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
Individual concerns: 111
Date range: 2013–2026
Stated actions: 176

Reports over time

Reports about this concern issued each year.

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

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.

15 Jun2026
Manchester North
Concerns raised1
1. Lack of refresher training in basic life support for prison officers
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Require local requalification to maintain prison staff first-aid competence during the three-year training validity period.
  Stated by the Minister for Prisons and Probation and the Ministry of JusticeStated completed
2. Action
  Provide refresher first-aid learning resources, including first-on-scene video guidance and CPR guidance for unresponsive casualties.
  Stated by the Minister for Prisons and Probation and the Ministry of JusticeStated completed
Respondent positions 1
1. Position
  Existing training, local requalification, policy requirements and refresher resources are considered sufficient to maintain prison staff first-aid capability.
  Stated by the Minister for Prisons and Probation and the Ministry of JusticeExisting arrangements considered sufficient
AI-generated summary

Mr Arron Hamer · 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 Arron Hamer, who had been in custody since 2009 and was held at HMP Buckley Hall, was found hanging in his cell on 18 June 2026. The principal concern was that prison officers did not cut the ligature or commence CPR for nearly three minutes, and that most prison officers do not receive mandatory refresher training in basic life support after their initial 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 refresher training in basic life support for prison officers
Wider context from the report
“(1) The Court heard there is no mandatory refresher training on basic life support for prison officers after they have conducted their initial prison officer training. If they do the first aid at work course this has to be refreshed every three years but only certain officers do this. For the majority they do not have refresher training. ”
Source location
Mr Arron Hamer · 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
Require local requalification to maintain prison staff first-aid competence during the three-year training validity period.

Verbatim wording from the response
“All new prison officers receive Emergency First Aid training as part of their initial foundation programme, which includes instruction in cardiopulmonary resuscitation (CPR). This training is mandatory, remains valid for three years, and is subject to local requalification to ensure staff maintain the necessary level of competence.”

Source location
Response from Prison, Probation and Reducing Reoffending
Page 1 · response
Published 2 September 2026
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 refresher first-aid learning resources, including first-on-scene video guidance and CPR guidance for unresponsive casualties.

Verbatim wording from the response
“To support ongoing staff capability, HMPPS provides a range of refresher materials and learning resources designed to maintain and enhance first aid knowledge and skills. This includes bespoke “first-on-scene” video content developed in partnership with St John Ambulance, which offers practical guidance for prison officers and frontline staff responding to emergencies prior to the arrival of healthcare professionals. There is also a CPR learning bulletin that provides guidance for staff on action to take when someone is found unresponsive, not breathing and/or has no pulse in accordance with guidance from Resuscitation Council UK.”

Source location
Response from Prison, Probation and Reducing Reoffending
Page 2 · response
Published 2 September 2026
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, local requalification, policy requirements and refresher resources are considered sufficient to maintain prison staff first-aid capability.

Verbatim wording from the response
“All new prison officers receive Emergency First Aid training as part of their initial foundation programme, which includes instruction in cardiopulmonary resuscitation (CPR). This training is mandatory, remains valid for three years, and is subject to local requalification to ensure staff maintain the necessary level of competence.”

Source location
Response from Prison, Probation and Reducing Reoffending
Page 1 · response
Published 2 September 2026
Open published response
9 Jun2026
Newcastle and North Tyneside
Concerns raised1
1. Limitation of Ambulance Support Practitioners' airway management training to supervised i-gel use
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Realign non-registered clinical staff scopes through additional education, training and competency assessments.
  Stated by North East Ambulance Service NHS Foundation TrustStated completed
Respondent positions 1
1. Position
  ASP i-gel insertion remains restricted to supervision or direction by a registered healthcare professional because it involves advanced airway risks.
  Stated by North East Ambulance Service NHS Foundation TrustExisting arrangements considered sufficient
AI-generated summary

Edie Grace Smart · 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

Edie Grace Smart, aged 13, died in hospital on 28 July 2025 after being rescued from the sea at Whitley Bay four days earlier. Emergency crews struggled to secure her airway, and the first ambulance personnel on scene were Ambulance Support Practitioners who were not permitted to use an i-gel without paramedic supervision. The substantive concern was that Ambulance Support Practitioners may often be first on scene at an out-of-hospital cardiac arrest but are trained to use i-gels only under paramedic supervision.

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
Limitation of Ambulance Support Practitioners' airway management training to supervised i-gel use
Wider context from the report
“Ambulance Support Practitioners are often first on scene on an out of hospital cardiac arrest but are only trained to use i gels to secure a patient's airway under the supervision of a paramedic. ”
Source location
Edie Grace Smart · 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
Realign non-registered clinical staff scopes through additional education, training and competency assessments.

Verbatim wording from the response
“ASPs are not registered healthcare professionals but are trained, assessed, and authorised to undertake a defined range of clinical interventions within an established scope of practice. The ASP role was formally implemented across NEAS on 01 November 2024. Since its introduction, all relevant non-registered clinical staff have undergone a process of scope-of-practice realignment, supported by additional education, training, and competency assessments, to ensure that they are”

Source location
Response from North East Ambulance Service
Page 1 · response
Published 13 August 2026
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
ASP i-gel insertion remains restricted to supervision or direction by a registered healthcare professional because it involves advanced airway risks.

Verbatim wording from the response
“For this reason, NEAS’ position remains that ASPs may independently undertake the specified basic airway interventions within their authorised scope of practice, whilst the insertion of an i-gel by an ASP should take place under the supervision or direction of a registered healthcare professional, as, for this take place without such supervision, would present an unacceptable level of additional risk to the patient, and unreasonable clinical expectation on ASPs who are not registered healthcare professionals.”

Source location
Response from North East Ambulance Service
Page 5 · response
Published 13 August 2026
Open published response
21 May2026
Dorset
Concerns raised1
1. Lack of mandatory refresher training in first aid and CPR for prison staff
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Provide ongoing refresher first-aid resources and learning materials, including bespoke first-on-scene emergency-response videos for prison and frontline staff.
  Stated by Ministry of Justice and The Verne PrisonStated completed
2. Action
  Undertake a comprehensive Training Needs Analysis to inform a structured First Aid training plan at HMP The Verne.
  Stated by Ministry of Justice and The Verne PrisonStated planned
3. Action
  Deliver monthly three-day First Aid at Work programmes from July 2026, supported by a forward-planned schedule of initial and refresher training.
  Stated by Ministry of Justice and The Verne PrisonStated planned
Respondent positions 1
1. Position
  Responsibility for prison officers’ refresher training lies with HM Prison and Probation Service, with the prisons minister best placed to respond.
  Stated by NHS EnglandRedirects responsibility
AI-generated summary

George Edward James Haldenby · 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

George Edward James Haldenby was a serving prisoner with severe heart failure who collapsed at HMP The Verne on 29 January 2022 and died that day at Dorset County Hospital. The report identifies delays in receiving an increased dose of Furosemide, and a delay in recognising the collapse and starting CPR, as substantive concerns. It also raises concerns about the absence of regular refresher training in first aid and CPR and the lack of a clear process for handling hospital prescriptions issued outside prison healthcare hours.

