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

    John WILLIAMS · 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 Williams hanged himself while he was a prisoner at HM Prison Pentonville, after telling staff that he would do so if his perceived needs were not met rather than intending to take his life. Concerns included inaccuracies and omissions in reception screening and referrals, inadequate understanding and use of the ACCT document, insufficient training for some support staff, confusion about emergency codes, and a lack of basic first aid and CPR training among 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 first aid and CPR training for prison officers

    Wider context from the report

    “7. The prison officers did not have even the most basic first aid and cardiopulmonary resuscitation (CPR) training. I am aware from other inquests that this is not provided at a national level. I have written about this before. It seems a significant gap, even allowing for the fact that there are always two trained nurses on site. ”

    Source location

    John WILLIAMS · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  2. Birmingham and Solihull

    AI-generated summary

    Robert Arthur Davidson · 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

    Robert Arthur Davidson, who had dementia, Alzheimer’s disease and PICA, died after choking on a plastic glove at a care home on 27 January 2016. The report identified concerns about inadequate transfer of information about his PICA, insufficient staff training and failures in emergency procedures, including calling emergency services and initiating 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

    Failure to train care staff in CPR and choking procedures

    Wider context from the report

    “1. During the inquest I heard evidence that Health care staff had not been trained on basic process as follows: • Making 999 calls – to obtain an outside line caller’s needed to first dial “9”. The HCA instructed to make the 999 call did not know this so the call was unsuccessful. The registered nurse looking after the patient whilst he was choking had to make the 999 call resulting in her leaving the patient. • When to Start CPR. The RGN and HCA (Health Care Assistants) staff had received no training on the CPR and choking policy The concern is that staff are not trained in basic processes and therefore not able to deal with emergency situations. ”

    Source location

    Robert Arthur Davidson · 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

    Implement an additional action plan and timetable responding to the inquest findings.

    Verbatim wording from the response

    “Unfortunately, whilst under the Restful Homes Group tenure, Aran Court had very few of these processes in place and where systems or processes were in situ they were often substandard. It remains an ongoing process to fully embed all of Avery’s policies and procedures and in light of the inquests findings an additional action plan and timetable for action has been implemented.”

    Source location

    2016-0363-Response-by-Avery
    Page 2 · response
    Published 26 February 2017

    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

    Continue embedding all organisational policies and procedures at Aran Court.

    Verbatim wording from the response

    “Unfortunately, whilst under the Restful Homes Group tenure, Aran Court had very few of these processes in place and where systems or processes were in situ they were often substandard. It remains an ongoing process to fully embed all of Avery’s policies and procedures and in light of the inquests findings an additional action plan and timetable for action has been implemented.”

    Source location

    2016-0363-Response-by-Avery
    Page 2 · response
    Published 26 February 2017

    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

    Inspect care homes’ emergency response, staff training, induction, and transfer-risk arrangements, including follow-up checks against the reported concerns.

    Verbatim wording from the response

    “During the course of the CQC focused inspection of Aran Court Care Centre on 09 March 2016, we found systems in place to ensure that nurses had training in emergency first aid. Emergency First Aid at work training provides delegates with an extensive first aid skill set so that they can identify incidents and manage them appropriately, whether the patient is conscious or unconscious. The course is designed to include first aid priorities, managing incidents, basic life support (CPR), unconsciousness, control of bleeding, burns and scolds, recording and reporting First Aid Priorities.”

    Source location

    2016-0363-Response-by-Care-Quality-Commission
    Page 2 · response
    Published 26 February 2017

    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

    Maintain the Care Certificate as an induction and development standard covering safe, effective care for health and social care workers.

    Verbatim wording from the response

    “In April 2015, the Government introduced the Care Certificate (as recommended by Camilla Cavendish in her July 2013 review), which is helping to ensure that support workers and their employers can deliver a consistently high quality standard of safe, effective and compassionate care. It includes 15 standards and outcomes that health and social care workers – in hospitals, care homes and people’s own homes – should know and be able to deliver in their daily work. Regarded as ‘best practice’ for the induction of new health and care assistants, it is also offering existing staff an opportunity to refresh or improve their knowledge.”

