Recurring concern

Inadequate staff competence to provide first aid

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First reported 30 Oct 2013•Latest report 15 Jun 2026

Definition

What this concern includes

Includes deficiencies in first-aid or basic-life-support training, currency, refresher provision, competence assessment, practical skill, emergency recognition or ability to provide CPR and other appropriate first aid where these concern staff expected or likely to respond to emergencies.

Not included

  • Excludes failures concerning unrelated professional, clinical or record-keeping competence where first aid is not the safety issue.
  • Excludes missing or inadequate first-aid equipment, facilities or emergency procedures unless the assertion also directly concerns staff competence to use them.
  • Excludes delays or failures by emergency services or other responders that are not attributed to staff first-aid competence.
  • Excludes generic workforce training deficiencies without a direct first-aid or basic-life-support component.
Reports
95

Distinct published reports

Individual concerns
111

A report can raise multiple concerns

Date range
2013–2026

First to latest report issue date

Stated actions
176

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

HM Prison and Probation Service18
Department of Health and Social Care10
Care Quality Commission9
Ministry of Justice9
NHS England7
Pentonville Prison6
Department for Education5
Practice Plus Group4
Care UK3
Department for Transport3
London Ambulance Service NHS Trust3
College of Policing2
Health and Safety Executive2
Metropolitan Police Service2
North West Ambulance Service NHS Trust2

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. Manchester South

    AI-generated summary

    Samuel Curless (Sam) · 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

    Samuel Curless died in hospital on 24 October 2022 after being found suspended from a ligature and receiving delayed life-support intervention. The concerns included failures to call an ambulance promptly, delays in checking vital signs and removing the ligature, and possible inadequacies in police training and refresher training for responding to hanging casualties.

    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 timely First Aid refresher training on Basic Life Support for hanging casualties

    Wider context from the report

    “4. There was evidence given to me by Detective Superintendent ████████ that there is an unknown number of GMP officers who are not meeting the expectation of receiving First Aid refreser training within 12 months, which since May 2022 has included training on how to resuscitate a hanging casualty. I am therefore concerned that there remains a cohort of officers who have not had the post May 2022 training that includes how to provide Basic Life Support to this kind of casualty until the arrival of an ambulance. ”

    Source location

    Samuel Curless (Sam) · 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

    Complete a national review of the First Aid Learning Programme, incorporating police clinical expertise and relevant external recommendations.

    Verbatim wording from the response

    “In 2020, the College of Policing commenced a national working group to review the First Aid Learning Programme (FALP). The review engaged and consulted with police clinical subject matter experts and input from clinical governance leads in forces, in addition to recommendations made by Coroners, the Independent Office for Police Conduct and the Manchester Arena Inquiry. The FALP has now been published with a focus on casualty care, preserving life and providing police officers and staff with the first aid skills required as first responders.”

    Source location

    Response from College of Policing
    Page 2 · response
    Published 22 February 2024

    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 the revised First Aid Learning Programme focused on casualty care, preserving life and first-responder skills.

    Verbatim wording from the response

    “In 2020, the College of Policing commenced a national working group to review the First Aid Learning Programme (FALP). The review engaged and consulted with police clinical subject matter experts and input from clinical governance leads in forces, in addition to recommendations made by Coroners, the Independent Office for Police Conduct and the Manchester Arena Inquiry. The FALP has now been published with a focus on casualty care, preserving life and providing police officers and staff with the first aid skills required as first responders.”

    Source location

    Response from College of Policing
    Page 2 · response
    Published 22 February 2024

    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

    Increase recommended annual refresher training from four to six hours and initial training from nine to twelve hours for public-facing officers.

    Verbatim wording from the response

    “Annual refresher training is a core requirement of the FALP licence, and as a result of the above mentioned review, the recommended training time for both refresher and initial training has been increased for all public facing officers.”

    Source location

    Response from College of Policing
    Page 2 · response
    Published 22 February 2024

    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

    Strengthen first-aid training governance through monitoring, regular attendance-data sharing, monthly governance oversight and compliance accountability.

