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

    Catherine Mary GIBBON · 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

    Catherine Mary Gibbon suffered a seizure while swimming at a gym on 1 June 2018 and remained face down in the water for around ten minutes. She sustained a hypoxic-ischaemic brain injury following non-fatal drowning and died. Concerns included inadequate pool monitoring and CCTV arrangements, a broken camera, insufficient staff training and emergency equipment, and gaps in first-aid certification systems.

    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 prevent first aid certificate lapses through a failsafe renewal system

    Wider context from the report

    “9. Fitness First had made the decision that all first aid certificates would be renewed after one year rather than the usual three, but then the certificates were allowed to lapse because one person made an error and there was no failsafe system. ”

    Source location

    Catherine Mary GIBBON · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report
  2. Inner South London

    AI-generated summary

    Yunis Malik Hadi · 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

    On 28 January 2018, Yunis Malik Hadi choked and collapsed while eating a snack at a Sunday school, and could not be resuscitated despite CPR efforts. The concerns included inadequate first-aid training for volunteers, lack of emergency medical equipment such as a defibrillator, and insufficient oversight of training, supervision and child safeguarding.

    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 formal first-aid and choking-response training among adult volunteers and teachers

    Wider context from the report

    “(1) A lack of formal training among the adult volunteers/teachers in first aid including response to choking incidents. ”

    Source location

    Yunis Malik Hadi · 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

    Advise the Centre about accessible first-aid training and provide training details.

    Verbatim wording from the response

    “The local authority does not offer free first aid training, however, subsequent to the incident the Education Safeguarding Manager contacted the Centre to advise about training that can be accessed through agencies such as St John's Ambulance or the British Red Cross.”

    Source location

    2018-0209-Response-by-London-Borough-of-Lambeth
    Page 2 · response
    Published 14 August 2018

    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

    The local authority does not offer free first-aid training, limiting its ability to provide that training directly.

    Verbatim wording from the response

    “The local authority does not offer free first aid training, however, subsequent to the incident the Education Safeguarding Manager contacted the Centre to advise about training that can be accessed through agencies such as St John's Ambulance or the British Red Cross.”

    Source location

    2018-0209-Response-by-London-Borough-of-Lambeth
    Page 2 · response
    Published 14 August 2018

    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

    The local authority has no specific enforcement powers in relation to the identified safeguarding, training and supervision matters.

    Verbatim wording from the response

    “The Charity Commission will be advised of this letter to enable their action and follow-up. Additionally Lambeth Council (schools safeguarding team) will follow-up on the actions indicated above through the safeguarding training taking place in mid-September and also via a visit by the Council’s Food, Health and Safety Manager. As indicated, we do not have any specific enforcement powers in relation to these matters. Any further findings from the Wandsworth Child Death Overview Panel, once completed, will be undertaken by Lambeth Council and its statutory partners once that review has concluded and its recommendations are known.”

    Source location

    2018-0209-Response-by-London-Borough-of-Lambeth
    Page 3 · response
    Published 14 August 2018

    Open published response
  3. Suffolk

    AI-generated summary

    ASHLEY ERNEST NOTSON · 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

    Ashley Notson died at age 55 after choking on a piece of meat at the care home where he lived, later dying in hospital from hypoxic brain injury resulting from the choking episode. The inquest raised concerns that the law did not require care-home carers to have first-aid training or to have access to a mobile or portable telephone to summon assistance without leaving the person they were caring for.

    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 a requirement for care providers to ensure that care-home carers have first-aid training

    Wider context from the report

    “The inquest heard that the law currently does not require care providers to ensure that carers in a care home have had first aid training. Fortunately, the carer on duty at the time of incident was trained in first aid and did what he could to assist Ashley, but a similar situation could clearly arise in another care home without such a suitably trained carer present. The inquest also heard that, at this care home, all carers carry a mobile or portable telephone so that they can summon assistance if an incident occurs without having to leave the person they are looking after, but that this was not a legal requirement either. ”

    Source location

    ASHLEY ERNEST NOTSON · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
  4. Inner North London

    AI-generated summary

    MARK ANTHONY DOYLE · 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

    Mark Anthony Doyle was found suspended by a ligature attached to his cell window bars on 21 March 2017 and died in hospital on 28 March 2017 from injuries sustained in the suspension. The inquest identified concerns including errors in recording a significant anniversary on his ACCT, his transfer from F Wing, and a delay in responding to his cell bell. Further concerns related to ACCT review and information-sharing practices, unclear criteria and recording for transfers from F Wing, and the lack of mandatory first-aid training for existing prison officers.