    Source location

    2016-0363-Response-by-Department-of-Health
    Page 1 · response
    Published 26 February 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

    Emergency first aid and basic life-support training is considered an appropriate level of training for staff responding to choking and CPR situations.

    Verbatim wording from the response

    “As a provider Avery Healthcare does have appropriate systems and documentation in situ to address each of the above points.”

    Source location

    2016-0363-Response-by-Avery
    Page 1 · response
    Published 26 February 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 emergency first-aid training, shift reminders and staff competence checks were considered sufficient to address emergency response concerns.

    Verbatim wording from the response

    “During the course of the CQC focused inspection of Aran Court Care Centre on 09 March 2016, we found systems in place to ensure that nurses had training in emergency first aid. Emergency First Aid at work training provides delegates with an extensive first aid skill set so that they can identify incidents and manage them appropriately, whether the patient is conscious or unconscious. The course is designed to include first aid priorities, managing incidents, basic life support (CPR), unconsciousness, control of bleeding, burns and scolds, recording and reporting First Aid Priorities.”

    Source location

    2016-0363-Response-by-Care-Quality-Commission
    Page 2 · response
    Published 26 February 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

    Care Certificate induction standards and workplace competence assessment were considered sufficient to ensure HCAs had necessary knowledge and skills.

    Verbatim wording from the response

    “The Care Certificate was developed jointly by Skills for Care, Health Education England and Skills for Health, and introduced on 01 April 2015. These Care Certificate standards apply across both social care and health, and link to the national occupational standards. The Care Certificate is designed for new HCA staff, it also offers opportunities for existing staff to refresh or improve their knowledge. The new standards encapsulated in the Care Certificate should ensure that the health and social care workers have the required values, behaviours, competences and skills to provide high quality, compassionate care.”

    Source location

    2016-0363-Response-by-Care-Quality-Commission
    Page 3 · response
    Published 26 February 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

    Care homes are responsible for providing and maintaining staff training, including emergency telephone, CPR and choking procedures.

    Verbatim wording from the response

    “Care organisations, including homes such as Aran Court Care Centre, are responsible for the induction and training of their staff. This should include the use of the telephone in emergency situations. Basic CPR training is a minimal expectation of those working in care settings. It is the responsibility of the care home to provide this training and ensuring that staff maintains their competence through regular updates. It may be necessary for the care home to access training in the NHS to meet these requirements.”

    Source location

    2016-0363-Response-by-NHS-England
    Page 1 · response
    Published 26 February 2017

    Open published response
  3. Surrey

    AI-generated summary

    Christopher James B Sears · 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

    Christopher James B Sears, a 13-year-old boy, died on 13 November 2014 after a seizure-like episode on a school bus; resuscitation attempts were unsuccessful. The report raised concerns about the absence of Basic Life Support training and emergency protocols for school-bus drivers, delays in calling emergency services, and difficulties alerting the bus company where there was no formal diagnosis.

    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 requirements for contracted pupil-transport bus companies to ensure driver Basic Life Support training

    Wider context from the report

    “1. There is no requirement for bus companies tendering for contracts from Local Authorities to transport pupils/students to ensure all their drivers have undergone training in Basic Life Support. ”

    Source location

    Christopher James B Sears · Prevention of Future Deaths report
    Page 2 · 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 a Basic Life Support qualification requirement for pupil-transport drivers

    Wider context from the report

    “2. There is no requirement for drivers transporting pupils/students to hold a Basic Life Support qualification. ”

    Source location

    Christopher James B Sears · 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

    Consult on a revised version of the guidance on school transport.

    Verbatim wording from the response

    “It is our intention that LAs should ensure that school bus drivers and escorts have training in basic life support skills and in the implementation of emergency protocols (your third ‘Matter of Concern’). We intend to consult on a revised version of the guidance on school transport in the autumn. Subject to any responses received in response to this consultation, we will consider whether we should further clarify both the description of the training that drivers should undertake and our expectation that training for bus drivers and escorts should include basic life support training alongside the implementation of healthcare protocols, including emergency protocols.”

    Source location

    2016-0212-Response-by-Department-for-Education
    Page 1 · response
    Published 25 May 2016

    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 clarifying training expectations for school bus drivers and escorts, including basic life support and emergency healthcare protocols.