    Verbatim wording from the response

    “GMP has also improved the governance around first aid training to ensure that officers remain up to date with their training requirements. The numbers are monitored by People & Development Branch Learning Services Team and reported to the Clinical Governance Panel. Attendance data is shared with GMP Districts and Branches on a regular basis, including individual officer details and course booking dates. In addition, First Aid Training is a standing item at GMP’s monthly Major Incident Response Governance Board (MIRGB) meeting which is chaired by the Deputy Chief Constable (DCC). At the monthly meeting the DCC holds Districts and Branches to account in respect of their compliance with the first aid training requirements. First Aid training will remain a focus of the MIRGB moving forward.”

    Source location

    Response from Greater Manchester Police
    Page 6 · response
    Published 22 February 2024

    Open published response
  2. Manchester City

    AI-generated summary

    Liam Turner · 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

    Liam Turner died at HMP Manchester on 6 December 2021 from mixed toxicity involving a psychoactive substance and prescription medication. Concerns were raised that prison officers were not required to have in-date basic first aid training, including CPR, and that 48% of HMP Manchester prison staff had expired training certification.

    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 in-date basic first aid training for prison officers

    Wider context from the report

    “It is not mandatory for prison officers to have basic first aid training (which includes the provision of CPR) which is in-date. Once a prison officer’s three-year period has expired, whilst they may be reminded by the prison establishment that their certification is no longer live, it is not mandatory for them to renew this. For example, at HMP Manchester, at present 52% of prison staff received Emergency First Aid at Work (EFAW) training within the past three years as part of their initial officer training. Therefore, 48% of prison staff will have training certification (which includes CPR) which has expired. The evidence admitted was that the main reason for this is due to it not being mandatory for prison staff to have up-to-date training. ”

    Source location

    Liam Turner · 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

    Re-issue the national first aid policy framework with requirements for emergency and prison first-aid training and appropriate staffing.

    Verbatim wording from the response

    “As you are aware, 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 HM Prison and Probation Service
    Page 1 · response
    Published 12 February 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Continue conducting regular reviews to ensure first-aid staffing and healthcare provision meet the prison’s needs.

    Verbatim wording from the response

    “At HMP Manchester, the requirement is for the provision of 21 trained first aiders and there are currently 39 officers with in-date training. Further to this, 52% of prison staff have received EFAW training within the last three years as part of their initial officer training. This is in addition to the provision of healthcare, which at HMP Manchester is 24 hours a day, 7 days a week, in line with the Category A status of the prison. As such, healthcare staff are able to provide emergency assistance should the need arise. Regular reviews will continue to be conducted to ensure that the needs of the prison are met.”

    Source location

    Response from HM Prison and Probation Service
    Page 1 · response
    Published 12 February 2024

    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 first-aid staffing, training, healthcare provision and CPR guidance are considered sufficient to address concerns about emergency medical responses.

    Verbatim wording from the response

    “As you are aware, 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 HM Prison and Probation Service
    Page 1 · response
    Published 12 February 2024

    Open published response
  3. Derby and Derbyshire

    AI-generated summary

    Thomas Roy LANGLEY · 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

    Thomas Roy Langley was found collapsed in a hotel room and died at the hotel on 22 May 2019 after taking toxic levels of MDMA. The report raised concerns about the absence of a fully trained first-aid employee on site overnight and the lack of basic first-aid training and refresher courses for all 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 all staff with comprehensive basic first-aid training and refresher courses

    Wider context from the report

    “1. There is no fully trained First aid trained employee on site at a Travel Lodge hotel premises for 24 hours of the day; at present there is a fully trained first aid employee on site from only 7am to 7pm. Emergency medical situations could present themselves between after 7pm and 7am and when there is only 1 Travel Lodge employee on the premises. 2. All staff employees do not presently have basic first aid training with regular follow up refresher courses. i.e. they do not have both online AND face to face practical training to assess and handle emergency medical situations that may present themselves day or night - situations that may cause an employee and residents staying at a Travel Lodge to panic. It may be the case that they have a lack of understanding of the present first aid training. This training is key at night when there is only 1 member of staff on site at a Travel Lodge hotel premises. ”

    Source location

    Thomas Roy LANGLEY · 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

    Extend basic first-aid training to all reception team members, including night-shift staff, by working through delivery logistics and implementing the training.

