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. Liverpool and Wirral

    AI-generated summary

    Ceara Marie Thacker · 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

    Ceara Marie Thacker, a 19-year-old University of Liverpool student with a history of self-harm and contact with mental health services, was found deceased hanging on 11 May 2018. Concerns included the lack of discussion about involving her family in care planning and the absence of attempts to cut her down after she was found hanging; the first-aid training received by the person who found her did not cover hangings.

    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

    First aid training lacking hanging-specific response content

    Wider context from the report

    “2. Concern was raised that once Ceara was found hanging, no attempts were made to cut her down. The pathologist gave evidence to the effect it would be difficult to say how quick the death would have occurred, however, there was a very small window after the hanging where a person could survive, be it with brain damage. He stated it was rare that an individual was not cut down. The Residential Adviser who found Ceara had received first aid training but this did not include anything in relation to hangings. ”

    Source location

    Ceara Marie Thacker · Prevention of Future Deaths report
    Page 3 · 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

    The NHS does not determine the content of public first aid courses.

    Verbatim wording from the response

    “One of the actions to prevent future deaths that you directed to NHS Improvement was related to the content of first aid courses for members of the public. The NHS does not determine the content of public first aid courses. We understand the appropriate body to consider action would be the British Red Cross who are a direct provider of first aid training and whose curriculum is the basis for most first training provided by a range of independent training organisations in workplaces, etc. They can be contacted at contactus@redcross.org.uk”

    Source location

    Response from NHS England
    Page 2 · response
    Published 4 June 2025

    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

    Responsibility for considering changes to public first aid course content rests with the British Red Cross.

    Verbatim wording from the response

    “One of the actions to prevent future deaths that you directed to NHS Improvement was related to the content of first aid courses for members of the public. The NHS does not determine the content of public first aid courses. We understand the appropriate body to consider action would be the British Red Cross who are a direct provider of first aid training and whose curriculum is the basis for most first training provided by a range of independent training organisations in workplaces, etc. They can be contacted at contactus@redcross.org.uk”

    Source location

    Response from NHS England
    Page 2 · response
    Published 4 June 2025

    Open published response
  2. London Inner (South)

    AI-generated summary

    ANNABEL NEWPORT · 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

    Annabel Newport collapsed shortly after boarding a train on 21 March 2018 and received CPR from passengers, but there was no defibrillator on board. She was taken to hospital after the train reached Waterloo and died two days later from brain damage suffered during cardiac arrest. The principal concerns were the lack of defibrillators, insufficient first-aid awareness among railway staff, and limitations in the operation of the emergency alarm system.

    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 first aid training of drivers and control staff

    Wider context from the report

    “(ii) First aid awareness among the South Western Railway train guards and other staff 4. South Western Railway train guards are not first aid trained, although under its “Caring for Customers – What to do when a person is taken ill on a train” Protocol, it is the guard who is primarily responsible for identifying whether an unwell passenger’s condition is “life-threatening”. 5. It is also not clear whether South Western Railway drivers and control staff are first aid trained. In this case, the driver knew that Ms Newport had collapsed and was unconscious. There was communication about her between him and the control staff. The control staff decided that the train would proceed to Waterloo, leading to a delay in Ms Newport in her receiving ambulance treatment. This was on the basis that it was not understood that her condition was life-threatening. 6. There is a concern that a lack of first aid training of the driver and/or the control staff may have led to a failure to recognise that being unconscious is a potentially life-threatening condition. ”

    Source location

    ANNABEL NEWPORT · 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

    Lack of first aid training for train guards responsible for identifying life-threatening conditions

    Wider context from the report

    “(ii) First aid awareness among the South Western Railway train guards and other staff 4. South Western Railway train guards are not first aid trained, although under its “Caring for Customers – What to do when a person is taken ill on a train” Protocol, it is the guard who is primarily responsible for identifying whether an unwell passenger’s condition is “life-threatening”. 5. It is also not clear whether South Western Railway drivers and control staff are first aid trained. In this case, the driver knew that Ms Newport had collapsed and was unconscious. There was communication about her between him and the control staff. The control staff decided that the train would proceed to Waterloo, leading to a delay in Ms Newport in her receiving ambulance treatment. This was on the basis that it was not understood that her condition was life-threatening. 6. There is a concern that a lack of first aid training of the driver and/or the control staff may have led to a failure to recognise that being unconscious is a potentially life-threatening condition. ”

    Source location

    ANNABEL NEWPORT · 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

    Publish a revised passenger-illness protocol booklet incorporating explicit life-threatening conditions, worst-case response guidance, and basic lifesaving and first-aid guidance.