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 refresher training in first aid and CPR for prison staff
Wider context from the report
“After prison officers and prison staff carry out their induction training which covers basic first aid training including the delivery of cardio pulmonary resuscitation (CPR), there is no further mandatory refresher training on first aid or CPR. During the evidence, a Custodial Manager at HMP the Verne stated that the last time he had first aid or CPR training was in 1991, 35 years ago, when he started as a prison officer. Whilst there is a requirement to have a duty first aider on site 24 hours a day, without all staff being suitably and regularly trained in signs of collapse and administering CPR, there could be a delay in delivering effective CPR as it may take time for the duty first aider to get to the prisoner, and a future death could occur. ”
Source location
George Edward James Haldenby · Prevention of Future Deaths report
Page 4 · 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 ongoing refresher first-aid resources and learning materials, including bespoke first-on-scene emergency-response videos for prison and frontline staff.

Verbatim wording from the response
“You will be aware that all new prison officers receive mandatory Emergency First Aid and CPR training as part of their foundation programme. This training remains valid for three years and is subject to requalification. In addition, the HMPPS First Aid Policy Framework (re-issued in August 2023) requires Governors to maintain sufficient first aid provision based on a local First Aid Needs Assessment. To support staff capability, HMPPS provides ongoing refresher resources and learning materials to maintain and enhance first aid knowledge and skills. For example, HMPPS has worked with St John Ambulance to develop bespoke “first-on-scene” video resources for prison officers and frontline staff, offering practical guidance on responding to a range of emergency situations prior to the arrival of healthcare professionals.”

Source location
2026-0312 - Response from HM Prison and Probation Service
Page 2 · response
Published 14 August 2026
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
Undertake a comprehensive Training Needs Analysis to inform a structured First Aid training plan at HMP The Verne.

Verbatim wording from the response
“HMP The Verne is undertaking a comprehensive Training Needs Analysis to inform the development of a structured First Aid training plan. From July 2026, the prison intends to deliver monthly three-day First Aid at Work training programmes. These sessions will be jointly led by the Head of Business Assurance and supported by the Health and Safety Manager. The programme is designed to increase the number of staff trained to a recognised First Aid at Work standard and strengthen the prison’s emergency response capability. Increasing the number of staff trained in First Aid at Work will enable the implementation of a 24-hour, seven-day nominated staff rota, to ensure a coordinated and timely response to emergencies. The initial rollout of training will prioritise key staff groups, including Custodial Managers, Supervising Officers, Care and Separation Unit staff, and Induction Wing staff.”

Source location
2026-0312 - Response from HM Prison and Probation Service
Page 2 · response
Published 14 August 2026
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 monthly three-day First Aid at Work programmes from July 2026, supported by a forward-planned schedule of initial and refresher training.

Verbatim wording from the response
“HMP The Verne is undertaking a comprehensive Training Needs Analysis to inform the development of a structured First Aid training plan. From July 2026, the prison intends to deliver monthly three-day First Aid at Work training programmes. These sessions will be jointly led by the Head of Business Assurance and supported by the Health and Safety Manager. The programme is designed to increase the number of staff trained to a recognised First Aid at Work standard and strengthen the prison’s emergency response capability. Increasing the number of staff trained in First Aid at Work will enable the implementation of a 24-hour, seven-day nominated staff rota, to ensure a coordinated and timely response to emergencies. The initial rollout of training will prioritise key staff groups, including Custodial Managers, Supervising Officers, Care and Separation Unit staff, and Induction Wing staff.”

Source location
2026-0312 - Response from HM Prison and Probation Service
Page 2 · response
Published 14 August 2026
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 prison officers’ refresher training lies with HM Prison and Probation Service, with the prisons minister best placed to respond.

Verbatim wording from the response
“The issue of training for prison officers is the responsibility of HM Prison and Probation Service, so NHS England is unable to answer this concern. We note that the Coroner has also addressed the Report to the Minister for Prisons, Probation and Reducing Reoffending, who will be best placed to answer this.”

Source location
2026-0312 - Response from NHS England
Page 1 · response
Published 14 August 2026
Open published response
8 May2026
West London
Concerns raised1
1. Inadequate staff training to conduct CPR unless a contrary decision exists
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 4
1. Action
  Require providers to strengthen life-support training, resuscitation knowledge, competency assessment and auditable compliance records.
  Stated by NHS South West London Integrated Care BoardStated planned
2. Action
  Require all Roy Kinnear House staff to repeat First Aid training and practical competency assessment, including CPR where no DNACPR exists.
  Stated by Choice SupportStated planned
3. Action
  Circulate organisation-wide guidance requiring CPR where no DNACPR exists, with updated CPR practice guidance.
  Stated by Choice SupportStated planned
1. Action
  Reinforce CPR and safe AED-use training for Roy Kinnear House staff.
  Stated by Choice SupportStated planned
AI-generated summary

Jake Daniel Taylor · 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

Jake Daniel Taylor, aged 19, suffered a cardiac arrest at his care home on 16 January 2025 and died in Kingston hospital on 20 January 2025. The report identified delays in first aid and concerns about the lack of individual emergency planning, staff training, immediately available equipment, and airway training and equipment.

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 staff training to conduct CPR unless a contrary decision exists
Wider context from the report
“No planning for this foreseeable emergency. Inadequate staff training (to always conduct CPR if no decision to the contrary) No defibrillator on site and staff misunderstanding of the function of a defibrillator. No airway training and equipment although Registered Nursing staff have this within their competencies. I consider that individual emergency planning for those service users with recognised high tier needs and life-threatening risk profiles is essential to ensure best possible outcomes and care tailored to their needs. Medical emergencies in this cohort of patients are predictable but are likely to happen suddenly and unexpectedly. In this case the staff were not able to respond and their evidence to the court demonstrated that they felt unprepared and uncertain about what to do. This is a situation that could be replicated throughout the services that care for individuals such as Jake. Those commissioning the services should consider if the individual emergency care planning is comprehensive and complete and reviewed where appropriate. ”
Source location
Jake Daniel Taylor · 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 providers to strengthen life-support training, resuscitation knowledge, competency assessment and auditable compliance records.

Verbatim wording from the response
“b. Resuscitation Training and Understanding of CPR Requirements All commissioned providers will be required to:”

Source location
Response from NHS South West London ICB
Page 3 · response
Published 2 July 2026
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 all Roy Kinnear House staff to repeat First Aid training and practical competency assessment, including CPR where no DNACPR exists.