    Verbatim wording from the response

    “However, in light of your concerns, we have decided to extend the level of training given to all reception team members, including those who cover the night shift, to include the basic level of first aid training currently provided to our management teams. This will result in over 3,500 extra Travelodge team members being provided with basic first aid training, and will ensure that there will always be a team member on duty that has had a basic level of first aid training 24hrs a day. We are currently working through the logistics of providing”

    Source location

    Response from Travelodge
    Page 2 · response
    Published 25 January 2024

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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

    Existing basic first aid training for hotel management teams remains adequate and appropriate given incident patterns, timing and the circumstances of the death.

    Verbatim wording from the response

    “Having reviewed our existing arrangements, taking into account the number of incidents reported, types of injuries reported that require first aid assistance, the times of day when incidents tend to occur and the specific circumstances relating to the passing of Mr Langley, I have concluded that our existing first aid arrangements of providing basic first aid training to the members of our hotel management teams, who are generally on site at hotels during the day when the majority of incidents requiring the provision of first aid occur, continues to be adequate and appropriate.”

    Source location

    Response from Travelodge
    Page 2 · response
    Published 25 January 2024

    Open published response
  4. Cheshire

    AI-generated summary

    Carl FULLALOVE · 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

    Carl Fullalove was arrested after being observed jumping on cars, behaving bizarrely and appearing to be under the influence of a substance. He was placed in prone restraint during a search in custody, became non-responsive and suffered cardiac arrest, and subsequently died in hospital. The principal concerns were that signs of acute behavioural disturbance or illness were not recognised, the risks of prone restraint and stimulant drugs were not sufficiently considered, and training did not adequately address calming intervention in an upright position.

    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

    First-aid training failing to include calming-intervention training

    Wider context from the report

    “(5)The First Aid Learning Programme (FALP) will be in place within Forces by April 2024 and includes amongst other things positional asphyxia, unconscious and not breathing, and ABD but does not mention training in calming intervention that on balance of probabilities may have led to a different outcome in this case. ”

    Source location

    Carl FULLALOVE · 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

    Develop and update Public and Personal Safety Training to cover ABD presentation and causes, de-escalation, restraint risks, medical assistance, monitoring, and scenario-based decision-making.

    Verbatim wording from the response

    “The College of Policing have designed and developed a new Public and Personal Safety Training (PPST) package for all police officers with the emphasis on de-escalation. It is twelve hours, scenario-based method of delivering training and is focused on learning, decision making, understanding decisions and de-briefing decisions. Some forces have already implemented the new training package, and all forces are to go live with this training in April 2024. From the evaluation of the training pilot, early, statistically significant data shows a reduction in police use of force incidents. The updated training will include a recently updated training package for ABD.”

    Source location

    Response from College of Policing
    Page 2 · response
    Published 28 November 2023

    Open published response
  5. Derby and Derbyshire

    AI-generated summary

    Kellie Jean POOLE · 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

    Kellie Jean POOLE died on 25 April 2022 after collapsing during a led cold water immersion session in the River Goyt. The report states that cold water likely triggered a heart rhythm disturbance and that she had an abnormal heart. The principal concerns were the limited oversight and regulation of cold water immersion providers, including health warnings, safety measures, leader training, first aid provision, insurance, risk assessments and guidance from relevant authorities.