    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 mandatory first aid training for existing prison officers

    Wider context from the report

    “(4) There is no mandatory first aid training for existing (as opposed to new) prison officers. I was informed that Orderly Officers and OSGs have / are being provided with first aid training, but I am concerned this remains a serious lacuna. I appreciate it is a nationally made resourcing decision and that it has been raised previously, but I raise it for further consideration; in light of the limited number of prison and nursing staff on duty overnight, there is a real prospect of medical emergencies arising where no trained first aider is available. ”

    Source location

    MARK ANTHONY DOYLE · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  5. Portsmouth and South East Hampshire

    AI-generated summary

    Ronald Frank JONES · 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

    Ronald Frank JONES fell in the bathroom of his sheltered housing on 25 January 2017, was moved to his bed, admitted to hospital the following day, and died on 4 February 2017. The principal concern was that staff who moved him after the fall had not received first aid training, creating a risk of injury or worsening existing injuries.

    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 staff involved with residents in sheltered housing schemes

    Wider context from the report

    “I was told in evidence at Mr JONES inquest that following his fall, he was moved to his bed by personnel who had not undergone first aid training as this had been discontinued by Portsmouth City Council. If persons are moved following a fall, unless this is done correctly, there is a risk that they may be injured or their existing injuries exacerbated, potentially fatally. The Council should consider re-activating this training for all staff involved with residents in the City council's sheltered housing schemes. ”

    Source location

    Ronald Frank JONES · 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

    Provide sheltered housing staff with responding-to-accidents-and-sudden-illness training.

    Verbatim wording from the response

    “The sheltered housing staff only provide housing related support to help residents maintain independent living in our sheltered housing schemes. All sheltered housing staff attend a 'responding to accidents and sudden illness' course which covers the typical type of incidents that arise in the schemes. All sheltered housing staff receive 'handling people' training which involves both theoretical and practical training. This training takes place for new members of staff and then every member of staff attends refresher training on this topic every 3 years. In addition to this, sheltered housing staff undertake Falls Prevention Awareness training which looks at risks and how these can be minimised.”

    Source location

    2017-0416-Response-by-Portsmouth-City-Council
    Page 1 · response
    Published 27 February 2018

    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 for sheltered housing staff is not required because their existing role-specific training is adequate and trained responders provide lifting support.

    Verbatim wording from the response

    “In light of these findings it does not seem that additional training in first aid for Portsmouth City Council Housing sheltered housing staff teams is required. The training they have is tailored to their role and responsibilities. The Night Responder Team who did attend to Mr Jones do have the appropriate training to lift Mr Jones and are first aid trained.”

    Source location

    2017-0416-Response-by-Portsmouth-City-Council
    Page 3 · response
    Published 27 February 2018

    Open published response
  6. Manchester City

    AI-generated summary

    Anthony William McCormack · 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

    Anthony William McCormack became unwell and collapsed while an aircraft was taxiing at Manchester Airport, later suffering cardiac arrest and dying after resuscitation attempts at Wythenshawe Hospital. The report identified concerns about Emirates staff recognising cardiac arrest and agonal breathing, starting CPR promptly, and procedures when the Tempus system could not provide assistance. It also raised concerns about ambulance response targets and the availability of only one paramedic at Manchester Airport.

    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 training of airline staff to recognise cardiac arrest and administer first aid or prompt CPR

    Wider context from the report

    “• The adequacy of the training of Emirates staff in respect of the recognition of possible cardiac arrest and signs thereof including agonal breathing and the administration of appropriate first aid/prompt CPR ”

    Source location

    Anthony William McCormack · 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 initial and annual refresher first-aid and CPR training to cabin crew, including recognition of abnormal breathing as a cardiac-arrest sign.

    Verbatim wording from the response

    “First Aid and CPR training is undertaken by all Emirates cabin crew both as part of their initial training and also on an annual basis as refresher training on medical procedures. The CPR training conducted by Emirates in each of these instances meets the rigorous standards set by leading international bodies, including the International Liaison Committee on Resuscitation (ILCOR), the American Heart Association (AHA) and the European Resuscitation Council. This training includes information on the recognition of abnormal breathing as a sign of cardiac arrest and this is reflected in the Emirates Operating Manuals and training materials covering this issue.”