Verbatim wording from the response
“All staff at Roy Kinnear House will re-complete First Aid Training and Practical Competency, with the understanding that staff should always conduct CPR if there is no decision to the contrary. Timescales: 31st July 2026”

Source location
Response from Choice Support
Page 3 · response
Published 2 July 2026
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
Circulate organisation-wide guidance requiring CPR where no DNACPR exists, with updated CPR practice guidance.

Verbatim wording from the response
“Circulate a briefing reminding all staff at Choice Support that CPR must be performed where no DNACPR exists, alongside updated CPR practice guidance in line with our First Aid Policy. Timescales: 30th June 2026”

Source location
Response from Choice Support
Page 3 · response
Published 2 July 2026
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
Reinforce CPR and safe AED-use training for Roy Kinnear House staff.

Verbatim wording from the response
“First Aid training already includes training and practical competency of CPR and safe use of AEDs in line with national guidance. This will be reinforced for the staff at Roy Kinnear House.”

Source location
Response from Choice Support
Page 4 · response
Published 2 July 2026
Open published response
17 Apr2026
Cumbria
Concerns raised1
1. Failure of advanced life support training to cover the need for a solid surface during CPR
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Reinforce CPR practice through resuscitation training.
  Stated by Lancashire & South Cumbria NHS Foundation TrustStated completed
Respondent positions 1
1. Position
  Current national guidance and aligned practice are considered sufficient; patients should not be moved from beds, with CPR mitigation used.
  Stated by Lancashire & South Cumbria NHS Foundation TrustExisting arrangements considered sufficient
AI-generated summary

Julie Ley · 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

Julie Ley, aged 71, died on 15 May 2025 at Westmorland General Hospital after her physical condition deteriorated while she was detained under the Mental Health Act. The inquest identified inadequate care, including failures in nutrition monitoring, physical health monitoring, transfer to a hospital able to provide appropriate treatment, and use of available legal powers to administer medication. A further concern was that CPR was performed on her bed, a soft surface, and a senior clinician was unaware that this could reduce its effectiveness.

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 advanced life support training to cover the need for a solid surface during CPR
Wider context from the report
“(1) The consultant who was involved in performing CPR on Mrs Ley agreed that she had been in bed at the time. When asked why he had not moved her to a solid surface he replied that he had attended many advanced life support training sessions and had never been told this was necessary. In their article "The impact of compliant surfaces on in-hospital chest compressions: Effects of common mattresses and a backboard" in the journal Resucitation (Vol 80, Issue 5, May 2009) the authors note that carrying out CPR in a hospital bed may be 50% less effective. I am concerned that despite receiving training a senior clinician was unaware of this and consider that it gives rise to a risk of future deaths. ”
Source location
Julie Ley · 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
Reinforce CPR practice through resuscitation training.

Verbatim wording from the response
“The Trust’s resuscitation practice is aligned with this current national guidance. In response to the matters raised in your report, the Trust has nevertheless taken steps to reinforce and assure this position through resuscitation training, policy review, equipment assurance and clinical governance processes, in order to minimise the risk of misunderstanding or inconsistent practice in the future.”

Source location
Response from Lancashire and South Cumbria NHS Foundation Trust
Page 2 · response
Published 21 August 2026
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
Current national guidance and aligned practice are considered sufficient; patients should not be moved from beds, with CPR mitigation used.

Verbatim wording from the response
“Since the publication of the article cited in your report, national and international resuscitation guidance has evolved. Current Resuscitation Council UK guidance recognises that, although a firm surface is optimal, rescuers should not move a person from a soft surface, such as a bed, to the floor in order to commence CPR. The guidance emphasises that CPR should be started without delay on the bed and that, where required, chest compressions should be delivered with increased depth to compensate for mattress compliance, alongside the use of appropriate mitigation such as backboards.”

Source location
Response from Lancashire and South Cumbria NHS Foundation Trust
Page 1 · response
Published 21 August 2026
Open published response
30 Mar2026
Inner North London
Concerns raised1
1. Less-than-fully-competent CPR attempts
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 5
1. Action
  Deliver annual RCUK-accredited ILS training including ROLE, audit compliance, and restrict emergency-radio assignment for staff whose training is out of date.
  Stated by Practice Plus GroupStated completed
2. Action
  Deliver the booked ILS training session to increase current training compliance above 90%.
  Stated by Practice Plus GroupStated planned
3. Action
  Publish and implement the purple-alert guidance clarifying BLS, ILS, ROLE, and CPR expectations, and remind staff of its application.
  Stated by Practice Plus GroupStated completed
1. Action
  Hold a June 2026 meeting with regional and nursing directors to review guidance, consider further scoping, and assess safe ILS/ROLE staffing levels.
  Stated by Practice Plus GroupStated planned
2. Action
  Introduce multidisciplinary, scenario-based resuscitation training for healthcare, prison, and prison-officer staff by July 2026.
  Stated by Practice Plus GroupStated in progress
Respondent positions 1
1. Position
  Responsibility for the concerns about HMPPS and HMP Pentonville rests with separate organisations, so no response is proposed.
  Stated by Practice Plus GroupRedirects responsibility
AI-generated summary

Rickie Wai Kee POON · 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

Rickie Poon, a dismissed police officer detained under the Mental Health Act and later remanded in custody at HMP Pentonville, was found hanging in his cell one month after arriving at the prison. The jury found failures in the prison’s ACCT process contributed to his death, including inadequate management, accountability, training, implementation of actions and the early closure of the ACCT; concerns were also raised about inappropriate CPR after he had 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
Less-than-fully-competent CPR attempts
Wider context from the report
“The nurse’s actions could not have had an impact on the outcome because Mr Poon was already dead when she arrived. However, conducting CPR on a person who had clearly died was not professional or appropriate, it did not afford Mr Poon dignity or privacy, it was neither acceptable nor kind. What concerns me particularly for the future is that there might be an occasion when a CPR attempt that is less than fully competent does have the potential to impact on the outcome. I sent PFD reports to PPG’s earlier incarnation, Care UK, and/or HMP Pentonville about the nature of attempts at resuscitation in respect of the following deceased: • William Davies (2014) • Adil Habib (2015) • Samuel Blair (2016) • Tedros Kahssay (2016) • Amir Faizi (2018) • Robert Ginn (2019) I recognise that I made the last of these reports over six years ago and I have heard descriptions of many changes since then, but I consider that I would be failing in my duty if I were not to flag up this issue now. I hope that by doing so, such a situation will be less likely to arise in the future. ”
Source location
Rickie Wai Kee POON · 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
Deliver annual RCUK-accredited ILS training including ROLE, audit compliance, and restrict emergency-radio assignment for staff whose training is out of date.