    Verbatim wording from the response

    “30 As noted during the Inquest, SWR had been preparing to revise the booklet containing our written protocol for dealing with passenger illness incidents, including cardiac arrest. SWR awaited the outcome of the Inquest so as to incorporate learning from it. We have since published a revised version of that protocol, incorporating a number of changes and improvements, in a booklet called “Caring for our Customers”.”

    Source location

    2019-0240-Response-by-South-Western-Railways
    Page 5 · response
    Published 12 September 2019

    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

    Distribute and embed the revised protocol through Guard and Driver access, Guard briefings, Development Days, Guard cue cards, and Control Centre prompt cards.

    Verbatim wording from the response

    “(a) Each Guard will be issued with, and will have to sign for, a hard copy of the Booklet for their use;”

    Source location

    2019-0240-Response-by-South-Western-Railways
    Page 6 · response
    Published 12 September 2019

    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

    Additional first-aid training would not improve Driver or Control Centre responses because their roles require communication and ambulance coordination.

    Verbatim wording from the response

    “16. Having given proper consideration to the concern raised, it is not clear in what circumstances first aid training of Drivers and staff at the Control Centre would make a difference to the treatment of an on-board passenger. We would certainly never dissuade an employee in either role from taking a first aid course. However, in respect of passenger emergency responses, neither is in a position to administer first aid.”

    Source location

    2019-0240-Response-by-South-Western-Railways
    Page 3 · response
    Published 12 September 2019

    Open published response
  3. East London

    AI-generated summary

    Edir Frederico Araujo DA COSTA · 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

    Edir Frederico Araujo DA COSTA died after his airway became obstructed by a plastic bag containing drugs while he was being restrained by police. The report identified concerns about emergency life-support training, supervision and safety-officer roles during restraint, risks associated with plastic bags and CS spray, recognition of agonal breathing, and communication with the ambulance service.

    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 maintain police officers’ mandatory Emergency Life Support training

    Wider context from the report

    “(1) The evidence at the Inquest revealed that not all police officers are up to date with mandatory Emergency Life Support training. In addition, the current system in place makes it difficult for supervisors to check whether members of their team have received mandatory training. I request that the working group, driven by Met training, review the attendance of officers at mandatory ELS training and review the systems in place for supervisors to monitor attendance. I request that in doing so they consider the concerns raised by Inspector BC in his evidence at the Inquest. ”

    Source location

    Edir Frederico Araujo DA COSTA · 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

    Drive strategic work to reduce officers overdue for mandatory Emergency Life Support and Officer Safety Training.

    Verbatim wording from the response

    “I lead a strategic group to address this challenge and I have been supported by Commander ████████ from ‘Front Line Policing’. Together we have significantly reduced the number of officers who are in need of training. In addition, new issue personal protective equipment is not being given to officers until they are suitably trained and in-date. Corporate communications have been published and the matter discussed personally with the Commissioner in her regular MPS-wide on-line questions and answer sessions. On 12th July 2019 a news item was published on the MPS intranet site confirming this instruction to all officers.”

    Source location

    2019-0211-Response-by-Metropolitan-Police
    Page 1 · response
    Published 23 August 2019

    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

    Withhold newly issued personal protective equipment from officers until their mandatory training is current.

    Verbatim wording from the response

    “I lead a strategic group to address this challenge and I have been supported by Commander ████████ from ‘Front Line Policing’. Together we have significantly reduced the number of officers who are in need of training. In addition, new issue personal protective equipment is not being given to officers until they are suitably trained and in-date. Corporate communications have been published and the matter discussed personally with the Commissioner in her regular MPS-wide on-line questions and answer sessions. On 12th July 2019 a news item was published on the MPS intranet site confirming this instruction to all officers.”

