10 Dec 2024 Craig Brendon SPIBY · Prevention of Future Deaths report Manchester West
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Concerns raised 1
Inadequate staff confidence in emergency first aid for choking cases View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 1
Bolton Cares
Provide anti-choking devices and training on their use to every service supporting individuals with SALT guidelines.
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Craig Brendon SPIBY · 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
Craig Brendon SPIBY, who had a condition that made him susceptible to choking, died on 13 July 2024 after choking on a sandwich while eating lunch unsupervised at an assisted living facility. The principal concerns were inconsistent understanding and use of monitoring and supervision requirements, inadequate clarity in care-plan terminology, insufficient professional curiosity when he was believed to be asleep, limited confidence in choking-related first aid, and a lack of training addressing confirmation bias.
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× 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 confidence in emergency first aid for choking cases
Wider context from the report “The deceased had an enduring risk of choking, especially at mealtimes, and was the subject of a Care and Support Plan; Bad Day Support Plan; Good Day Consistency and bespoke Eating and Drinking Guidelines that had been updated in 2018.
The Care and Support plan made clear that at mealtimes in particular, the deceased ought
to be ‘monitored’.
The Speech and Language Therapy guidance made clear that at mealtimes the deceased was to be ‘supervised’.
Managers gave evidence that their definition of ‘monitoring’ and ‘supervising’ was an expectation that the deceased would be kept in ‘line of sight’ at all times.
Care workers gave evidence that they were expected only to ‘monitor’ the deceased – which had the consequence of meaning they felt it appropriate to leave the deceased unsupervised but within earshot, in differing rooms of the care facility for short period of time.
Care workers also gave evidence to the effect that improvement to first aid training when dealing with a choking or aspiration emergency would be beneficial.
It follows that the following matters of specific concern arise:
1. A lack of understanding and/or training as to the specific requirements and expectations as to the role of care staff when supervising/monitoring a service user.
2. The confusion that arises in the existence differing language that applies in Care Plans and Guidance with no corresponding definition of the terms used.
3. How and why staff having assumed the deceased to have fallen asleep at a mealtime after a period of absence from the room, did not use more professional curiosity to evaluate whether such an assumption was correct or safe.
4. The lack of confidence expressed by staff in the emergency first aid training provided when responding in a choking case.
5. An absence of training to guard against confirmation bias with long term service users who have enduring high risk of choking, but with no actual previously recorded episodes of such events.
” Source location Craig Brendon SPIBY · Prevention of Future Deaths report
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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 anti-choking devices and training on their use to every service supporting individuals with SALT guidelines.
Verbatim wording from the response “Since the incident we have provided every service that supports individuals with SALT guidelines with anti-choking devices and provided training on their use to put additional safeguards in place.” Source location Response from Bolton Cares
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing face-to-face first-aid training includes dedicated choking-response instruction and exceeds required standards.
Verbatim wording from the response “During our internal investigation into this matter, Bolton Cares considered the training provided to our workforce. All staff supporting Craig at the time of the incident had completed their mandatory First Aid training. In Bolton Cares Supported Living, we provide one day, face-to-face First Aid training which is accompanied by a face-to-face refresher training course every three years. The level of training provided is above the standards required. Online Training is considered an acceptable option, but we believe that face-to-face training is more effective and therefore provide this.” Source location Response from Bolton Cares
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Concerns raised 2
Failure to provide refresher first aid and CPR training to prison officers View source Failure to provide prison officers with foundation first aid and CPR training View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
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Stephen Anthony SLEAFORD · 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
Stephen Anthony Sleaford, a prisoner at Gartree Prison, was found with a ligature around his neck in his cell on 27 October 2022 and was pronounced dead at 08:01. The concerns included inadequate first-aid and CPR training for prison officers, gaps in the earliest emergency response, obscured cell observation panels, and unclear guidance about entering cells during emergencies.
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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 refresher first aid and CPR training to prison officers
Wider context from the report “1) Evidence was heard that the majority of those prison officers who had commenced in their roles prior to 2018 had no first aid/basic life-saving skills and no ability/training in undertaking cardiopulmonary resuscitation (‘CPR’). Officers who had completed prison officer training between approximately April 2018 and April 2024 did have first aid training, but there had been no refresher training, subsequently, for that cohort .