    Verbatim wording from the response

    “It is our intention that LAs should ensure that school bus drivers and escorts have training in basic life support skills and in the implementation of emergency protocols (your third ‘Matter of Concern’). We intend to consult on a revised version of the guidance on school transport in the autumn. Subject to any responses received in response to this consultation, we will consider whether we should further clarify both the description of the training that drivers should undertake and our expectation that training for bus drivers and escorts should include basic life support training alongside the implementation of healthcare protocols, including emergency protocols.”

    Source location

    2016-0212-Response-by-Department-for-Education
    Page 1 · response
    Published 25 May 2016

    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

    Mandatory basic life-support training for bus drivers is not proposed because existing guidance and flexible Driver CPC arrangements are considered sufficient.

    Verbatim wording from the response

    “The Driver CPC is purposely designed to be flexible in its application – no specific part of the periodic training syllabus is mandatory, and the Department believes that this is important to ensure that training can be focussed on every individual’s specific training needs. In 2014/15 275,900 drivers chose to undertake training courses that taught them either basic or more advanced first aid techniques; while that total includes both bus and HGV drivers, it nevertheless suggests strong take-up.”

    Source location

    2016-0212-Response-by-Department-for-Transport
    Page 2 · response
    Published 25 May 2016

    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 requiring bus companies to provide drivers with basic life support training rests with the Department for Transport.

    Verbatim wording from the response

    “Your concern that LA contractual arrangements do not require tendering bus companies to ensure that their drivers are qualified in basic life support skills is a matter for the Department for Transport (DfT), and we understand that Andrew Jones is replying separately to you on this issue.”

    Source location

    2016-0212-Response-by-Department-for-Education
    Page 1 · response
    Published 25 May 2016

    Open published response
  4. Inner North London

    AI-generated summary

    Samuel Rodney Darren BLAIR · 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

    Rodney Blair, who had a history of paranoid schizophrenia, alcohol dependency, multiple drug use and depression, was remanded in custody at HM Prison Pentonville and was found hanging in his cell on 2 August 2015. The inquest concluded that his death was suicide, with several contributing factors. Concerns included gaps in assessment and management of his mental health and antidepressant treatment, and delays and procedural issues in the prison emergency response.

    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 mandatory basic life support and first aid training for all prison officers

    Wider context from the report

    “The prison officers who found Mr Blair hanging did not have current basic life support training and so were not able to commence cardiopulmonary resuscitation (CPR) before the arrival of nurses. One officer tried to take Mr Blair’s pulse, but was unclear about the correct procedure for this. This is a situation that I have noted before at HMP Pentonville. I have not made a prevention of future deaths report in the past, because I am aware that the fact that there is no mandatory first aid (including CPR) training for all prison officers is a nationally made, resource led decision. However, it seems to me that you, as the decision maker regarding not providing such training, should be aware of the impact that this may have on the prison population. ”

    Source location

    Samuel Rodney Darren BLAIR · 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

    Ensure sufficient suitably trained first aiders are available through establishment first-aid risk assessments and current competency certification.

    Verbatim wording from the response

    “The report that you addressed to NOMS expresses concern that the staff who discovered Mr Blair had not received cardiopulmonary resuscitation (CPR) training. It correctly states that the NOMS position is that such training is not mandatory for all prison staff. However, it is not correct to characterise this as a ‘resource-led’ decision. NOMS is committed to ensuring that a sufficient number of suitably trained first aiders is always available in prisons to enable First Aid to be given to employees, prisoners and visitors. Prison Service Instruction 29/2015 First Aid, issued on 16 November 2015, requires every establishment to carry out a First Aid risk assessment to identify the number of trained first aiders required to provide cover throughout the day.”

    Source location

    2016-0196-Response-by-NOMS
    Page 1 · response
    Published 19 May 2016

    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 risk-assessed first-aid staffing and 24-hour healthcare cover were considered sufficient, so CPR training was not mandatory for all prison staff.