Verbatim wording from the response
“It is important to note that all clinical staff are trained to ILS (Immediate Life Support) standards. This is a RCUK accredited course for healthcare professionals to manage patients in cardiac arrest before the ambulance team arrives. It focuses on the ABCDE approach, airway management, and safe defibrillation. All staff are expected to complete this training which is done yearly to ensure ongoing competence. This is also subject to audit, which currently shows a 74% compliance rate. Anyone who does not have the training in date would not be assigned to an emergency radio and would be expected to book and complete the training as soon as possible. There is a session booked on the week commencing 25th June 2026 which will raise the compliance to over 90%.”

Source location
Response from Practice Plus Group
Page 3 · response
Published 10 April 2026
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 the booked ILS training session to increase current training compliance above 90%.

Verbatim wording from the response
“It is important to note that all clinical staff are trained to ILS (Immediate Life Support) standards. This is a RCUK accredited course for healthcare professionals to manage patients in cardiac arrest before the ambulance team arrives. It focuses on the ABCDE approach, airway management, and safe defibrillation. All staff are expected to complete this training which is done yearly to ensure ongoing competence. This is also subject to audit, which currently shows a 74% compliance rate. Anyone who does not have the training in date would not be assigned to an emergency radio and would be expected to book and complete the training as soon as possible. There is a session booked on the week commencing 25th June 2026 which will raise the compliance to over 90%.”

Source location
Response from Practice Plus Group
Page 3 · response
Published 10 April 2026
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
Publish and implement the purple-alert guidance clarifying BLS, ILS, ROLE, and CPR expectations, and remind staff of its application.

Verbatim wording from the response
“A purple alert (which is a companywide safety notification) was published for all Heads of Healthcare to action, which clarified the organisational position on cardiopulmonary resuscitation following updated guidance by NHSE on 19 March 2026, which is being actioned in line with the deadline given in the alert. A copy of this alert is attached to this response for ease of reference. The purple alert highlights to all services within Practice Plus Group (PPG) that we fully support the national HMPPS/NHS England guidance that cardiopulmonary resuscitation (CPR) should begin immediately when an individual is unresponsive, not breathing and/or has no pulse, unless there are unmistakable signs of irreversible death. However, it recognises that PPG’s clinical training model differs from the national assumption that prison healthcare staff are trained only to Basic Life Support (BLS) level.”

Source location
Response from Practice Plus Group
Page 4 · response
Published 10 April 2026
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
Hold a June 2026 meeting with regional and nursing directors to review guidance, consider further scoping, and assess safe ILS/ROLE staffing levels.

Verbatim wording from the response
“In light of the Prevention of Future Deaths (PFD) report, the site has also requested a meeting with the Regional Director and the Director of Nursing, due to be held in June 2026. The purpose of this meeting is to:”

Source location
Response from Practice Plus Group
Page 4 · response
Published 10 April 2026
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 multidisciplinary, scenario-based resuscitation training for healthcare, prison, and prison-officer staff by July 2026.

Verbatim wording from the response
“As a service, we are committed to further strengthening our resuscitation response following the issues highlighted in the PFD. To support this, we are introducing multidisciplinary, scenario-based training by July 2026. This programme will involve healthcare staff, prison staff, and prison officers where appropriate, ensuring that learning is shared across the whole custodial environment and that all parties understand their roles during a medical”

Source location
Response from Practice Plus Group
Page 4 · response
Published 10 April 2026
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 the concerns about HMPPS and HMP Pentonville rests with separate organisations, so no response is proposed.

Verbatim wording from the response
“We do not propose to respond to the points raised above in respect of HMPPS and HMP Pentonville as these matters are for separate organisation.”

Source location
Response from Practice Plus Group
Page 3 · response
Published 10 April 2026
Open published response
20 Feb2026
Inner North London
Concerns raised4
1. Inadequate assessment of first aid knowledge and competence
2. Insufficient emphasis on urgent life-preserving first aid measures
3. Failure of first aid staff to provide complete resuscitation measures
1. Inadequate first aid training for seizures and other emergencies
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 4
1. Action
  Create and require staff to complete a separate online medical-emergency vehicle course covering emergency response, basic life support and related vehicle incidents, with an 80% pass threshold.
  Stated by Serco Group plcStated completed
2. Action
  Revise relevant prisoner welfare, vehicle escort, death-in-custody and associated procedures, and align corresponding training materials.
  Stated by Serco Group plcStated completed
3. Action
  Review recovery-position training adequacy and whether additional or new content should be included in the vehicle-emergencies module.
  Stated by Serco Group plcStated in progress
1. Action
  Review training with Highfield to explore including a seizure video to improve seizure recognition and response retention.
  Stated by Serco Group plcStated in progress
AI-generated summary

Sean Perry 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

Sean Williams died in the back of a Serco van outside Thames Magistrates’ Court after suffering a fit during transport and then a cardiac arrest. Concerns included gaps in his custody healthcare assessment and treatment, inadequate Serco first-aid training and competence assessment, failure to provide timely first aid, unclear emergency procedures, and insufficient emphasis on preserving life.