    Source location

    2019-0211-Response-by-Metropolitan-Police
    Page 1 · response
    Published 23 August 2019

    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

    Progress an external-system change to produce and circulate monthly training-compliance reports to senior managers.

    Verbatim wording from the response

    “Recognising that the current electronic training system ‘PSOP’ has some limitations on the data being provided to supervisors, a request for a change with our external partner is being progressed to allow a monthly compliance package to be produced and circulated to senior managers. In the interim, the MPS is re-introducing a paper ‘Form 250C’ training card to be carried by all officers which will be stamped with the date of their last attendance at an approved Officer Safety Training/Emergency Life Support training session. This will make the information more accessible for officers and supervisors to check compliance. As a shorter term measure I have also issued local data packs to enable police commanders to readily understand which of their officers are in need of up-to-date training.”

    Source location

    2019-0211-Response-by-Metropolitan-Police
    Page 2 · response
    Published 23 August 2019

    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

    Reintroduce paper training cards recording officers’ latest approved Officer Safety or Emergency Life Support training attendance.

    Verbatim wording from the response

    “Recognising that the current electronic training system ‘PSOP’ has some limitations on the data being provided to supervisors, a request for a change with our external partner is being progressed to allow a monthly compliance package to be produced and circulated to senior managers. In the interim, the MPS is re-introducing a paper ‘Form 250C’ training card to be carried by all officers which will be stamped with the date of their last attendance at an approved Officer Safety Training/Emergency Life Support training session. This will make the information more accessible for officers and supervisors to check compliance. As a shorter term measure I have also issued local data packs to enable police commanders to readily understand which of their officers are in need of up-to-date training.”

    Source location

    2019-0211-Response-by-Metropolitan-Police
    Page 2 · response
    Published 23 August 2019

    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

    Issue local training data packs enabling commanders to identify officers requiring up-to-date training.

    Verbatim wording from the response

    “Recognising that the current electronic training system ‘PSOP’ has some limitations on the data being provided to supervisors, a request for a change with our external partner is being progressed to allow a monthly compliance package to be produced and circulated to senior managers. In the interim, the MPS is re-introducing a paper ‘Form 250C’ training card to be carried by all officers which will be stamped with the date of their last attendance at an approved Officer Safety Training/Emergency Life Support training session. This will make the information more accessible for officers and supervisors to check compliance. As a shorter term measure I have also issued local data packs to enable police commanders to readily understand which of their officers are in need of up-to-date training.”

    Source location

    2019-0211-Response-by-Metropolitan-Police
    Page 2 · response
    Published 23 August 2019

    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

    Explore incorporating Officer Safety and Emergency Life Support training into team rosters as rostered duty.

    Verbatim wording from the response

    “In the longer term, the MPS is actively exploring opportunities for OST and ELS training to be built into team rosters making it a rostered tour of duty (as opposed to the self-service system currently in place). This work is expected to deliver improvements from April 2020.”

    Source location

    2019-0211-Response-by-Metropolitan-Police
    Page 2 · response
    Published 23 August 2019

    Open published response
  4. South Yorkshire (Eastern)

    AI-generated summary

    Darren McGuin · 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 McGuin, a serving prisoner at HMP Lindholme, was found unresponsive in his cell on 22 February 2018 and later pronounced deceased. The report identified a delay in starting CPR because the prison officers present had not received basic life support training, and noted that some prison staff had never received such 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