    Verbatim wording from the response

    “The report that you addressed to NOMS expresses concern that the staff who discovered Mr Blair had not received cardiopulmonary resuscitation (CPR) training. It correctly states that the NOMS position is that such training is not mandatory for all prison staff. However, it is not correct to characterise this as a ‘resource-led’ decision. NOMS is committed to ensuring that a sufficient number of suitably trained first aiders is always available in prisons to enable First Aid to be given to employees, prisoners and visitors. Prison Service Instruction 29/2015 First Aid, issued on 16 November 2015, requires every establishment to carry out a First Aid risk assessment to identify the number of trained first aiders required to provide cover throughout the day.”

    Source location

    2016-0196-Response-by-NOMS
    Page 1 · response
    Published 19 May 2016

    Open published response
  5. Surrey

    AI-generated summary

    Mr Critall · 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

    Mr Critall, an 80-year-old man, developed a haemothorax after insertion of a chest drain while being treated for pneumonia and died on 6 July 2014 after further deterioration and emergency treatment. The report raised concerns about the necessity and technique of the drain insertion, the failure to confirm its position, inadequate monitoring and resuscitation, and the hospital’s lack of appropriate emergency facilities and protocols. It also recorded that his family were not contacted after he became unwell or died.

    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 Acute or Basic Life Support training for the radiologist

    Wider context from the report

    “10. The radiologist did not have Acute or Basic Life Support training as would be expected for all clinical hospital staff as part of mandatory training for NHS appointments. ”

    Source location

    Mr Critall · 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

    Require annual consultant reporting of completed mandatory training through the updated BMI practising privileges policy.

    Verbatim wording from the response

    “In 2014 the BMI Practicing Privileges policy required confirmation of a completed appraisal whereby a consultant’s Responsible Officer /Clinical Director would confirm that all requirements for the appraisal were met. Since that time an updated practicing privileges policy has been introduced across all BMI hospitals which includes a requirement that details of completed mandatory training are provided by all consultants on an annual basis.”

    Source location

    2016-0187-Response-by-Mount-Alvernia-Hospital
    Page 7 · response
    Published 16 May 2016

    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

    Consultants were required to maintain basic life-support training through practising-privileges and annual appraisal arrangements.

    Verbatim wording from the response

    “All consultants are required to have basic life support training as a minimum. As part of the practising privileges that are granted to consultants to allow them to practice at the hospital, annual practice appraisals are conducted, part of which is a requirement for a consultant’s responsible officer to confirm that basic life support training has been completed.”

    Source location

    2016-0187-Response-by-Mount-Alvernia-Hospital
    Page 7 · response
    Published 16 May 2016

    Open published response
  6. Shropshire, Telford and Wrekin

    AI-generated summary

    Derrick Edward ROSE-FOWLER · 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

    Derrick Edward ROSE-FOWLER was found hanging by his neck from his prison cell window on 5 June 2015 and was pronounced dead after being transferred to hospital. The concerns included the first attending prison officer not being first-aid trained, the handling of alleged bullying, and the failure to raise concerns about the deceased at a MASH meeting despite several relevant factors.

    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 among first-attending prison officers

    Wider context from the report

    “(1) Although on the facts of this case it made no difference to the outcome, the first prison officer on the scene was not first aid trained. The evidence at the inquest was that there was no national requirement for all prison officers to be first aid trained provided a certain proportion were. (2) In hanging cases time is of the essence for CPR and if there is any significant delay by reason of the first attending prison officer not being first aid trained there is the risk of future deaths occurring. ”

    Source location

    Derrick Edward ROSE-FOWLER · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
  7. Nottinghamshire

    AI-generated summary

    Steven James May · 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

    Steven James May died by hanging at HMP Ranby on 25 May 2015 at 01:45, after previously expressing suicidal intent and being placed on the ACCT programme. The report identified concerns about failures in reception health screening, ACCT documentation and reviews, information handovers, staff training and involvement, emergency first aid, cell-entry procedures, and access to health and mental health 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

    Inadequate First Aid training for prison staff

    Wider context from the report

    “(9) The inadequacy of First Aid training provided to prison staff in any event (namely, the administration of CPR by prison staff whilst the deceased was lying on a bed); ”

    Source location

    Steven James May · Prevention of Future Deaths report
    Page 2 · 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

    Selective emergency First Aid training among prison staff

    Wider context from the report

    “(7) The selective training of prison staff in emergency First Aid (namely the first member of prison staff on the scene of the death was not trained in the administration of CPR and was ignorant of the location of and method of use of defibrillators); ”

    Source location

    Steven James May · 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

    Review the bands, grades and numbers of staff requiring first-aid training.