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 assessment of first aid knowledge and competence
Wider context from the report
“For the MPS The MPS had already recognised before inquest that, following Mr Williams’ detention, he was not seen by a custody nurse for 23 hours. However, there was another sub optimal element of his care that did not appear to have been identified. The custody nurse who reviewed Mr Williams on two separate occasions in the twelve hours immediately before he attended court, did not on the second occasion take any observations of Mr Williams’ vital signs before (or after) prescribing dihydrocodeine, and did not record any part of Mr Williams’ clinical picture. Despite having prescribed dihydrocodeine for drug withdrawal, when giving evidence in court the nurse was unable to describe the signs and symptoms of withdrawal. For Serco By 18.11 hours, the Serco van that was transporting Mr Williams had returned to the court car park entrance and the driver had got out of the cab and into the back of the van. At that point, neither the escort nor the driver opened the door to Mr Williams’ cell to administer first aid - at the very least to relieve his slumped, squashed position to try to deal with any potential airway obstruction. At 18.15 hours when he stopped showing any signs of life, they still did not open his door. They only opened his door at 18.23 hours, removing him from the cell at 18.24 hours, and administering chest compressions at 18.25 hours. The driver did not press the emergency button in the cab to alert the operations control centre of the situation. The Serco crew did call the London Ambulance Service from the van, but were unable to give the postcode of their location. I put it to the Serco driver that the focus of the two Serco crew members seemed to be on talking to the three other prisoners in their cells, on phone calls, in fact on anything except getting Mr Williams out of his cell to see if the crew could help him. The driver agreed. The Serco driver eventually administered chest compressions but could not face giving rescue breaths. He seemed to have forgotten that he had a face guard hanging from his belt. Despite evidence from Serco that they were satisfied with the first aid training that was given to the two officers, the jury found that: - the Serco first aid training was inadequate; - it did not include a video of a seizure; - it did not sufficiently emphasise the urgency of potentially life saving measures such as use of the recovery position; - the Serco assessment of the first aid knowledge and competence of its staff was inadequate; - Serco failed to provide clear guidance on the emergency button procedures; - Serco’s policy appeared to conflict with its training slides about whether staff should or are even permitted to drive a casualty direct to hospital; - Serco gave insufficient emphasis on urgency and the paramount importance of preserving life. ”
Source location
Sean Perry WILLIAMS · 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
Insufficient emphasis on urgent life-preserving first aid measures
Wider context from the report
“For the MPS The MPS had already recognised before inquest that, following Mr Williams’ detention, he was not seen by a custody nurse for 23 hours. However, there was another sub optimal element of his care that did not appear to have been identified. The custody nurse who reviewed Mr Williams on two separate occasions in the twelve hours immediately before he attended court, did not on the second occasion take any observations of Mr Williams’ vital signs before (or after) prescribing dihydrocodeine, and did not record any part of Mr Williams’ clinical picture. Despite having prescribed dihydrocodeine for drug withdrawal, when giving evidence in court the nurse was unable to describe the signs and symptoms of withdrawal. For Serco By 18.11 hours, the Serco van that was transporting Mr Williams had returned to the court car park entrance and the driver had got out of the cab and into the back of the van. At that point, neither the escort nor the driver opened the door to Mr Williams’ cell to administer first aid - at the very least to relieve his slumped, squashed position to try to deal with any potential airway obstruction. At 18.15 hours when he stopped showing any signs of life, they still did not open his door. They only opened his door at 18.23 hours, removing him from the cell at 18.24 hours, and administering chest compressions at 18.25 hours. The driver did not press the emergency button in the cab to alert the operations control centre of the situation. The Serco crew did call the London Ambulance Service from the van, but were unable to give the postcode of their location. I put it to the Serco driver that the focus of the two Serco crew members seemed to be on talking to the three other prisoners in their cells, on phone calls, in fact on anything except getting Mr Williams out of his cell to see if the crew could help him. The driver agreed. The Serco driver eventually administered chest compressions but could not face giving rescue breaths. He seemed to have forgotten that he had a face guard hanging from his belt. Despite evidence from Serco that they were satisfied with the first aid training that was given to the two officers, the jury found that: - the Serco first aid training was inadequate; - it did not include a video of a seizure; - it did not sufficiently emphasise the urgency of potentially life saving measures such as use of the recovery position; - the Serco assessment of the first aid knowledge and competence of its staff was inadequate; - Serco failed to provide clear guidance on the emergency button procedures; - Serco’s policy appeared to conflict with its training slides about whether staff should or are even permitted to drive a casualty direct to hospital; - Serco gave insufficient emphasis on urgency and the paramount importance of preserving life. ”
Source location
Sean Perry WILLIAMS · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure of first aid staff to provide complete resuscitation measures
Wider context from the report
“For the MPS The MPS had already recognised before inquest that, following Mr Williams’ detention, he was not seen by a custody nurse for 23 hours. However, there was another sub optimal element of his care that did not appear to have been identified. The custody nurse who reviewed Mr Williams on two separate occasions in the twelve hours immediately before he attended court, did not on the second occasion take any observations of Mr Williams’ vital signs before (or after) prescribing dihydrocodeine, and did not record any part of Mr Williams’ clinical picture. Despite having prescribed dihydrocodeine for drug withdrawal, when giving evidence in court the nurse was unable to describe the signs and symptoms of withdrawal. For Serco By 18.11 hours, the Serco van that was transporting Mr Williams had returned to the court car park entrance and the driver had got out of the cab and into the back of the van. At that point, neither the escort nor the driver opened the door to Mr Williams’ cell to administer first aid - at the very least to relieve his slumped, squashed position to try to deal with any potential airway obstruction. At 18.15 hours when he stopped showing any signs of life, they still did not open his door. They only opened his door at 18.23 hours, removing him from the cell at 18.24 hours, and administering chest compressions at 18.25 hours. The driver did not press the emergency button in the cab to alert the operations control centre of the situation. The Serco crew did call the London Ambulance Service from the van, but were unable to give the postcode of their location. I put it to the Serco driver that the focus of the two Serco crew members seemed to be on talking to the three other prisoners in their cells, on phone calls, in fact on anything except getting Mr Williams out of his cell to see if the crew could help him. The driver agreed. The Serco driver eventually administered chest compressions but could not face giving rescue breaths. He seemed to have forgotten that he had a face guard hanging from his belt. Despite evidence from Serco that they were satisfied with the first aid training that was given to the two officers, the jury found that: - the Serco first aid training was inadequate; - it did not include a video of a seizure; - it did not sufficiently emphasise the urgency of potentially life saving measures such as use of the recovery position; - the Serco assessment of the first aid knowledge and competence of its staff was inadequate; - Serco failed to provide clear guidance on the emergency button procedures; - Serco’s policy appeared to conflict with its training slides about whether staff should or are even permitted to drive a casualty direct to hospital; - Serco gave insufficient emphasis on urgency and the paramount importance of preserving life. ”
Source location
Sean Perry WILLIAMS · 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
Inadequate first aid training for seizures and other emergencies
Wider context from the report
“For the MPS The MPS had already recognised before inquest that, following Mr Williams’ detention, he was not seen by a custody nurse for 23 hours. However, there was another sub optimal element of his care that did not appear to have been identified. The custody nurse who reviewed Mr Williams on two separate occasions in the twelve hours immediately before he attended court, did not on the second occasion take any observations of Mr Williams’ vital signs before (or after) prescribing dihydrocodeine, and did not record any part of Mr Williams’ clinical picture. Despite having prescribed dihydrocodeine for drug withdrawal, when giving evidence in court the nurse was unable to describe the signs and symptoms of withdrawal. For Serco By 18.11 hours, the Serco van that was transporting Mr Williams had returned to the court car park entrance and the driver had got out of the cab and into the back of the van. At that point, neither the escort nor the driver opened the door to Mr Williams’ cell to administer first aid - at the very least to relieve his slumped, squashed position to try to deal with any potential airway obstruction. At 18.15 hours when he stopped showing any signs of life, they still did not open his door. They only opened his door at 18.23 hours, removing him from the cell at 18.24 hours, and administering chest compressions at 18.25 hours. The driver did not press the emergency button in the cab to alert the operations control centre of the situation. The Serco crew did call the London Ambulance Service from the van, but were unable to give the postcode of their location. I put it to the Serco driver that the focus of the two Serco crew members seemed to be on talking to the three other prisoners in their cells, on phone calls, in fact on anything except getting Mr Williams out of his cell to see if the crew could help him. The driver agreed. The Serco driver eventually administered chest compressions but could not face giving rescue breaths. He seemed to have forgotten that he had a face guard hanging from his belt. Despite evidence from Serco that they were satisfied with the first aid training that was given to the two officers, the jury found that: - the Serco first aid training was inadequate; - it did not include a video of a seizure; - it did not sufficiently emphasise the urgency of potentially life saving measures such as use of the recovery position; - the Serco assessment of the first aid knowledge and competence of its staff was inadequate; - Serco failed to provide clear guidance on the emergency button procedures; - Serco’s policy appeared to conflict with its training slides about whether staff should or are even permitted to drive a casualty direct to hospital; - Serco gave insufficient emphasis on urgency and the paramount importance of preserving life. ”
Source location
Sean Perry WILLIAMS · 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
Create and require staff to complete a separate online medical-emergency vehicle course covering emergency response, basic life support and related vehicle incidents, with an 80% pass threshold.