2) Evidence was heard that after April 2024, basic first aid training (including CPR training) has been omitted from the foundation training programme for those training to be prison officers, meaning that NO new prison officers will have first aid/related training. I am gravely concerned that this situation (i.e. a lack of such training provided as foundation training), if it prevails, will probably lead to future deaths in prison custody.
” Source location Stephen Anthony SLEAFORD · Prevention of Future Deaths report
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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 prison officers with foundation first aid and CPR training
Wider context from the report “1) Evidence was heard that the majority of those prison officers who had commenced in their roles prior to 2018 had no first aid/basic life-saving skills and no ability/training in undertaking cardiopulmonary resuscitation (‘CPR’) . Officers who had completed prison officer training between approximately April 2018 and April 2024 did have first aid training, but there had been no refresher training, subsequently, for that cohort.
2) Evidence was heard that after April 2024, basic first aid training (including CPR training) has been omitted from the foundation training programme for those training to be prison officers , meaning that NO new prison officers will have first aid/related training. I am gravely concerned that this situation (i.e. a lack of such training provided as foundation training ), if it prevails, will probably lead to future deaths in prison custody.
” Source location Stephen Anthony SLEAFORD · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Re-issue the HMPPS First Aid Policy Framework nationally, including requirements for emergency first-aid training and local staffing risk assessments.
Verbatim wording from the response “The HMPPS First Aid Policy Framework was re-issued nationally in August 2023. The revised policy highlights the training requirements for Emergency First Aid and First Aid in prisons, including the importance of Governors ensuring that there is an appropriate number of trained staff on duty at all times. To achieve this, a detailed local first aid risk assessment must be produced to determine the number of First Aiders at Work (FAW) and Emergency First Aiders at work (EFAW) required at an establishment at any given period, ensuring that they are deployed appropriately.” Source location Response from HMPPS
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop First Aid Awareness training videos with St John Ambulance to refresh staff understanding of first-aid procedures.
Verbatim wording from the response “Additionally, First Aid Awareness training videos have been developed by the HMPPS Health and Safety Function in conjunction with St John Ambulance as a tool to promote awareness and refresh key elements of first aid for staff, in particular those staff who do not completely refresh the Emergency First Aid or First Aid at Work certificated training packages. This is expected to be launched in November 2024.” Source location Response from HMPPS
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Launch the developed First Aid Awareness training videos for staff.
Verbatim wording from the response “Additionally, First Aid Awareness training videos have been developed by the HMPPS Health and Safety Function in conjunction with St John Ambulance as a tool to promote awareness and refresh key elements of first aid for staff, in particular those staff who do not completely refresh the Emergency First Aid or First Aid at Work certificated training packages. This is expected to be launched in November 2024.” Source location Response from HMPPS
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14 Oct 2024 Sally Mills · Prevention of Future Deaths report Berkshire
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Concerns raised 1
Lack of understanding of first aid for unresponsive people View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
AS Chiltern Homecare Ltd T/A Caremark (Three Rivers & Chiltern
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
AS Chiltern Homecare Ltd T/A Caremark (Three Rivers & Chiltern
Deliver extended three-and-a-half-hour in-person basic life support and manual handling refresher training to care staff.
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AS Chiltern Homecare Ltd T/A Caremark (Three Rivers & Chiltern
Deliver externally provided in-person basic life support training with practical demonstrations, practice and mandatory competency assessments across four staff sessions.
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AS Chiltern Homecare Ltd T/A Caremark (Three Rivers & Chiltern
Add first aid as a standing agenda item at full-team meetings and regular supervision sessions to discuss incidents, best practice and staff concerns.
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AS Chiltern Homecare Ltd T/A Caremark (Three Rivers & Chiltern
Discuss the medication concerns policy and first aid procedures with staff at the scheduled December team meeting, including emergency scenarios and policy access.
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AI-generated summary
Sally Mills · 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
Sally Mills choked on prescribed medication at home on 23 July 2023 after experiencing difficulty swallowing during its administration, and died later that day in hospital. The principal concerns were gaps in first-aid understanding for an unresponsive person and failures to appropriately escalate difficulties encountered during medication administration.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of understanding of first aid for unresponsive people
Wider context from the report “(1) First Aid training. The evidence revealed there is still a lack of understanding of providing first aid to those becoming unresponsive .
” Source location Sally Mills · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver extended three-and-a-half-hour in-person basic life support and manual handling refresher training to care staff.