    Verbatim wording from the response

    “The PSI becomes effective on 16 May 2016, and in preparation for its implementation, the Governor of HMP Ranby is reviewing the band/grade and numbers of staff who need to be trained in first aid. The prison currently has 61 staff trained in FAW and 73 in EFAW. 86 staff have received training in the use of defibrillators, and all staff have been provided with information on the location and use of defibrillators through a staff information notice issued on 16 July 2015.”

    Source location

    Steven-May-Response
    Page 2 · response
    Published 16 March 2016

    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

    Ensure first-aid training is delivered by competent, approved or currently certificated instructors.

    Verbatim wording from the response

    “PSI 29/2015 is clear that all training provided to NOMS staff must be delivered by competent instructors, either by external providers from an approved list or trained and currently certificated NOMS trainers.”

    Source location

    Steven-May-Response
    Page 3 · response
    Published 16 March 2016

    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 staff information on defibrillator locations and use.

    Verbatim wording from the response

    “The PSI becomes effective on 16 May 2016, and in preparation for its implementation, the Governor of HMP Ranby is reviewing the band/grade and numbers of staff who need to be trained in first aid. The prison currently has 61 staff trained in FAW and 73 in EFAW. 86 staff have received training in the use of defibrillators, and all staff have been provided with information on the location and use of defibrillators through a staff information notice issued on 16 July 2015.”

    Source location

    Steven-May-Response
    Page 2 · response
    Published 16 March 2016

    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

    Healthcare concerns are assigned to NHS England and Nottinghamshire Healthcare NHS Foundation Trust, which addressed them separately.

    Verbatim wording from the response

    “You will be aware that healthcare at HMP Ranby is commissioned by NHS England and provided by Nottinghamshire Healthcare NHS Foundation Trust, and I understand that the matters of concern that you have raised at points 1, 2 and 10 have been addressed separately by the Chief Executive of the Trust in a letter dated 13 April 2016, and by the Clinical Quality Manager at NHS England in a letter dated 5 May 2016. This response therefore addresses the matters of concern at points 3 to 9.”

    Source location

    Steven-May-Response
    Page 1 · response
    Published 16 March 2016

    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 remaining seven concerns were matters for HM Prison Service and other parties, so the Trust could not respond to them.

    Verbatim wording from the response

    “The Trust cannot respond to the other 7 concerns highlighted in the Prevent Future Death report as they are matters for HM Prison Service and/or other parties.”

    Source location

    2016-0109-Response-by-Nottingham-Healthcare-NHS-Trust
    Page 4 · response
    Published 16 March 2016

    Open published response
  8. Bedfordshire and Luton

    AI-generated summary

    Eitvydas ZDANYS · 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

    Eitvydas ZDANYS, aged 19, died at the scene on 2 August 2015 after a motorcycle collision while intoxicated and carrying a pillion passenger. The report raised concerns that attending police officers were unable to assess his serious injuries or commence potentially life-saving resuscitation, although it concluded that the delay did not contribute to his 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 basic life support training for Police Officers expected to act as first responders

    Wider context from the report

    “During the course of the Investigation my attention was drawn to the video footage from the Officers who originally attended this road traffic incident. It would appear that these Officers were unable to assess a seriously injured motorcyclist and were unable to commence what could have been life-saving resuscitation. There perhaps needs to be a review of the training of all Police Officers to ensure that they have all received training in basic life support if they are at any time expected to take on the role of ‘first responder’. One of the Officers who investigated the collision was of the opinion “….CPR should have been administered at a much earlier stage……” I am satisfied that the delay in attending to the deceased did not in any way contribute to his death. ”

    Source location

    Eitvydas ZDANYS · 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 the two officers with training on when and how to administer CPR.

    Verbatim wording from the response

    “The abovementioned officers will shortly receive training on when and how to administer CPR so that they are better equipped to make the right decisions should such an emergency decision arise in the future. Furthermore all officers will be reminded during their annual refresher training of when it is necessary and appropriate to commence CPR.”