Verbatim wording from the response
“In addition, in order to remind staff of the required process and aid their retention of the information provided during the training, in March 2025 we created a new online course on Serco’s LMS. This is a mandatory course for all staff members and includes what to do in an emergency medical incident, basic life support, self-harm incidents, vehicle breakdown, fire and anything deemed a vehicle emergency. The content provides a refresher of the training covered in the ITC course, to reinforce learning and gives additional prominence by being a separate module and links together the concepts that staff have learned during their Highfield First Aid training.”

Source location
Response from Serco
Page 3 · response
Published 24 February 2026
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
Revise relevant prisoner welfare, vehicle escort, death-in-custody and associated procedures, and align corresponding training materials.

Verbatim wording from the response
“Since the death of Mr Williams we have revised Standard Operating Procedure (SOP) 038 Prisoner Welfare on a Vehicle, SOP 009 Duties of a Vehicle Escort Officer and SOP 047 Death or attempted suicide of a prisoner in custody, to improve the clarity of the steps to be taken where a medical emergency is suspected and I understand copies of the updated SOPs have been provided to you. The changes have also been reflected in other SOPs and training documents to ensure consistency.”

Source location
Response from Serco
Page 1 · response
Published 24 February 2026
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 recovery-position training adequacy and whether additional or new content should be included in the vehicle-emergencies module.

Verbatim wording from the response
“I note the jury’s findings and that one particular concern related to seizures. As you will note the First Aid slides include a whole section on seizures (slides 118-122). Nevertheless, while seizure recognition and response forms part of existing first-aid training, this finding has prompted Serco to consider whether additional measures are required to strengthen staff confidence and recognition with respect to this issue in practice. Similarly, the findings relating to the use of the recovery position have informed a focused review of how this aspect of training is emphasised and reinforced. That said, once again, you will have noted that there is a whole section on the recovery position within the training slides (slides 49-57). I can also confirm that aspects of both of these sections are included in the assessment of staff when the training is concluded.”

Source location
Response from Serco
Page 2 · response
Published 24 February 2026
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 training with Highfield to explore including a seizure video to improve seizure recognition and response retention.

Verbatim wording from the response
“We are also in the process of reviewing the training provided with the awarding organisation, Highfield, to explore the possibility of including a video of a seizure in the training, to assist staff in identifying a seizure, and in retaining the instruction provided on how to deal with a seizure should they encounter one. A review of the adequacy of the training on the recovery position is also being undertaken to ascertain that any possible improvements are implemented. We are also reviewing whether it would be appropriate to include additional and new training on the recovery position within the training module on vehicle emergencies, to emphasise its importance, and to assist in retention of this very importance aspect of the training.”

Source location
Response from Serco
Page 3 · response
Published 24 February 2026
Open published response
9 Feb2026
Inner North London
Concerns raised1
1. Failure to provide regular mandatory basic life support training to prison officers
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Develop and provide first-aid instructional materials through staff e-learning platforms.
  Stated by HM Prison and Probation ServiceStated completed
2. Action
  Deliver basic life-saving and CPR refresher sessions to staff through qualified Physical Education Instructors.
  Stated by HM Prison and Probation ServiceStated planned
3. Action
  Promote the first-aid-at-work course and encourage wider staff participation to maintain sufficient qualified first aiders.
  Stated by HM Prison and Probation ServiceStated in progress
AI-generated summary

Gareth Chumber-Kelly · 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

Gareth Chumber-Kelly died after hanging himself while in custody at HMP Pentonville on 17 July 2023. The report identified concerns about lost or incomplete transfer documentation, inadequate recognition and management of suicide and self-harm risks, insufficient staff training, failures to provide basic life support, and inadequate staffing and support during crucial periods.

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 regular mandatory basic life support training to prison officers
Wider context from the report
“(3) The court heard evidence that the first two officers on the scene failed to provide any form of basic life support despite having received training on how to do so. Both officers described how they panicked and did not know what to do. The court heard evidence from a consultant paramedic from the London Ambulance service with extensive experience in resuscitation who explained that for every minute without CPR there is a 10-22% drop in survival rates. It is critically important that the first person on the scene in such emergency situations (who will almost always be the prison officers) are properly and regularly trained in basic life support so that they are able to render such aid immediately on arrival. The Governor of the prison told the court that no refresher CPR training had been provided to prison staff since 2023 notwithstanding the 5 deaths of prisoners by ligature suspension that have occurred since. This is deeply concerning given that this very same issue was raised in a Prevention of Future Deaths Report by Mary Hassell, HM Senior Coroner of Inner North London on 18th September 2023 relating to the death of Amarjit Singh and yet in the 2 years since that PFD was issued there is still no mandatory basic life support training for prison officers. The failure of the prison to provide regular, mandatory basic life support to all prison officer creates a risk of future deaths. ”
Source location
Gareth Chumber-Kelly · 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
Develop and provide first-aid instructional materials through staff e-learning platforms.

Verbatim wording from the response
“More widely, HMPPS develops staff capability through refresher courses and communication packages. Materials, including instructional videos, have been developed and are available to staff through E-learning platforms to update and maintain their first aid knowledge and skills. These provide practical guidance on what to do in several potential scenarios that staff may encounter in the course of their duties.”

Source location
Response from HMPPS
Page 3 · response
Published 12 February 2026
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 basic life-saving and CPR refresher sessions to staff through qualified Physical Education Instructors.

Verbatim wording from the response
“The Pentonville Speed School will support this work by utilising Physical Education Instructors, who are qualified first aid trainers, to deliver basic life-saving skills to staff, including training in CPR. These short, practical sessions will ensure that staff receive essential refresher training and thereby increasing their confidence when responding to medical emergencies. In addition, HMP Pentonville is promoting the first aid at work course and encouraging wider staff participation to ensure that key areas of the establishment maintain sufficient qualified first aiders.”