Verbatim wording from the response “This was extended to a 3 and a half hour session from 31st October 2024 and also covered manual handling techniques.
At present, all members of our care team are in date with their mandatory training which includes refresher training sessions in basic life support. ████████ is responsible for ensuring that all care team members complete the required training within the relevant time frame, and this is managed via People Planner. There” Source location Response from Caremark (Chiltern & Tree Rivers)
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver externally provided in-person basic life support training with practical demonstrations, practice and mandatory competency assessments across four staff sessions.
Verbatim wording from the response “In person Basic Life Support training from January 2025
We have now engaged the support of an external provider, The Training Centre (London) Ltd to deliver in person Basic Life Support training to our staff. The first session will take place on 21st January 2025. The session will train up to 12 members of staff and as such 4 sessions in total will be arranged at the beginning of 2025. The session will comprise demonstrations, practice of practical skills and a competency assessment at the end. All staff will be required to pass the competency assessment. This session will cover attending to a person who is unresponsive (and breathing, unresponsive and not breathing) and where choking is suspected.
Our intention is to seek feedback from the provider as to the frequency of refresher training and format to be adopted moving forwards.” Source location Response from Caremark (Chiltern & Tree Rivers)
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Add first aid as a standing agenda item at full-team meetings and regular supervision sessions to discuss incidents, best practice and staff concerns.
Verbatim wording from the response “At this stage, we confirm that our basic life support training will be delivered in person from now on both in terms of the induction programme and the refresher sessions.
Given the importance of the issue, we have decided to add first aid as an agenda item to all of our full team meetings or regular supervision sessions. We will discuss any issues encountered and talk about the best practices which should be followed. As well as giving care assistants an opportunity to raise any concerns or seek any further clarifications.” Source location Response from Caremark (Chiltern & Tree Rivers)
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Discuss the medication concerns policy and first aid procedures with staff at the scheduled December team meeting, including emergency scenarios and policy access.
Verbatim wording from the response “Concern 2 - Escalation of issues encountered by Care Assistants
Evidence demonstrated efforts have been made in this regard, such as a new checklist and new policy dated September 2023; the evidence revealed a lack of knowledge of the policy and the embedding of it.
The care team are the organisation’s eyes and ears on the ground and as such we are reliant on them to communicate their concerns to the office in a timely manner. It became apparent that further work should be undertaken to embed section 2.27 (Raising Concerns) of the Medication Procedures September 2023 (the ‘Policy’) and ensure staff are familiar with and understand its requirements.
We have decided that the Policy will also be discussed with staff at the full team meetings held in December.” Source location Response from Caremark (Chiltern & Tree Rivers)
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29 Jul 2024 Lamarah Grace Scarlett · Prevention of Future Deaths report Gloucestershire
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Concerns raised 1
Lack of a requirement for transport crew to be qualified first aiders View source
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 1
Department for Education
Publish statutory guidance strengthening local-authority arrangements for children’s home-to-school travel, including medical-needs risk assessment, suitable support and staff training.
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Lamarah Grace Scarlett · 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
Lamarah Grace Scarlett, a 12-year-old girl with alternating hemiplegia of childhood, became distressed and experienced breathing difficulties while being transported home from school on 24 September 2021. Her head became hyperextended, obstructing her airway; she arrived home unresponsive and was pronounced deceased despite resuscitation efforts. Concerns included the regulation, training, safety-plan compliance, handovers, first-aid qualifications, assessment, and oversight of operators providing home-to-school transport for children with special educational needs.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of a requirement for transport crew to be qualified first aiders
Wider context from the report “Whether there is sufficient regulation of transport operators who provide category 1 home to school transport services to Special Educational Needs children?
The following specific issues were identified:
• The patient safety plans are not always read and understood by transport crew,
• Home visits between passenger and transport crew often do not occur when contractually required,
• The local authority are often not notified of personnel changes in the transport crew,
• The need for proper handovers at drop off and pick up is not understood
• There is no requirement for transport crew to be qualified first aiders ,
• The passenger assessment test requires further improvement,
• There is no comprehensive schedule for inspection of transport operators,
• There is no mandatory training or forums for operators to attend where information can be cascaded to them.
• Operators have to approach multiple organisations which leads to confusion and inconsistency.