    Lack of basic life support training for prison staff

    Wider context from the report

    “1) There was clearly a delay between Mr McGuin being found unresponsive by the prison officers and the commencement of CPR by members of the healthcare staff. Although, earlier CPR would not have altered the outcome in this particulate set of circumstances, it may on a different occasion. 2) Prison officers will usually be first on scene, particularly if a prisoner is found in their cell and this lack of basic life support training is leading to a delay in the commencement of CPR. The evidence before the Court was that prison officers who’s employment either started prior 2005 or after 2017, completed a compulsory three-day Basic Life Support and First Aid course as part of their mandatory training. However, at a date unknown at this time, this training requirement ceased. This inquest has highlighted that there are a number of staff working within the prison service who have never received basic life support training. It is my understanding that there are no efforts being made to identify and provide retrospective training to those members of staff who were appointed during this period of time where basic life support training was not provided. The Ministry of State for Prisons is asked to consider whether it is appropriate for a review to take place to identify and subsequently provide appropriate basic life skill training to all prison staff, who have not received if as part of their mandatory training. ”

    Source location

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

    Open source report
  5. East Sussex

    AI-generated summary

    Ryan Stephen TRIMMER · 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

    Ryan Trimmer was remanded to HMP Lewes on 4 March 2017, had a history of self-harm and suicide attempts, and was found hanging in his cell on 22 April; he died in hospital on 26 April 2017. The inquest identified inadequate ACCT reviews as a matter that caused or contributed to his death. The report also raised concerns about prison staff resourcing on the healthcare wing and the lack of first-aid training among some frontline staff.

    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 training for frontline prison staff

    Wider context from the report

    “Prison staff are often first responders to medical emergencies of prisoners, but not all have received first aid training. One frontline prison staff member gave evidence that he had not received training in 16 years of working for HMPS and felt he needed refresher training. ”

    Source location

    Ryan Stephen TRIMMER · Prevention of Future Deaths report
    Page 1 · 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

    Deliver monthly first aid training to prison staff through two on-site trainers.

    Verbatim wording from the response

    “Two on-site first aid trainers will be delivering first aid training to staff as part of the prison’s monthly training provision, and a one-day refresher course will be introduced to ensure that training levels are maintained. Custodial Managers (the most senior uniformed grade of staff) and Officer Support Grades (staff that support the duties of Prison Officers) have been provided with this training first, in order to ensure that those covering the Orderly Officer role”

    Source location

    2019-0215-Response-by-HM-Prison-and-Probabtion-Service
    Page 1 · response
    Published 23 August 2019

    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

    Introduce a one-day first aid refresher course to maintain staff training levels.

    Verbatim wording from the response

    “Two on-site first aid trainers will be delivering first aid training to staff as part of the prison’s monthly training provision, and a one-day refresher course will be introduced to ensure that training levels are maintained. Custodial Managers (the most senior uniformed grade of staff) and Officer Support Grades (staff that support the duties of Prison Officers) have been provided with this training first, in order to ensure that those covering the Orderly Officer role”

    Source location

    2019-0215-Response-by-HM-Prison-and-Probabtion-Service
    Page 1 · response
    Published 23 August 2019

    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

    Provide priority first aid training to Custodial Managers and Officer Support Grades.

    Verbatim wording from the response

    “Two on-site first aid trainers will be delivering first aid training to staff as part of the prison’s monthly training provision, and a one-day refresher course will be introduced to ensure that training levels are maintained. Custodial Managers (the most senior uniformed grade of staff) and Officer Support Grades (staff that support the duties of Prison Officers) have been provided with this training first, in order to ensure that those covering the Orderly Officer role”

    Source location

    2019-0215-Response-by-HM-Prison-and-Probabtion-Service
    Page 1 · response
    Published 23 August 2019

    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

    Require new prison officers to complete mandatory level 3 Emergency First Aid at Work training, including CPR and defibrillator use.

    Verbatim wording from the response

    “At a national level, since 2016 all new prison officers have completed a mandatory level 3 qualification in Emergency First Aid at Work as part of their Prison Officer Entry Level Training. This includes the application of CPR and the use of a defibrillator. Whilst there is currently no national requirement for all prison staff to be trained in first aid, we are currently reviewing the provision of first aid in prison, and we expect this to result in revisions to first aid policy and training. We have also been working with the Awarding Body on the development of a custodial First Aid awareness course, focusing on key areas and situations that may arise in the prison environment.”

    Source location

    2019-0215-Response-by-HM-Prison-and-Probabtion-Service
    Page 2 · response
    Published 23 August 2019

    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

    Review the provision of first aid in prisons.