    Source location

    E-Zdanys-Response
    Page 2 · response
    Published 9 February 2016

    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

    Remind all officers during annual refresher training when it is necessary and appropriate to commence CPR.

    Verbatim wording from the response

    “The abovementioned officers will shortly receive training on when and how to administer CPR so that they are better equipped to make the right decisions should such an emergency decision arise in the future. Furthermore all officers will be reminded during their annual refresher training of when it is necessary and appropriate to commence CPR.”

    Source location

    E-Zdanys-Response
    Page 2 · response
    Published 9 February 2016

    Open published response
  9. Cornwall

    AI-generated summary

    Norman Dorn · 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

    Norman Dorn was found presumed dead in an armchair at a residential home after eating a jam sandwich, with food in his mouth. He was known to have swallowing problems, and staff did not remove the food or attempt resuscitation; the report also states that the GP and other emergency services did not attend in a timely manner. The concerns included whether care homes had adequate policies and staff training for recognising or confirming death and for 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

    Lack of appropriate care-home resuscitation policies and staff preparation to preserve life

    Wider context from the report

    “2. That some care home in Cornwall may not have an appropriate resuscitation policy in place to ensure that all attempts have been made to preserve life (when appropriate). If such policies are in place that they are regularly updated and staff are made aware of them and given the appropriate training. ”

    Source location

    Norman Dorn · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
  10. West Yorkshire Eastern

    AI-generated summary

    Paul David Whitehead · 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

    Paul David Whitehead sustained severe crush injuries after becoming trapped between the moving conveyors of a packing machine at work and subsequently died in hospital. Concerns were raised that the workplace emergency response, including first aid provision and contacting and directing emergency services, was not sufficiently efficient or effective.

    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 of First Aid provision to maintain effective resuscitation capability

    Wider context from the report

    “(1) When Mr Whitehead was released from the machine and fell on to the floor, a witness said that there was no one in the vicinity able to give First Aid to the casualty. (2) The designated First Aider from the Security Office, when informed of the incident, rang the Health and Safety Manager before calling for an Ambulance. The statement giving this evidence was challenged, however, by the evidence taken at the Inquest from the Health and Safety Manager. (3) The First Aider who attended the casualty was herself in shock and unable to carry out mouth to mouth resuscitation. (4) The Paramedic who initially attended in response to the 999 call said in a statement that on arriving at the large site of W E Rawson Ltd the Ambulance stopped in a small car park but could not see anyone around and had to drive back on to the main road before eventually finding someone stood by a fire exit door. The Paramedic’s statement said that from arriving at the site to arriving with the patient took approximately five minutes. These factors in combination suggest that the emergency response procedures at W E Rawson Ltd were not sufficiently efficient or effective. Whilst it is unlikely that these factors contributed to Mr Whitehead’s eventual death, they do give rise to the concern that if another emergency were to arise involving a time critical situation, an avoidable death might occur. Evidence was taken at the Inquest to the effect that the Disaster Recovery Plan at W E Rawson Ltd was reviewed after Mr Whitehead’s death but the conclusion reached that no significant changes were required. I consider that a further review of the standard of First Aid provision is merited along with the actions to be taken in the immediate aftermath of an unexpected occurrence to ensure that the Emergency Services are contacted immediately and steps taken to expedite their arrival with any casualty. ”

    Source location

    Paul David Whitehead · 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

    Refresh all first aiders’ first-aid training regularly in line with HSE guidance.

    Verbatim wording from the response

    “We will prepare all of our first aiders so far as possible by refreshing their first aid training on a regular basis in line with HSE guidance. The First Aider in question has already been provided with refresher training following the incident.”

    Source location

    Paul-Whitehead-Response
    Page 2 · response
    Published 14 December 2015

    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

    It is difficult to prepare non-medical first aiders to avoid freezing from shock during incidents as severe as this one.

    Verbatim wording from the response

    “3) The First Aider was unable to perform mouth to mouth resuscitation.”

    Source location

    Paul-Whitehead-Response
    Page 2 · response
    Published 14 December 2015

    Open published response
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Data last updated 7 September 2026