypostasis and rigor mortis, insufficient training in identifying these conditions, and potentially confusing definitions in CPR guidance.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Insufficient life support training coverage of hypostasis and rigor mortis identification

    Wider context from the report

    “3. Management of the nurses accepted in evidence that more focus on the identification of those conditions should have been covered in better depth during the nurse’s life support training. ”

    Source location

    Darren Adams · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Introduce mandatory ILS teaching on hypostasis, lividity and rigor mortis, including mandatory decision-making scenarios, through the revised curriculum from July 2021.

    Verbatim wording from the response

    “• Practice Plus Group mandates annual Intermediate Life Support Training (ILS) for all clinical staff in recognition of their critical role in providing pre hospital life support. Non clinical staff are trained in Basic Life Support and agency staff are required to have undertaken ILS training and can access the training provided by Practice Plus Group. The curriculum for PPG’s ILS training has been adapted by our training provider to include prison specific scenarios. The training is delivered by Resuscitation Council accredited trainers. Following this request, the training provider has spoken to staff who have been involved in resuscitation decision-making scenarios to hear their experiences and understand the issues that are faced, including the challenges of diagnosing hypostasis. Our training provider has amended the content of the previously provided ILS course to include:”

    Source location

    Response from Practice Plus Group
    Page 2 · response
    Published 4 May 2021

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Detailed training in recognising rigor mortis and hypostasis falls outside the scope of RCUK training courses.

    Verbatim wording from the response

    “6. Training and clinical experience are required to be able to reliably diagnose irreversible death based on the presence of rigor mortis and hypostasis. Detailed training in the recognition of rigor mortis and hypostasis is outside the scope of RCUK training courses.”

    Source location

    2021-0125-Response-from-Resuscitation-Council-UK_Published
    Page 2 · response
    Published 4 May 2021

    Open published response

  6. Staffordshire South

    AI-generated summary

    Kevin John LOVATT · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Kevin John LOVATT was a serving prisoner at HMP Dovegate who died at the prison on 22 December 2017 after swallowing a package of illicit drugs and choking. The report identified concerns about communication, the response to choking, confusion at the scene, access to Advanced Life Support-trained staff and training on managing prisoners with items in their mouths that could compromise breathing.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Insufficient provision of Advanced Life Support-trained staff in the prison estate

    Wider context from the report

    “During evidence at the inquest I heard that nursing staff at HMP Dovegate (and throughout the prison estate) are trained to an Intermediate Life Support level. I realise it would be impractical for all nursing staff at prisons to be trained to an Advanced Life Support level however I was informed that at some stage there was at least one paramedic employed at HMP Dovegate who was trained to ALS level. I wonder if there might be some limited provision of ALS trained staff in the prison estate and if this could be part of the appropriate commissioning arrangements. ”

    Source location

    Kevin John LOVATT · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Advanced Life Support training is not appropriate for prison healthcare professionals because it may require procedures outside their registered clinical competencies.

    Verbatim wording from the response

    “The Resuscitation Council UK, who provide the recognised guidelines, including training, for England, outline that Advanced Life Support is appropriate for healthcare professionals who would undertake advanced life support as part of their clinical duties. This includes doctors, paramedics and nurses working in acute care areas (e.g. Emergency Departments, Coronary Care Units, Intensive Care Units, high dependency units, operating theatres, acute medical admissions units) or on resuscitation/medical emergency Critical Care outreach Teams. Advanced Life Support also involves some specialist clinical procedures which, to be clinically effective and cause no harm, must be performed as a regular part of clinical duties.”