” Source location Lamarah Grace Scarlett · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish statutory guidance strengthening local-authority arrangements for children’s home-to-school travel, including medical-needs risk assessment, suitable support and staff training.
Verbatim wording from the response “The Department for Education publishes statutory guidance to assist local authorities in meeting their home-to-school transport duty. The latest version of the guidance was published in 2023 and includes much more comprehensive guidance about meeting a child’s needs than the version that was available at the time of Lamarah’s death. It is available here: www.gov.uk/government/publications/home-to-school-travel-and-transport-guidance. I believe it goes a long way to addressing the concerns you have raised in this case. In particular, it recommends that drivers and passenger assistants are trained in basic life support skills. It expects local authorities to conduct risk assessments, to consider how a child’s medical needs might affect them during their journey, and to put in place proportionate arrangements to manage those needs.” Source location Response from Department for Education
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25 Jun 2024 James Reginald Capstick · Prevention of Future Deaths report Cumbria
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Concerns raised 1
Failure to retain and apply basic resuscitation training View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Care Quality Commission Nursing and Midwifery Council WESTMORLAND HEALTHCARE LIMITED
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 6
WESTMORLAND HEALTHCARE LIMITED
Provide basic life-support training for all senior staff and registered nurses.
View source
WESTMORLAND HEALTHCARE LIMITED
Conduct daily walk-round audits that test staff knowledge of ABCDE assessment and recognition of cardiac arrest.
View source
Care Quality Commission
Followed up the provider’s actions addressing the CPR incident, including staff refresher training and action concerning the involved nurse.
View source
Nursing and Midwifery Council
Continue the fitness-to-practise investigation into the registered nurse and decide whether to progress or close the case for public-protection reasons.
View source
Nursing and Midwifery Council
Complete a risk assessment to determine whether urgent interim restrictions or suspension are required to protect the public.
View source
Nursing and Midwifery Council
Keep the decision not to impose an interim order under review pending new information.
View source See 3 more actions
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James Reginald Capstick · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
James Reginald Capstick died in hospital on 1 October 2022 after sustaining multiple rib fractures during more than 20 minutes of chest compressions when he was not in cardiac arrest, followed by respiratory insufficiency and pneumonia. The report raised concerns about the quality of care at Westmorland Court, the reliability of care records, the absence of a defibrillator at the time, and the failure to recognise signs of life during the resuscitation attempt.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to retain and apply basic resuscitation training
Wider context from the report “(3) To Nursing and Midwifery Council. A Registered nurse was in charge of the home on the night of Reg's injury. Her statement told us that she forgot her basic training and had never had to attempt CPR before . Despite clear signs of breathing and resistance to her efforts she continued to be guided by the call handler at NWAS who had been confused by her inconsistent responses to his questions. Basic checks and signs of life were ignored. I was told at inquest that after being stepped down from nursing duty for a while she had had further training and was back in position. I was told that a referral to yourselves had been made and acknowledged but nothing further had been heard, has the referral been closed?
” Source location James Reginald Capstick · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide basic life-support training for all senior staff and registered nurses.
Verbatim wording from the response “As a Home, we are keen to drive “lessons learned” improvements across our care quality and practice. Ongoing discussions have been taking place and have been had with all staff about the case and understandably the concerns outlined by the Coroner in relation to basic life support and accuracy of record keeping. All senior staff and registered nurses now have the appropriate training in place for basic life support.” Source location Response from Westmorland Court Care Home
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct daily walk-round audits that test staff knowledge of ABCDE assessment and recognition of cardiac arrest.
Verbatim wording from the response “Daily walk round audits are conducted which include testing staffs’ knowledge of the ABCDE assessment process to competently assess a resident and identify whether a person is in cardiac arrest.” Source location Response from Westmorland Court Care Home
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Followed up the provider’s actions addressing the CPR incident, including staff refresher training and action concerning the involved nurse.
Verbatim wording from the response “CQC were informed of the outcome of the local authority safeguarding investigation into the use of CPR on 1 December 2021 including actions to be taken to prevent further incidents. Actions included internal investigation by the provider, audit of the incident, a refresher of basic life support training for all staff, and a referral to the NMC regarding the individual nurse’s conduct. CQC followed up these actions and were reassured that staff had received refresher training in basic life support and that the provider had taken appropriate actions in relation to the registered nurse involved in the incident.” Source location Response from CQC
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue the fitness-to-practise investigation into the registered nurse and decide whether to progress or close the case for public-protection reasons.
