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.

3 Feb2014
West Yorkshire (East)
Concerns raised1
1. Insufficient Prison Officer competence and refresher training in first aid and CPR
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 1
1. Action
  Train all custodial managers in First Aid at Work and operational support night-patrol staff in Emergency First Aid at Work.
  Stated by HM Prison and Probation ServiceStated in progress
AI-generated summary

Ryan Patrick John Clark · Prevention of Future Deaths report

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

Report summary

Ryan Patrick John Clark, aged 17, died on 18 April 2011 after being discovered in his cell at HMYOI Wetherby with a ligature around his neck; his death was certified at Harrogate District Hospital. The concerns included ineffective implementation of the Personal Officer Scheme, failures in ACCT checks and trainee roll counts, and insufficient first-aid and CPR training for 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
Insufficient Prison Officer competence and refresher training in first aid and CPR
Wider context from the report
“At HMYOI Wetherby (1) The Personal Officer Scheme was not properly implemented and did not operate effectively vis a vis trainees; (2) ACCT checks of a trainee were not made and/or were not made in accordance with the times prescribed by the trainee's ACCT document; (3) The correct procedure when conducting a roll count of trainees was not adopted by Prison Officers; (4) Prison Officers were not fully conversant in the administration of first aid and CPR and had not received regular refresher training in relation thereto. ”
Source location
Ryan Patrick John Clark · 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
Train all custodial managers in First Aid at Work and operational support night-patrol staff in Emergency First Aid at Work.

Verbatim wording from the response
“First Aid and CPR PSI 01/2014 First Aid describes the process for ensuring effective provision of first aid that enables NOMS to discharge its duty of care to its employees, to prisoners and to visitors to our premises. Governors are required to ensure that at all times such numbers of suitably trained first aiders as is sufficient and appropriate for the circumstances are available. A First Aid risk/needs assessment is undertaken by the local Health and Safety Advisor to determine the appropriate numbers. Governors must ensure that first aiders are trained to levels which are appropriate for the circumstances and hold a valid certificate of competence in either First Aid at Work (FAW) or Emergency First Aid at Work (EFAW).”

Source location
2014-0057-Response-by-NOMS
Page 2 · response
Published 3 February 2014
Open published response
22 Jan2014
York City
Concerns raised1
1. Lack of hypothermia coverage in police first aid training
This report raised 10 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.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Paul Alan Rogerson · 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 Alan Rogerson, aged 26, fell into the River Ouse in York on 26 March 2011 after consuming several pints of beer and drowned. The report raised concerns about inadequate life-buoy and throwing-line provision and maintenance, a lack of warning signs, and shortcomings in river-rescue training, communication and 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
Lack of hypothermia coverage in police first aid training
Wider context from the report
“(5) North Yorkshire Police officers receive first aid training in CPR and wounds but Hypothermia is currently not covered. ”
Source location
Paul Alan Rogerson · Prevention of Future Deaths report
Page 2 · concerns
Open source report
16 Dec2013
Surrey
Concerns raised1
1. Unclear alignment of resuscitation training with current guidance
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.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Sarah Anne Shepherd · 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

Sarah Anne Shepherd, a patient detained under the Mental Health Act, was found in her room with a plastic bin liner over her head on 12 September 2011 and died in hospital the following day. The report identified concerns about unclear referral processes to the Psychiatric Intensive Care Unit, failures to attempt resuscitation in accordance with guidance, and uncertainty and misleading materials concerning resuscitation 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
Unclear alignment of resuscitation training with current guidance
Wider context from the report
“(2) It was apparent from the evidence that the nursing staff who found the Deceased in an unresponsive state on the 12th September 2011 did not attempt to resuscitate her in accordance with the guidelines of the Resuscitation Council. They understood that resuscitation should be started if the patient was not “breathing” whereas the Council states that it should be started if the patient is not “breathing normally”. The evidence heard as to what training the nursing staff had been given concerning when resuscitation should be started was unclear and confusing. It remains unclear whether the resuscitation training now being given to clinical staff (a) is fully and clearly in accordance with the current guidance of the Resuscitation Council and (b) includes training as to what observations should be taken and recorded. Further, it was apparent from the evidence that the resuscitation bags used by staff contain a laminated aide memoire which is itself misleading as it refers to the use of resuscitation when the patient is not “breathing” rather than “breathing normally”. ”
Source location
Sarah Anne Shepherd · Prevention of Future Deaths report
Page 2 · concerns
Open source report
6 Dec2013
Manchester South
Concerns raised2
1. Insufficient paediatric first aid training among nursery staff
2. Lapsed first aid certification among staff
This report raised 1 other concern. 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 2
1. Action
  Propose reinforcing the requirement for a first-aid-trained staff member to be available whenever children are present.
  Stated by Edward Timpson MPStated completed
2. Action
  Propose specifying the suitable course content for paediatric first-aid training in the Early Years Foundation Stage framework.
  Stated by Edward Timpson MPStated completed
Respondent positions 1
1. Position
  Responsibility for mandatory paediatric first-aid training of nursery staff rests with the Department for Education.
  Stated by Department of Health and Social CareRedirects responsibility
AI-generated summary

Millie Elizabeth Josephine Thompson · 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

Millie Elizabeth Josephine Thompson, aged 9 months, choked while being fed Shepherd’s Pie at a nursery on 23 October 2012. Food lodged in her left main bronchus, leading to a tension pneumothorax and cardiac arrest. Concerns included insufficient paediatric first-aid training and lapsed certification among nursery staff, an incorrect ambulance call allocation, and unsuitable paediatric equipment on the first ambulance.