    Source location

    2017-0241-Response-by-Emirates
    Page 1 · response
    Published 2 October 2017

    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 training, manuals and ongoing monitoring of resuscitation developments are considered sufficient; no additional cardiac-arrest training action is proposed.

    Verbatim wording from the response

    “First Aid and CPR training is undertaken by all Emirates cabin crew both as part of their initial training and also on an annual basis as refresher training on medical procedures. The CPR training conducted by Emirates in each of these instances meets the rigorous standards set by leading international bodies, including the International Liaison Committee on Resuscitation (ILCOR), the American Heart Association (AHA) and the European Resuscitation Council. This training includes information on the recognition of abnormal breathing as a sign of cardiac arrest and this is reflected in the Emirates Operating Manuals and training materials covering this issue.”

    Source location

    2017-0241-Response-by-Emirates
    Page 1 · response
    Published 2 October 2017

    Open published response
  7. Manchester South

    AI-generated summary

    William Joseph WILSON · 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

    William Joseph WILSON choked on a piece of steak, suffered hypoxic brain damage and remained in a coma before receiving end-of-life care and dying in hospital on 2 February 2017. Concerns included that the designated first aider was not called, there was no clear system for alerting the first aider, and staff attending Mr Wilson were unfamiliar with all life-saving first-aid techniques.

    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 familiarity with first-aid life-saving techniques

    Wider context from the report

    “[BRIEF SUMMARY OF MATTERS OF CONCERN] (1) I was informed in evidence by the manager of the Church Inn that the designated first aider was the Chef who was not called to the scene. (2)The Manager of the Church Inn was unable to inform me of the system for alerting the first aider to any problem to ensure he attended the scene. (3)The manager and his colleague who attended upon the deceased were unfamiliar with all of the first aid life saving techniques when dealing with Mr Wilson. ”

    Source location

    William Joseph WILSON · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
  8. Inner North London

    AI-generated summary

    Nasar AHMED · 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

    Nasar died following an anaphylactic reaction contributed to by asthma while he was in the internal exclusion room at school. The concerns included delayed or inappropriate advice about using his adrenaline auto-injector, discrepancies and gaps in asthma and allergy care planning, unsuitable emergency inhaler equipment, inadequate medication review systems, and shortcomings in staff awareness, training and emergency procedures.

    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 first-aid training for staff supervising pupils