    Verbatim wording from the response

    “At a national level, since 2016 all new prison officers have completed a mandatory level 3 qualification in Emergency First Aid at Work as part of their Prison Officer Entry Level Training. This includes the application of CPR and the use of a defibrillator. Whilst there is currently no national requirement for all prison staff to be trained in first aid, we are currently reviewing the provision of first aid in prison, and we expect this to result in revisions to first aid policy and training. We have also been working with the Awarding Body on the development of a custodial First Aid awareness course, focusing on key areas and situations that may arise in the prison environment.”

    Source location

    2019-0215-Response-by-HM-Prison-and-Probabtion-Service
    Page 2 · response
    Published 23 August 2019

    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

    Develop a custodial First Aid awareness course with the awarding body.

    Verbatim wording from the response

    “At a national level, since 2016 all new prison officers have completed a mandatory level 3 qualification in Emergency First Aid at Work as part of their Prison Officer Entry Level Training. This includes the application of CPR and the use of a defibrillator. Whilst there is currently no national requirement for all prison staff to be trained in first aid, we are currently reviewing the provision of first aid in prison, and we expect this to result in revisions to first aid policy and training. We have also been working with the Awarding Body on the development of a custodial First Aid awareness course, focusing on key areas and situations that may arise in the prison environment.”

    Source location

    2019-0215-Response-by-HM-Prison-and-Probabtion-Service
    Page 2 · response
    Published 23 August 2019

    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 arrangements require sufficient first-aid-trained staff on duty, with at least two nurses and one trained prison staff member available at HMP Lewes.

    Verbatim wording from the response

    “Your second concern is that whilst prison staff can often be first on scene at a medical emergency, not all have received training in first aid. The Governors of each prison are required to ensure that there are sufficient numbers of staff trained in first aid on duty, and at HMP Lewes at least two trained nurses and one trained member of prison staff are available at all times.”

    Source location

    2019-0215-Response-by-HM-Prison-and-Probabtion-Service
    Page 1 · response
    Published 23 August 2019

    Open published response
  6. West Sussex

    AI-generated summary

    James William Francis · 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

    James William Francis, who had a history of falls and balance difficulties, suffered an unwitnessed fall at his care home on 9 April 2017 and later developed repeated vomiting and deterioration. He was admitted to hospital with a large subdural haematoma and died on 11 April 2017. The principal concerns included failures in shift handover and monitoring, delays in seeking medical advice, inadequate information provided to paramedics, the patient’s positioning, staff training, and whether relevant guidelines sufficiently addressed this type of injury in elderly patients.

    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 current basic first-aid training for care staff

    Wider context from the report

    “I heard evidence from a number of staff members that they had received no training at all or it was some time (up to 3 years) since they had had any basic first aid training. In addition, the paramedics indicated that when the care home staff were asked what their protocol and understanding was of a head injury with someone who was prescribed anticoagulant, it seemed the staff could not answer. Nor could they spot the signs and symptoms of head injury even though this is basic first-aid ”

    Source location

    James William Francis · 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

    Increase and maintain staff safety training, competency assessment, mandatory-training tracking and first-aider coverage on every shift.

    Verbatim wording from the response

    “All care staff now receive training on “Recognising a Deteriorating Service User” and in addition they also receive first aid training.”

    Source location

    2019-0202-Response-by-Shaw-Healthcare
    Page 3 · response
    Published 23 August 2019

    Open published response
  7. North Wales (East and Central)

    AI-generated summary

    Kathleen Smith · 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

    Kathleen Smith, who had advanced dementia and was at risk of choking, died after being fed unsuitable food and aspirating. The report raised concerns about inadequate staff training, failure to assist during the choking emergency, poor communication, and insufficient management oversight of safe food and fluid care.