Source location
Response from HMPPS
Page 3 · response
Published 12 February 2026
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
Promote the first-aid-at-work course and encourage wider staff participation to maintain sufficient qualified first aiders.

Verbatim wording from the response
“The Pentonville Speed School will support this work by utilising Physical Education Instructors, who are qualified first aid trainers, to deliver basic life-saving skills to staff, including training in CPR. These short, practical sessions will ensure that staff receive essential refresher training and thereby increasing their confidence when responding to medical emergencies. In addition, HMP Pentonville is promoting the first aid at work course and encouraging wider staff participation to ensure that key areas of the establishment maintain sufficient qualified first aiders.”

Source location
Response from HMPPS
Page 3 · response
Published 12 February 2026
Open published response
25 Nov2025
Nottinghamshire
Concerns raised1
1. Lack of evidence of improvement in Emergency Assessment Unit staff ability to respond effectively to cardiac arrest
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 9
1. Action
  Deliver and continue in-situ cardiac-arrest simulation sessions for Emergency Assessment Unit nursing and medical staff.
  Stated by Sherwood Forest Hospitals NHS Foundation TrustStated in progress
2. Action
  Implement the revised Advanced Life Support course format, including AED demonstrations and practical skills assessment.
  Stated by Sherwood Forest Hospitals NHS Foundation TrustStated planned
3. Action
  Provide prompt Advanced Life Support training for newly appointed Band 6 nurses.
  Stated by Sherwood Forest Hospitals NHS Foundation TrustStated completed
1. Action
  Monitor Advanced Life Support compliance through monthly service-line performance meetings and escalate issues as required.
  Stated by Sherwood Forest Hospitals NHS Foundation TrustStated planned
2. Action
  Book new Emergency Assessment Unit staff onto the next available Immediate Life Support course.
  Stated by Sherwood Forest Hospitals NHS Foundation TrustStated planned
3. Action
  Procure additional AEDs for practical mandatory resuscitation training.
  Stated by Sherwood Forest Hospitals NHS Foundation TrustStated planned
4. Action
  Introduce practical AED training into mandatory resuscitation sessions for nursing, midwifery, allied health professional and medical staff.
  Stated by Sherwood Forest Hospitals NHS Foundation TrustStated planned
5. Action
  Include resuscitation-service teaching on equipment and defibrillator operation in doctor induction programmes.
  Stated by Sherwood Forest Hospitals NHS Foundation TrustStated completed
6. Action
  Review reported cardiac arrests trust-wide through the resuscitation team and provide feedback to relevant area leads.
  Stated by Sherwood Forest Hospitals NHS Foundation TrustStated completed
Respondent positions 1
1. Position
  Three planned Emergency Assessment Unit simulation sessions were cancelled because staffing and operational constraints prevented their delivery.
  Stated by Sherwood Forest Hospitals NHS Foundation TrustUnable to act
AI-generated summary

Connor Nelson · 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

Connor Nelson died at Kings Mill Hospital on 30 November 2024 from hypoxic ischaemic encephalopathy following a prolonged cardiac arrest on 10 November 2024. The report describes an undiagnosed congenital prolonged QT syndrome, a nine-minute delay in administering a necessary shock, and concerns about cardiac-arrest response and processes for identifying and investigating prolonged QTc syndrome.

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 evidence of improvement in Emergency Assessment Unit staff ability to respond effectively to cardiac arrest
Wider context from the report
“1. The lack of evidence of any improvement in the ability of Emergency Assessment Unit staff to respond effectively to a cardiac arrest ”
Source location
Connor Nelson · 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
Deliver and continue in-situ cardiac-arrest simulation sessions for Emergency Assessment Unit nursing and medical staff.

Verbatim wording from the response
“In situ skills and drills simulation sessions: During December 2025, a total of nine simulation sessions were scheduled to be undertaken on EAU with both nursing and medical staff, with additional sessions continuing into subsequent months. These sessions were being led by the resus team and were set to include the following key topics:”

Source location
Response from Sherwood Forest Hospitals NHS Foundation Trust
Page 1 · response
Published 3 December 2025
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
Implement the revised Advanced Life Support course format, including AED demonstrations and practical skills assessment.

Verbatim wording from the response
“Advanced Life Support Training: Since the inquest was held the Resuscitation Council UK (RCUK) has introduced a revision to training protocols, now permitting the use of an Automated External Defibrillator (AED) during cardiac arrest demonstrations, as well as the discussion of AED usage within the CPR and defibrillation skill station as part of the Advanced Life Support (ALS) course. This updated course format became effective as of 1st January 2026 nationally, and its implementation will commence with the ALS courses, consisting of 1-day online learning plus 1 day of hands-on training with a comprehensive skill station assessment, scheduled for 21st and 22nd January at Sherwood Forest Hospitals (SFH).”

Source location
Response from Sherwood Forest Hospitals NHS Foundation Trust
Page 2 · response
Published 3 December 2025
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 prompt Advanced Life Support training for newly appointed Band 6 nurses.

Verbatim wording from the response
“It is recognised, that the rotation of new staff within EAU has the potential to affect training compliance rates, particularly for training such as ALS. To address this, a comprehensive plan has been implemented to ensure that all new Band 6 staff promptly receive the necessary training upon appointment. Furthermore, measures are being explored to provide existing Band 5 registered nurses looking for development opportunity therefore supporting both ongoing professional development and the maintenance of a highly skilled workforce.”

Source location
Response from Sherwood Forest Hospitals NHS Foundation Trust
Page 2 · response
Published 3 December 2025
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
Monitor Advanced Life Support compliance through monthly service-line performance meetings and escalate issues as required.

Verbatim wording from the response
“ALS training compliance will now be included in the service line performance meetings monthly commencing February 2026 to enable consistent monitoring and escalation as required.”

Source location
Response from Sherwood Forest Hospitals NHS Foundation Trust
Page 2 · response
Published 3 December 2025
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
Book new Emergency Assessment Unit staff onto the next available Immediate Life Support course.

Verbatim wording from the response
“Immediate Life Support Training: As of 23rd January 2026 91% of registered nurses working on EAU had undergone Immediate Life Support Training and the remaining 9% of staff are booked onto courses.”

Source location
Response from Sherwood Forest Hospitals NHS Foundation Trust
Page 3 · response
Published 3 December 2025
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
Procure additional AEDs for practical mandatory resuscitation training.