    Wider context from the report

    “The respiratory paediatrician who gave evidence at inquest was firmly of the view that generic adrenaline auto-injectors should be available, in much the same way as defibrillators, in public spaces. Is this a suggestion that could be given wider consideration? 1. While staff at Nasar’s school were waiting for an ambulance, they asked for advice from the call operator about whether to administer his EpiPen. They were put through to a paramedic, who advised not to use it, I think because the classic signs of anaphylaxis were not obvious. However, the firm view expressed to me at inquest by Nasar’s respiratory paediatrician was that, if a person has an adrenaline auto-injector and: - has any respiratory compromise, or - there is a loss of consciousness, or - if there is doubt, then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately. He explained that any harm caused by giving intra muscular adrenaline from an auto-injector in this situation is likely to be minimal, even if it proves not to have been needed, whereas the good if it is needed is potentially lifesaving. 1. The picture presented by Nasar to his respiratory paediatrician did not accord, the consultant discovered at inquest, with that given to Nasar’s general practitioner. Nasar reported to his consultant that he was experiencing few symptoms, and he did extremely well in his last lung function test. Yet his GP found Nasar’s asthma control score to be 14 out of 25, which is poor; and his GP was prescribing 30 inhalers a year, the necessity for which is well recognised as being a risk factor for death. Nasar should have seen his consultant again. There must be a way of identifying a child in his position. For instance, could there be an automatic flag raised if excess medication is prescribed? 2. The asthma pump in Nasar’s medication box at school was an Accuhaler, which I heard from his respiratory consultant is inappropriate for an emergency situation such as this, and would not have assisted him. Moreover, the appropriate inhaler should have been accompanied by a spacer for best administration. I wonder whether there is a widespread lack of understanding of the best treatment in this situation? 3. The school nurse had updated Nasar’s care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before, the allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it. There must be a way of ensuring that the care plan is accurate and up to date, and that there are identical copies stored at home, school, the GP surgery and within the hospital records. 4. Even if the correct action plan had been used, it does not give the instruction that if a person has an adrenaline auto-injector and: - has any respiratory compromise, or - there is a loss of consciousness, or - if there is doubt, then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately. This was the very firm view of Nasar’s respiratory consultant. Is there a way of disseminating this advice more widely? 1. Although Nasar’s mother was present for Nasar’s medication review conducted by the school nurse, there was no school representative such as the year learning manager there for the meeting, contrary to school policy. 2. The school nurse identified Nasar’s medication as being out of date, and asked that in-date medication be provided, but there was no robust system for ensuring that he was booked in for further review when this was provided. 3. Although all staff at the Bow School were encouraged to familiarise themselves with pupils’ care plans, they often did not unless there was a school excursion. The internal exclusion room (IER) supervisor had not done this for the pupils in the IER. Even the deputy headteacher, who had in the past taught Nasar, did not know about Nasar’s food allergies or the fact that he had a care plan and allergy action plan when he placed Nasar in the IER. 4. Not everyone involved in trying to help Nasar was first aid trained, most notably not the learning assistant who was supervising the IER. She said that she would not have thought of looking for and retrieving his care plan. 5. Even those members of staff who were first aid trained it seemed might benefit from additional and/or more frequent training. One member of staff did not share with others the fact that Nasar had asked for this asthma pump. Another looked at his individual healthcare plan, but could not remember looking at the allergy action plan. 6. One member of staff forgot Nasar’s name. It is of course not possible for members of staff to remember the names of all pupils, but perhaps typed forms accompanied by a photograph might help? 7. Although not followed in this instance, I heard that the school policy dictates that the headteacher’s personal assistant should be contacted to telephone the emergency services. Such a stipulation would surely be guaranteed to add delay. 1. When the school nurse (employed by Compass Wellbeing) conducted a review of Nasar’s medication in May 2016, he did not have the medication stored in school in front of him at the time, but relied on its description by a school receptionist. 2. Although Nasar’s mother was present for the review, there was no school representative, such as the year learning manager (head of year), there for the meeting. 3. The school nurse then updated the care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it. 4. He identified the medication as being out of date, and asked that in-date medication be provided, but did not diary forward to the following week to ensure that current medication was now in the box. This meant that he also did not complete the action plan with the dose of the relevant medication. These points raise issues about the actions of this particular nurse and potentially of other nurses in this role in other schools. ”

    Source location

    Nasar AHMED · Prevention of Future Deaths report
    Page 12 · 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 staff access to pupils’ medical-needs information through electronic registers and require confirmation that key medical-needs and safeguarding policies are understood.

    Verbatim wording from the response

    “The Coroner commented that school staff were encouraged to familiarise themselves with pupil’s care plans and required to do so for school excursions, but in other circumstances staff may not have been familiar with health needs of all pupils. In response to this the school now have a clear understanding between Compass Wellbeing, parents and pupils that information regarding a child’s medical needs will be shared with all staff on the basis that all staff need to have access to, and understanding of, this information. This information has been made more visible for staff as detailed below and policies and processes have been revised to reflect this common understanding, for example, all staff have access to the school’s electronic medical needs registers. The amended policies are due to be ratified by the Governing Body on the 12.07.17.”

    Source location

    Response from Bow School
    Page 3 · response
    Published 3 May 2023

    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 additional HSE-approved first-aid training, prioritising staff supervising higher-risk or small-group settings.

    Verbatim wording from the response

    “The school is also grateful for the opportunity this report affords them to provide assurance that staff and pupils have been offered additional first aid training and to report that the whole school community have embraced those opportunities. A further 25 members of staff have volunteered to complete a first aid course approved by the HSE over the next academic year, many have already completed their training including all staff responsible for supervising internal exclusion room. The safeguarding committee have devised a first aid training plan, which was presented to and approved by the Governing Body’s standards committee on the 14.06.17. This ensures that staff supervising areas of small group work, learning assistants and those who lead in higher risk subjects (e.g. PE, technology and science) are prioritised for HSE first aid training.”