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 paediatric first aid training among nursery staff
Wider context from the report
“During the course of the evidence it became apparent that there were only a few members of staff at the Nursery who had undergone Paediatric First Aid training, and that there is a need for specialist training when confronted with certain medical conditions affecting very young children. Other members of staff had general First Aid training but this appears to have been less useful in the circumstances. It also transpired that the First Aid certification of some of the staff had lapsed by the passage of time, so that although they had undergone the training it now needed updating. The EMD (call-taker) for the Ambulance Trust is a non-medically trained person who simply takes the details and reads from the appropriate “card” as to what questions should be asked and what advice should be given as well as determining how the case is to be triaged and allocated. It appears that because of a misinterpretation by that person as to the question of “ineffective/effective breathing”, the case was wrongly allocated. I took the view that ALL nursery staff should be subject to mandatory paediatric First Aid training; that there should be better selection and training of Call-Takers for the ambulance service; that ALL emergency ambulances (including rapid response vehicles) should be equipped with suitable paediatric life-saving kit. ”
Source location
Millie Elizabeth Josephine Thompson · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lapsed first aid certification among staff
Wider context from the report
“During the course of the evidence it became apparent that there were only a few members of staff at the Nursery who had undergone Paediatric First Aid training, and that there is a need for specialist training when confronted with certain medical conditions affecting very young children. Other members of staff had general First Aid training but this appears to have been less useful in the circumstances. It also transpired that the First Aid certification of some of the staff had lapsed by the passage of time, so that although they had undergone the training it now needed updating. The EMD (call-taker) for the Ambulance Trust is a non-medically trained person who simply takes the details and reads from the appropriate “card” as to what questions should be asked and what advice should be given as well as determining how the case is to be triaged and allocated. It appears that because of a misinterpretation by that person as to the question of “ineffective/effective breathing”, the case was wrongly allocated. I took the view that ALL nursery staff should be subject to mandatory paediatric First Aid training; that there should be better selection and training of Call-Takers for the ambulance service; that ALL emergency ambulances (including rapid response vehicles) should be equipped with suitable paediatric life-saving kit. ”
Source location
Millie Elizabeth Josephine Thompson · 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
Propose reinforcing the requirement for a first-aid-trained staff member to be available whenever children are present.

Verbatim wording from the response
“In July 2013 we published plans to further improve the quality and availability of childcare. In tandem with this publication, the Government launched a public consultation, “The Regulation of Childcare”, which ran from 16 July to 30 September 2013. The consultation sought views on proposals to amend the current childcare regulatory system and set out the measures needed to ensure children’s safety. As part of that, we proposed to reinforce the need that a first-aid trained member of staff must be available at all times.”

Source location
2013-0356-Response-by-Edward-Timpson-MP
Page 1 · response
Published 6 December 2013
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
Propose specifying the suitable course content for paediatric first-aid training in the Early Years Foundation Stage framework.

Verbatim wording from the response
“We also proposed to say more in the EYFS about the specific content of suitable courses. We expect to be able to publish the results of the consultation shortly during February 2014 and make any changes needed later this year.”

Source location
2013-0356-Response-by-Edward-Timpson-MP
Page 2 · response
Published 6 December 2013
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 mandatory paediatric first-aid training of nursery staff rests with the Department for Education.

Verbatim wording from the response
“I note that you have sent a copy of this Regulation 28 report to the Department for Education (DfE) and the North West Ambulance Service Trust (NWAS). The training of nursery staff is the responsibility of DfE whilst the selection and training of call taking staff at the NWAS is a matter for the NWAS Trust. I believe that these two issues should properly be addressed by the DfE and the NWAS.”

Source location
2013-0356-Response-by-Department-of-Health
Page 2 · response
Published 6 December 2013
Open published response
30 Oct2013
Liverpool
Concerns raised1
1. Lack of refresher training in basic life support
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.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Damion Anthony Andre Martin · 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

Damion Anthony Andre Martin was remanded to HMP Liverpool on 6 December 2011 and was found hanging in the toilet area of his cell on 11 December 2011; attempts to resuscitate him were unsuccessful. The report raised concerns about the identification of domestic-abuse-related suicide risk during reception, basic life-support refresher training, the restricted view into the toilet area, and whether a prison officer completed a roll-check visit.

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
Wider context from the report
“The first prison officer to respond to Mr Martin did not commence CPR sine he felt out of date with his first aid. This raised concerns that there is no refresher training or a cycle of refresher training in basic life support. ”
Source location
Damion Anthony Andre Martin · Prevention of Future Deaths report
Page 2 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Insufficient Prison Officer competence and refresher training in first aid and 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

Concerns raised1

Lack of hypothermia coverage in police first aid training

Concerns raised1

Unclear alignment of resuscitation training with current guidance

Concerns raised2

Insufficient paediatric first aid training among nursery staff

Lapsed first aid certification among 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.2

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 refresher training in basic life support

Actions described in response 1

Actions described in response 2

Respondent positions 1