    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 training in first aid and assisting residents at risk of choking

    Wider context from the report

    “1. Staff were not sufficiently trained in first aid or how to assist a resident who was at risk of choking. 2. Staff did not intervene to assist the resident for whom the internal emergency alarm had been sounded as help was needed. 3. Staff were not sufficiently trained in how to select and prepare correct foods and fluids for residents with special dietary needs and who had a documented risk of choking. 4. The above training remains incomplete approximately 11 months after the death of Mrs Smith. 5. Staff could not demonstrate they understood how to deliver safe care and treatment regarding food and fluids and manage the risk of choking. 6. There is no adequate management oversight to ensure staff are appropriately deployed to those residents at risk of choking and or who require one to one assistance with food and fluids. ”

    Source location

    Kathleen Smith · 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

    Establish at least one qualified first aider on duty at all times.

    Verbatim wording from the response

    “1a. You expressed concerns in your report regarding our lack of adequate first aiders. Since then I have, despite difficulty obtaining vacant slots, several members of staff on first aid courses. This now allows us to have at least one qualified First Aider on duty.”

    Source location

    2019-0184-Response-by-Coed-Duon-Care-Home
    Page 2 · response
    Published 14 August 2019

    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

    Train current staff in basic dysphagia awareness.

    Verbatim wording from the response

    “1b. All current staff have now been trained on basic awareness of Dysphagia. Also all new staff members have been booked on next available SALT (IDDS) training day which is on 6/08/19. We also now have 2 Dysphagia champions who have done the training for Dysphagia and who are now fully equipped to carry out to train all our staff.”

    Source location

    2019-0184-Response-by-Coed-Duon-Care-Home
    Page 2 · response
    Published 14 August 2019

    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

    Train new staff on SALT IDDS dysphagia procedures at the scheduled training session.

    Verbatim wording from the response

    “1b. All current staff have now been trained on basic awareness of Dysphagia. Also all new staff members have been booked on next available SALT (IDDS) training day which is on 6/08/19. We also now have 2 Dysphagia champions who have done the training for Dysphagia and who are now fully equipped to carry out to train all our staff.”

    Source location

    2019-0184-Response-by-Coed-Duon-Care-Home
    Page 2 · response
    Published 14 August 2019

    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

    Establish two trained dysphagia champions to support staff training.

    Verbatim wording from the response

    “1b. All current staff have now been trained on basic awareness of Dysphagia. Also all new staff members have been booked on next available SALT (IDDS) training day which is on 6/08/19. We also now have 2 Dysphagia champions who have done the training for Dysphagia and who are now fully equipped to carry out to train all our staff.”

    Source location

    2019-0184-Response-by-Coed-Duon-Care-Home
    Page 2 · response
    Published 14 August 2019

    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

    Teach new staff safe care for residents at choking risk and prohibit assistance before completing this training.

    Verbatim wording from the response

    “3. As part of their induction training all new staff members are taught how to deliver safe care in residents with a choking risk. We have also made it very clear to new staff that they are NOT allowed to assist residents at risk of choking until this training has been done.”

    Source location

    2019-0184-Response-by-Coed-Duon-Care-Home
    Page 2 · response
    Published 14 August 2019

    Open published response
  8. Inner North London

    AI-generated summary

    Karanbir Singh CHEEMA · 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

    Karanbir Singh CHEEMA, a pupil at William Perkin High School with multiple food allergies and asthma, went into anaphylactic shock after another pupil threw cheese at him on 28 June 2017 and died. Concerns included inadequate awareness of his allergies, insufficient checking and availability of EpiPens, an out-of-date EpiPen, failures in sharing and standardising allergy action plans, a cancelled follow-up appointment, and shortcomings in emergency response guidance and 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

    Failure to communicate emergency adrenaline instructions effectively in school staff training

    Wider context from the report

    “10. These instructions were not communicated effectively as part of the school staff’s first aid and EpiPen training. ”

    Source location

    Karanbir Singh CHEEMA · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report
  9. South Yorkshire (Western)

    AI-generated summary

    Abigail Hall · 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

    Abigail Hall died at home on 23 September 2015 from aspiration pneumonitis and viral gastro-enteritis. Evidence at the inquest showed that there was no defibrillator at the premises and Derwent staff were not first aid trained; this position apparently still persisted.