Verbatim wording from the response “We can confirm that our investigations in relation to the concerns raised about the registered nurse in charge of the home on the night of Mr Capstick’s injury are ongoing. We have shared your concerns as set out in the PFD with the investigating team. We have also contacted Westmorland Court for further information and obtained details about the registered nurse’s current practice. We have contacted the registered nurse to give them the ability to comment on the concerns and are waiting for their response. We expect to make a decision in the next two to three weeks on whether to progress our investigations on the basis that we need to take action to protect the public or whether we can close the case on the basis that there are no public protection issues.” Source location Response from NMC
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete a risk assessment to determine whether urgent interim restrictions or suspension are required to protect the public.
Verbatim wording from the response “We also carried out a risk assessment upon receipt of the referral to establish whether urgent interim action needed to be taken to suspend or restrict the individual’s practice. We concluded an interim order was not necessary for public protection and was not otherwise in the public interest. We continue to keep this under review pending receipt of new information.” Source location Response from NMC
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Keep the decision not to impose an interim order under review pending new information.
Verbatim wording from the response “We also carried out a risk assessment upon receipt of the referral to establish whether urgent interim action needed to be taken to suspend or restrict the individual’s practice. We concluded an interim order was not necessary for public protection and was not otherwise in the public interest. We continue to keep this under review pending receipt of new information.” Source location Response from NMC
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Without defibrillators, suitable resuscitation policies, procedures and trained staff are considered an appropriate alternative.
Verbatim wording from the response “Where equipment such as defibrillators are not installed, we would expect a provider to be able to demonstrate that they have suitable policies and procedures in place to ensure appropriate resuscitation methods can be carried out if required by suitably trained staff.” Source location Response from CQC
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation An interim order restricting or suspending the nurse’s practice was not considered necessary for public protection or otherwise in the public interest.
Verbatim wording from the response “We also carried out a risk assessment upon receipt of the referral to establish whether urgent interim action needed to be taken to suspend or restrict the individual’s practice. We concluded an interim order was not necessary for public protection and was not otherwise in the public interest. We continue to keep this under review pending receipt of new information.” Source location Response from NMC
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11 Jun 2024 Yuri Hatton · Prevention of Future Deaths report Inner West London
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Concerns raised 2
Failure of first aid training to be prison specific for recognising unconsciousness View source Failure to centrally record and monitor first aid training View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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Yuri Hatton · 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
Yuri Hatton, who was detained at HMP Wandsworth, died in hospital on 9 November 2018 after being found unresponsive following a suspected opiate overdose and later showing features of brain stem death. The jury identified four failures that cumulatively possibly contributed to his death, including failures involving emergency response, clinical observations and communications. The report also raised concerns about limited OSG training, the frequency and monitoring of first aid training, and the lack of prison-specific training on recognising unconsciousness.
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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 training to be prison specific for recognising unconsciousness
Wider context from the report “(3) Recognising unconsciousness. The First Aid training offered, whilst addressing unconsciousness, is not prison specific . A new induction package was said to be rolled out imminently which will include instructions about what a member of prison staff should do if they believe that a prisoner could be unconscious and will reiterate the instruction to call a code blue in such circumstances. This training has not yet been implemented.
” Source location Yuri Hatton · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to centrally record and monitor first aid training
Wider context from the report “(2) The frequency and monitoring of first aid training. First Aid training is said to be refreshed locally annually. Training logs of some staff members involved in the Inquest did not show centrally all the training received , instead a local training log is said to be kept, but which were absent at the inquest or post-inquest .
” Source location Yuri Hatton · Prevention of Future Deaths report
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11 Jun 2024 Daniel Beckford · Prevention of Future Deaths report Inner West London
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Concerns raised 1
Lack of clarity in first aid training on the use of rescue breaths during resuscitation attempts View source
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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Daniel Beckford · 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
Daniel Beckford was detained at HMP Wandsworth and was found hanging in his cell after taking an overdose of prescribed antibiotic medication. He was transferred to St George’s Hospital, where he was declared deceased. The report identified concerns about the provision and content of first aid training, including a lack of clarity about the use of rescue breaths during resuscitation attempts.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of clarity in first aid training on the use of rescue breaths during resuscitation attempts
Wider context from the report “(1) The provision and content of first aid training. The evidence of witnesses revealed an absence of clarity in the first aid training to prison officers on the use of rescue breaths during resuscitation attempts , as per current advice from the Resuscitation Council UK.