    Source location

    Response from Bow School
    Page 5 · response
    Published 3 May 2023

    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

    There is no requirement for all school staff to be first aiders, and teachers are not contractually required to provide first aid.

    Verbatim wording from the response

    “A fourth issue identified by the Coroner was that not everyone involved in trying to help Nasar was first aid trained. This is correct, however, there is no requirement that all school staff are first aiders. The ‘First aid in schools’ guidance⁶ is explicit that it is not a condition of a teacher’s employment contract that they provide first aid. It is a matter for individuals whether they wish to volunteer for those responsibilities, though as an employer a school’s Governing Body must ensure that they have sufficient first aiders to provide first aid for school staff. The Health and Safety Executive (‘HSE’) advises that organisations such as schools consider possible risks to pupils and visitors within their risk assessments and allow for this when determining the number of first aiders personnel they may require.”

    Source location

    Response from Bow School
    Page 4 · response
    Published 3 May 2023

    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

    The school had an appropriate number of first aiders on site at all times, including when the death occurred.

    Verbatim wording from the response

    “It is important to clarify that the school does have an appropriate number of first aiders on site at all times including, on the 10.11.16. Furthermore, whilst it wasn’t referenced within the narrative determination, the school’s arrangements to safeguard students was subject to review by OFSTED on the 17.11.16 and found to be effective, in particular OFSTED commended the rigour of risk assessments for school trips.”

    Source location

    Response from Bow School
    Page 4 · response
    Published 3 May 2023

    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

    School staff are not expected to perform first aid to the standard of clinicians; guidance requires only their best endeavours to secure pupil welfare.

    Verbatim wording from the response

    “The Coroner rightly recognised within the narrative determination this was ‘a very pressured situation’. She queried whether staff may have responded differently if they had received training or, for those who had, whether they may benefit from additional first aid training. It is important to highlight that staff administering first aid are not expected to perform those responsibilities to the standard of clinicians trained to perform emergency medical interventions where they are held. The guidance simply requires that staff use their ‘best endeavours’ to secure the welfare of the pupil. It is understood that the Coroner did not intend her comments to be taken as a criticism of the actions of staff on that day. To do so may well have an unintended consequence of deterring otherwise willing volunteers from taking on these vital responsibilities.”

    Source location

    Response from Bow School
    Page 4 · response
    Published 3 May 2023

    Open published response
  9. Birmingham and Solihull

    AI-generated summary

    David Sheppard · 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

    David Sheppard choked on a doughnut at Boldmere Court on 31 July 2016 and suffered a cardiac arrest and severe hypoxic brain injury. He was taken to Good Hope Hospital, where treatment was withdrawn, and he died on 3 August 2016. The principal concerns were inadequate emergency response, poor communication, failures in record keeping, insufficient first-aid training, and inadequate post-event investigation.

    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 staff first aid training and choking-sign recognition

    Wider context from the report

    “3. Training. Several of the staff who gave evidence had not received first aid training. They did not understand the signs of choking displayed by the deceased. ”

    Source location

    David Sheppard · Prevention of Future Deaths report
    Page 2 · 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 registered care provider is responsible for ensuring sufficient, qualified, competent and appropriately trained staff are deployed.

    Verbatim wording from the response

    “It is the responsibility of Boldmere Court Care Home as the registered provider to ensure there are sufficient numbers of suitably qualified, competent, skilled and experienced persons deployed and appropriately trained as necessary to enable them to carry out their duties.”

    Source location

    David-Sheppard-Response
    Page 1 · response
    Published 10 July 2017

    Open published response
  10. Staffordshire South

    AI-generated summary

    Ondrej SUHA · 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

    Ondrej Suha, a serving prisoner, was found hanging in his cell on 21 December 2015 and died in hospital on 25 December 2015. Concerns included the lack of specific night-shift training for the responding prison officer and the absence of first-aid training enabling initial staff to attempt resuscitation.

    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 ensure responding staff have basic resuscitation training

    Wider context from the report

    “(2) The initial staff responding to the incident did not have first aid training to enable them to attempt resuscitation. Subsequently many staff at HMPOI Brinsford have had this training. However I wonder if basic resuscitation should form part of a Prison Officer's training or indeed if the quotas for staff on duty at any one time in a prison with such training should be reviewed. ”

    Source location

    Ondrej SUHA · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
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Data last updated 7 September 2026