Verbatim wording from the response
“Mandatory resuscitation training: In addition, further measures have been implemented to enhance resuscitation training across all staff at SFH. Additional AEDs have been procured to facilitate the inclusion of AEDs as a practical, hands-on component within mandatory resuscitation training sessions. The introduction of this practical element will commence in April 2026, following the conclusion of the winter pause in mandatory training. This initiative will be delivered in conjunction with the E-Learning for Healthcare (E-LfH) content, which will be utilised by nursing, midwifery, and allied health professional (N.M&AHP) staff to fulfil Resuscitation Level 1 and 2 theoretical requirements, in alignment with the broader NHS training transferability plan. Simultaneously, mandatory sessions for medical staff will also be adapted to incorporate practical AED training from April 2026 onwards.”

Source location
Response from Sherwood Forest Hospitals NHS Foundation Trust
Page 3 · response
Published 3 December 2025
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 practical AED training into mandatory resuscitation sessions for nursing, midwifery, allied health professional and medical staff.

Verbatim wording from the response
“Mandatory resuscitation training: In addition, further measures have been implemented to enhance resuscitation training across all staff at SFH. Additional AEDs have been procured to facilitate the inclusion of AEDs as a practical, hands-on component within mandatory resuscitation training sessions. The introduction of this practical element will commence in April 2026, following the conclusion of the winter pause in mandatory training. This initiative will be delivered in conjunction with the E-Learning for Healthcare (E-LfH) content, which will be utilised by nursing, midwifery, and allied health professional (N.M&AHP) staff to fulfil Resuscitation Level 1 and 2 theoretical requirements, in alignment with the broader NHS training transferability plan. Simultaneously, mandatory sessions for medical staff will also be adapted to incorporate practical AED training from April 2026 onwards.”

Source location
Response from Sherwood Forest Hospitals NHS Foundation Trust
Page 3 · response
Published 3 December 2025
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
Include resuscitation-service teaching on equipment and defibrillator operation in doctor induction programmes.

Verbatim wording from the response
“Changes to Doctor induction: Effective from 3rd December 2025, the doctor induction programme now incorporates a dedicated session delivered by the trust resuscitation service. This session provides an overview of the adult resuscitation trolley and its contents, as well as instruction on the two defibrillator models used at SFHFT and their operational functions. The session is made available to Foundation Year 2 (FY2) doctors and higher at each entry point throughout the training year. Foundation Year 1 (FY1) doctors receive a separate induction covering the same material in July.”

Source location
Response from Sherwood Forest Hospitals NHS Foundation Trust
Page 3 · response
Published 3 December 2025
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 reported cardiac arrests trust-wide through the resuscitation team and provide feedback to relevant area leads.

Verbatim wording from the response
“Review of cardiac arrests on EAU in December 2025: To provide further assurance regarding improvements in the management of a cardiac arrest, all cardiac arrests on EAU during the period from 1st December to 30th December 2025 were reviewed by the trust resus team. It was confirmed that EAU initiated three 2222 calls (emergency calls), of these, one was categorised as a medical emergency for which cardiopulmonary resuscitation (CPR) was not required. The remaining two incidents were audited in accordance with the cardiac arrest governance process. One case raised no concerns, while the other identified issues related to Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) documentation—specifically, that although the DNACPR decision appeared to have”

Source location
Response from Sherwood Forest Hospitals NHS Foundation Trust
Page 3 · response
Published 3 December 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
Three planned Emergency Assessment Unit simulation sessions were cancelled because staffing and operational constraints prevented their delivery.

Verbatim wording from the response
“Of the planned sessions, six were successfully delivered, attended by 18 staff members, resulting in an average attendance of three participants per session. Three sessions were cancelled due to staffing and operational constraints. Furthermore, nine additional sessions are scheduled for January 2026. It should be noted that, owing to the small group sizes and the restricted nature of the space utilised for "in situ" training, these sessions are not directly comparable to previous simulation events. Within the limitations of the skills practised, staff performance was assessed by the trust resuscitation team to be of a satisfactory standard.”

Source location
Response from Sherwood Forest Hospitals NHS Foundation Trust
Page 2 · response
Published 3 December 2025
Open published response
13 Oct2025
East Sussex
Concerns raised1
1. Inadequate life support training for healthcare staff
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Provide annual accredited Immediate Life Support training for relevant staff, with agency staff required to hold current certification and compliance monitored monthly.
  Stated by Practice Plus GroupStated completed
AI-generated summary

Jamie Stuart Funnell · 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

Jamie Stuart Funnell died at HMP Lewes on 16 December 2023 while withdrawing from alcohol and drugs. The inquest concluded that his death was due to the effects of drug and alcohol withdrawal, exacerbated by omissions by healthcare and prison staff. Concerns included failures in withdrawal assessment and monitoring, communication, CPR response, staff training, equipment maintenance, and updating relevant 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
Inadequate life support training for healthcare staff
Wider context from the report
“2. I heard evidence describing the care given to Jamie Funnell after his collapse as chaotic, with faulty equipment and incorrect CPR technique. The Ambulance crews witnessed the healthcare members carrying out CPR before taking over. After Jamie’s death was confirmed, a crew member raised concerns with the Duty Governor about the CPR attempts she had witnessed. I have heard evidence that although 32 eligible healthcare staff have now completed life support training, I have not heard any evidence regarding the level of this training and remain concerned, especially in light of the unsatisfactory response by PPG in its Action Plan for the PFO Report dated September 2024 that adequate training of staff and monitoring of equipment to prevent faults in its operation have been undertaken to prevent a fatality occurring in similar circumstances. ”
Source location
Jamie Stuart Funnell · 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 annual accredited Immediate Life Support training for relevant staff, with agency staff required to hold current certification and compliance monitored monthly.

Verbatim wording from the response
“At HMP Lewes, all of our substantive and bank nursing staff, GP staff and health care assistants receive annual Immediate Life Support training which is accredited with the Resuscitation Council UK. Agency staff receive annual training through their employing agency and are not able to work at Practice Plus Group sites without having an in-date certificate of completion. Current compliance figures for Immediate Life Support training are 96% which is monitored monthly so that timely courses can be booked to ensure staff remain up to date.”

Source location
Response from Practice Plus Group
Page 4 · response
Published 14 October 2025
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Lack of refresher training in basic life support for prison officers

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Limitation of Ambulance Support Practitioners' airway management training to supervised i-gel use

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Lack of mandatory refresher training in first aid and CPR for prison staff

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Inadequate staff training to conduct CPR unless a contrary decision exists

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4

Concerns raised1

Failure of advanced life support training to cover the need for a solid surface during CPR

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Less-than-fully-competent CPR attempts

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Actions described in response 2

Respondent positions 1

Actions described in response 1

Respondent positions 1

Actions described in response 3

Respondent positions 1

Actions described in response 4

Actions described in response 1

Respondent positions 1

Actions described in response 5

Respondent positions 1