” Source location Daniel Beckford · Prevention of Future Deaths report
Open source report
Concerns raised 1
Lack of refresher training for paediatric first aid staff between three-year renewals View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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Oliver Steeper · 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
Oliver Steeper choked on finely chopped pasta bolognaise at a nursery on 23 September 2021 and died on 29 September 2021 after suffering a hypoxic/ischaemic brain injury. The report raises concerns about the number and validity period of paediatric first-aid qualifications available at nurseries, the standard of first aid provided, and staff education and systems for assessing and recording babies’ weaning stages.
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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 for paediatric first aid staff between three-year renewals
Wider context from the report “2. Paediatric First Aid Training Validity Period.
Evidence heard at the inquest was that staff PFA certificates lasted for a period of 3 years before requiring renewal.
The EYFS Framework currently states as follows:
[§3.25]: PFA training must be renewed every three years and be relevant for workers caring for young children and where relevant, babies.
The guidelines for the management of paediatric choking that were current at the time of this incident were published by the Resuscitation Council UK, and this remains the case today.
It was apparent from the evidence heard in this inquest that when confronted with an emergency situation with a choking child, the nursery staff were not able to comply with the Resuscitation Council UK guidelines. The expert stated: “the first aid care delivered overall was of a relatively poor standard for nursery staff trained and current in paediatric first aid.”
I am concerned that staff with a valid PFA training certificate, may have had that training up to 3 years earlier without having had any refresher training in the interim . They would still be compliant with the EYFS statutory framework requirements, but staff may not be able to recall the detail of their training to ensure correct and effective first aid is given, due to the passage of time .
” Source location Oliver Steeper · Prevention of Future Deaths report
Open source report
Concerns raised 1
Lack of first aid training for accommodation staff View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Lily Precious JAHANY · 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
Lily Precious Jahany was an 18-year-old medical student with a complex mental health history who died after taking increased doses of medication and suspending herself by a ligature in her student accommodation. The report identified concerns about the lack of first-aid training among student accommodation staff and failures to obtain and share relevant mental-health risk information, including from private clinicians.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of first aid training for accommodation staff
Wider context from the report “(1) Lily resided at student accommodation provided by Student Roost. They describe themselves on their website as ‘a student accommodation provider who puts your wellbeing first. Our aim is to provide the very best experience for you to make the most of student living.’
Since they were established in 2017, Student Roost has grown to offer 50+ properties across the UK.
Student Roost run a 24/7 service including a Night Owl Service which is an excellent idea and provides a 24 hour service to help students with everything from loosing their keys, broken taps, but also their wellbeing.
During the course of hearing evidence, it is evident that all of Lily’s extreme acts of self-harm took place at her student accommodation. She took at least 3 overdoses and also carried out 2 acts of ligating which she had to be either untied or cut down from. One of those I heard required CPR. I am therefore surprised to learn that no staff (certainly in the 6 properties offering accommodation within Leicester) had first aid training and that it isn’t mandatory, such that no staff are trained by Student Roost in first aid . It transpires therefore that any immediate first aid provided to Lily was provided by those who fortuitously had that training from other organisations before they joined Student Roost. In the context of this case but also wider than that, members of the accommodation staff could potentially be the first people at the scene of a situation requiring first aid and then emergency services ; where death may occur the fact therefore that they receive no training concerns me.
” Source location Lily Precious JAHANY · Prevention of Future Deaths report
Open source report
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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 23 operational team members in first aid, with programmes commencing in August 2024 to provide trained-first-aider access across all properties.
Verbatim wording from the response “As soon as we received this report, our Senior Leadership Team conducted an analysis of our property teams. I’m pleased to share with you that this has resulted in our decision to train 23 operational team members in first aid, with training programmes commencing in August 2024.” Source location Response from Student Roost
Open published response
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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 Student Roost is responsible for addressing the first matter of concern; the Trust will respond only to the second matter relevant to it.