    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 training to Derwent staff

    Wider context from the report

    “During the inquest, evidence showed:- There was no defibrillator at the premises nor were Derwent staff first aid trained. This position apparently still persists. ”

    Source location

    Abigail Hall · Prevention of Future Deaths report
    Page 1 · 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

    Review the staff training schedule to address emergency first-aid provision.

    Verbatim wording from the response

    “1. Derwent has reviewed its training schedule and a programme of emergency first aid training for staff has commenced. The training is not compulsory. The training that is scheduled to be delivered will be Emergency First Aid at Work. The Course overview is attached to this response as Appendix 1.”

    Source location

    2018-0286-Response-by-Derwent-Facilities-Management-Limited
    Page 1 · response
    Published 8 January 2019

    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

    Deliver a programme of Emergency First Aid at Work training for staff, targeting approximately 80% of relevant personnel.

    Verbatim wording from the response

    “1. Derwent has reviewed its training schedule and a programme of emergency first aid training for staff has commenced. The training is not compulsory. The training that is scheduled to be delivered will be Emergency First Aid at Work. The Course overview is attached to this response as Appendix 1.”

    Source location

    2018-0286-Response-by-Derwent-Facilities-Management-Limited
    Page 1 · response
    Published 8 January 2019

    Open published response
  10. Liverpool and the Wirral

    AI-generated summary

    Jack Riding · 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

    Jack Riding collapsed while playing football after a genetic heart condition caused his heart to stop, and he was declared dead in hospital on 15 August 2018. The report raised concerns about delays in deploying a defibrillator and directing ambulance personnel to the pitch, as well as the adequacy of emergency medical risk assessments, first-aid training, and related procedures. The report stated that these delays could not be said to have contributed to Mr Riding’s death but presented a risk of future death.

    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 clearly defined first aid training

    Wider context from the report

    “(3) I have seen a limited risk assessment to consider what should be done in the case of a medical emergency on the pitch. I have seen no clear indication of the extent and subject matter of any first aid training. I have seen evidence that training has taken place. In the absence of any such evidence I am concerned that a lack of training may present a risk of future death. ”

    Source location

    Jack Riding · 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

    Provide all club staff with scenario-based emergency First Aid training, including on-site role-play, video learning and annual refreshers.

    Verbatim wording from the response

    “As part of this rollout, situational training and emergency First Aid scenario training will be provided and role-played by all club staff and refreshed annually. Details of this can be found in the response to the training concern detailed in S5 (3).”

    Source location

    2018-0303-Responses
    Page 6 · response
    Published 13 December 2018

    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

    Provide General Managers, Regional Managers and Operations Team members with Level 3 First Aid at Work training by 31 July 2019.

    Verbatim wording from the response

    “Since the incident we have committed to significant increases to further enhance the level of training staff receive:”

    Source location

    2018-0303-Responses
    Page 7 · response
    Published 13 December 2018

    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

    Provide Emergency First Aid at Work training to reception staff working at least 16 hours weekly by 31 July 2019 and all qualifying reception staff by 1 January 2020.

    Verbatim wording from the response

    “• By 31st July 2019 any staff member working 16 hours or more on reception will receive the ‘Emergency First Aid at work’ 1-day course covering practical training and assessment, in addition to video training. Course specification Appendix 7.”

    Source location

    2018-0303-Responses
    Page 7 · response
    Published 13 December 2018

    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

    Add practical defibrillator training and assessment to the First Aid training syllabus and continue providing it to relevant staff.

    Verbatim wording from the response

    “The final level of in-depth and practical training is provided for all Duty Managers. In 2015 we proactively implemented steps to improve Defibrillator training levels. Until 2018 the First Aid training syllabus did not cover practical training in the use of Defibrillators, however following consultation with our First Aid provider, we added Defibrillator practical training into our First Aid syllabus. At this time this training was not a standard topic within the syllabus of the standard qualification (Level 2 Emergency First Aid at Work QCF). Goals consciously implemented Defibrillator practical training well before this was made mandatory.”

    Source location

    2018-0303-Responses
    Page 7 · response
    Published 13 December 2018

    Open published response
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Data last updated 7 September 2026