    Source location

    2021-0012-Response-from-NHS-England-and-NHS-Improvement_Published
    Page 2 · response
    Published 20 January 2021

    Open published response

  7. Gwent

    AI-generated summary

    John Allan TUCKER · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    John Allan Tucker had significant coronary artery disease, underwent four-vessel coronary artery bypass grafting in 2018, and later died from congestive cardiac failure associated with cardiomegaly, ischaemic heart disease, coronary artery disease, and reported drugs and alcohol intake. Concerns were raised about the nature and extent of basic life support and first aid training provided to Gwent Police staff who may encounter people with respiratory problems.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Uncertainty about the nature and extent of basic life support and first aid training for police staff

    Wider context from the report

    “The information from ████████ of the MOSOVO team and DS ████████ ████████ raised some concerns about the nature and extent of basic life support and first aid training provided to the different staff employed by Gwent police who of course may be in regular contact with people who are unwell or injured giving rise to respiratory problems. ”

    Source location

    John Allan TUCKER · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  8. Lancashire and Blackburn with Darwen

    AI-generated summary

    Brett Anthony Marrs · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Brett Anthony Marrs, a long-term drug user, was found collapsed in his prison cell after morning unlock on 4 September 2018. The inquest concluded that he died as a result of synthetic cannabinoid and morphine toxicity. Concerns included inadequate first-aid and resuscitation training for prison officers and failures to conduct welfare checks during morning cell unlocks.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of first-aid and resuscitation training for prison officers

    Wider context from the report

    “1. Two long-serving prison officers who gave evidence at the inquest deposed to the fact that they had never been given first-aid training, including training in resuscitation techniques, during their service as prison officers despite the fact that prior to 2016 such training was meant to form part of core training for prison officers. Evidence was further given that first aid refresher training is to be rolled out but that no date has yet been fixed for completion of such training programmes. ”

    Source location

    Brett Anthony Marrs · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to complete first-aid refresher training programmes

    Wider context from the report

    “1. Two long-serving prison officers who gave evidence at the inquest deposed to the fact that they had never been given first-aid training, including training in resuscitation techniques, during their service as prison officers despite the fact that prior to 2016 such training was meant to form part of core training for prison officers. Evidence was further given that first aid refresher training is to be rolled out but that no date has yet been fixed for completion of such training programmes. ”

    Source location

    Brett Anthony Marrs · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  9. Black Country

    AI-generated summary

    Zachary James Johnson · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Zachary James Johnson was born in a birthing pool on 15 October 2016 after his foetal heart rate could not be auscultated for approximately 38 minutes because no working waterproof sonicaid was available. He was born floppy and unresponsive, and problems occurred during resuscitation, including incorrect ventilation-to-compression ratios, a period without chest compressions, and an interruption in airway management during transfer to hospital. The concerns included the availability of appropriate monitoring equipment and insufficiently frequent mandatory refresher training in newborn life support skills.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Insufficient mandatory refresher training in newborn life support skills

    Wider context from the report

    “(6) I also heard evidence that most midwives will go through their whole career without experiencing a situation requiring new born resuscitation. I heard evidence that the mandatory training on NBLS was valid for 4 years and whilst the Walsall Healthcare NHS Trust had provided annual refresher training this was not guaranteed to continue. My concern is that there is insufficient frequent mandatory refresher training in new born life support skills. ”

    Source location

    Zachary James Johnson · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  10. Brighton and Hove

    AI-generated summary

    Bethany Tengquist · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Bethany Tengquist hanged herself on 29 December 2018 after two telephone charging cables had been removed from her room but her dressing gown cord remained available. The report raises concerns that room checks and the removal of dangerous items were incomplete and flawed, and that staff may not have been properly trained.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Inadequate emergency life support and first aid training for healthcare staff

    Wider context from the report

    “3. First aid training. I am gravely concerned by the evidence that not all health care staff working on Caburn Ward were adequately trained in emergency life support or first aid. It is axiomatic that all members of health care staff must be competent and able to deal with circumstances were first aid skills may need to be deployed. At least one member of staff admitted that she did not have these skills even when she gave evidence to the jury, notwithstanding that she had been appointed as a substantive member of staff some seven months following the death, and three months before she gave evidence. ”

    Source location

    Bethany Tengquist · Prevention of Future Deaths report
    Page 5 · concerns

    Open source report
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Data last updated 7 September 2026