Verbatim wording from the response “In your Report, you raised two Matters of Concern. The first of these Matters of Concern is better addressed by Student Roost who no doubt will respond direct. I will therefore respond to the second matter of concern which is relevant to the Trust.” Source location 2024-0273 Response from Leicestershire Partnership Trust
Open published response
11 Mar 2024 Ronald James JEPSON · Prevention of Future Deaths report Coventry
View report summary
Concerns raised 1
Failure to provide sufficiently frequent and effective emergency response training for care home staff View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
J&K Partnership
Provide face-to-face basic life-support and Level 1 first-aid training covering choking recognition, immediate response and escalation; training has reached 82% of staff.
View source
J&K Partnership
Give the two staff members without face-to-face training choking-response guidance and e-learning training.
View source
J&K Partnership
Deliver a face-to-face three-day Level 3 first-aid qualification to all service shift leaders.
View source
J&K Partnership
Introduce tabletop emergency exercises alongside face-to-face training and continuing e-learning.
View source See 1 more action
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AI-generated summary
Ronald James JEPSON · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Ronald James Jepson, who resided at a mental healthcare facility and had a known risk of choking, suffered an unwitnessed choking episode after being provided with supper and died in hospital on 15 March 2023. Concerns included delayed and suboptimal CPR, staff calling 111 rather than 999, and infrequent and ineffectual emergency training for care home staff.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to provide sufficiently frequent and effective emergency response training for care home staff
Wider context from the report “i. Timely and commensurate interventions of care staff can have a significant positive bearing upon the outcome of a choking episode. Training on how to deal with emergency situations is not ingrained in care home staff.
ii. The circumstances of this inquest touching upon the death of Ronald JEPSON accentuated this point. The evidence was that Mr Jepson 'gargling' and becoming unresponsive was an emergency. 111 (a non-emergency number) was called by care home staff and not 999.
iii. A call handler recognising it was an emergency escalated matters and guidance was given to care staff as to CPR. First attempts as resuscitation by care staff were following an appreciable period of time (ascribed to inexperience and panic) and the cardiopulmonary resuscitation was sub optimal.
iv. The removal of the food occluding the airway of Mr Jepson and effective CPR was provided by paramedics immediately lead a reduced cyanosis.
v. A choking episode, of itself, is a time critical event.
vi. Such training at the time of the incident was ineffectual and infrequent (online) with the consequence being that when an emergency arose the actions of staff to aid a resident were cumulatively sub optimal.
vii. Following the incident there has been no significant increase in training frequency such as would better enable commensurate training to be ingrained in staff which may make significant difference in averting an adverse outcome for a resident in need of emergency care/ assistance.
” Source location Ronald James JEPSON · Prevention of Future Deaths report
Open source report
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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 face-to-face basic life-support and Level 1 first-aid training covering choking recognition, immediate response and escalation; training has reached 82% of staff.
Verbatim wording from the response “ii) At the time of Mr. Ronald James Jepson, staff at Meadow House had all completed e-learning 1st aid training. To ensure staff team are further prepared to deal with medical emergencies that might arise during support and care delivery, Provider sourced Face-to-Face Basic Life Support Training for staff, for which 82% of the staff attended. Since the incident, the Provider has sourced and supplied Level 1 1st Aid. The training encompassed a practical session for various emergencies that might arise in the service including recognizing when a resident is choking, immediate actions to take and escalation.” Source location Response from Meadow House
Open published response
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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 Give the two staff members without face-to-face training choking-response guidance and e-learning training.
Verbatim wording from the response “iii) Remedial measures have been implemented for when the 2 members of staff are on duty that haven’t had their face-to-face training; they have received step by step guide for dealing with a choking service user from the registered manager as well as having completed their e-learning.” Source location Response from Meadow House
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver a face-to-face three-day Level 3 first-aid qualification to all service shift leaders.
Verbatim wording from the response “iv) Advanced Life Support Training for all Senior Care and Support Workers in the Services. To ensure a high level of skill set in dealing with medical emergencies in the service, the Provider has taken further steps by sourcing face to face 3-day course, Level 3 Award in First Aid at Work (RQF). The training is aimed at all Shift Leaders in the Service and is due to be delivered from the 15th May 2024 to the 18th May 2024” Source location Response from Meadow House
Open published response
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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 tabletop emergency exercises alongside face-to-face training and continuing e-learning.
Verbatim wording from the response “iii) From the face-to-face training provided and the desk top exercises now in place, the provider is assured that should a similar incident occur staff will act accordingly without panic and in a timely manner.” Source location Response from Meadow House
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.