    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 adequate first aid training and equipment for cold water immersion sessions

    Wider context from the report

    “There seems to be very little oversight of these businesses in their provision of cold water immersion covering matters such as pre-session health advice or warnings, public liability insurance, training and experience of the session leader, first aid training and equipment, or written risk assessments. I am not aware of the issuing of specific health and safety guidance. ”

    Source location

    Kellie Jean POOLE · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  6. Inner North London

    AI-generated summary

    Amarjit SINGH · 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

    Amarjit Singh, aged 41, was found dead in his cell at HMP Pentonville on the morning of 21 November 2021 after his cellmate reported that he had suffered a fit, but medical attention was not sought and the cell door remained locked. The inquest jury determined that he died from natural causes, contributed to by neglect. Outstanding concerns included a careless cell-sharing risk assessment and gaps in prison staff and prisoner guidance and first-aid understanding, including failures to recognise the need for CPR or distinguish unconsciousness from death.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of ongoing first aid training for prison officers

    Wider context from the report

    “3. Whilst the fact that not all prison officers receive ongoing first aid training is a national resourcing issue, the level of first aid understanding of some prison officers at HMP Pentonville seemed surprisingly low. One officer told me that it did not cross his mind to start CPR in the three minutes it took nurses to arrive after Mr Singh was found not breathing. (Mr Singh had been assessed by a custodial manager as having died, but the other officer did not know this at the time.) A different officer told me he did not know that there is a difference between a person who is unconscious and a person who is dead. ”

    Source location

    Amarjit SINGH · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Low first aid understanding among prison officers

    Wider context from the report

    “3. Whilst the fact that not all prison officers receive ongoing first aid training is a national resourcing issue, the level of first aid understanding of some prison officers at HMP Pentonville seemed surprisingly low. One officer told me that it did not cross his mind to start CPR in the three minutes it took nurses to arrive after Mr Singh was found not breathing. (Mr Singh had been assessed by a custodial manager as having died, but the other officer did not know this at the time.) A different officer told me he did not know that there is a difference between a person who is unconscious and a person who is dead. ”

    Source location

    Amarjit SINGH · 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

    Issue emergency response guides to all prisons, covering required actions and circumstances for calling a medical emergency response code.

    Verbatim wording from the response

    “At a national level, new emergency response guides were issued to all prisons which set out the actions required of staff in a medical emergency, including all the circumstances listed in the PSI 03/2013 Medical Emergency Response Codes under which a medical emergency response code”

    Source location

    Response from HM Prison and Probation Service
    Page 1 · response
    Published 22 September 2023

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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

    Distribute emergency response pocket cards to prisons and staff as reminders of how to respond to medical emergencies.

    Verbatim wording from the response

    “should be called. In 2021, all Prisons were also issued with a supply of emergency response pocket cards which were shared with staff. The cards provided an instant reminder of how to respond to a medical emergency. In March 2022, a further supply of the emergency response pocket cards were issued to Regional Group Safety Leads for them to share with their prisons.”

    Source location

    Response from HM Prison and Probation Service
    Page 2 · response
    Published 22 September 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Publish, introduce and circulate the national First Aid and Emergency Aid Manual to prison staff at HMP Pentonville.

    Verbatim wording from the response

    “The HMPPS National Health and Safety Arrangements for First Aid and Emergency Aid Manual was published and introduced in August 2023 and this was circulated to all prison staff at HMP Pentonville.”

    Source location

    Response from HM Prison and Probation Service
    Page 2 · response
    Published 22 September 2023

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Prison authorities, rather than healthcare, are responsible for addressing staff training and prisoner guidance on managing seizures and first aid.

    Verbatim wording from the response

    “Only number 1 above relates to healthcare, and therefore PPG, so we do not propose to respond to points 2 and 3, which no doubt will be addressed by the Prison.”

    Source location

    Response from Practice Plus Group
    Page 2 · response
    Published 22 September 2023

    Open published response
  7. Swansea and Neath Port Talbot

    AI-generated summary

    Christopher James Locke · Prevention of Future Deaths report

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

    Report summary

    Christopher James Locke sustained a cardiac arrest at a public house on 21 October 2021 and died at Morriston Hospital on 29 October 2021 from hypoxic ischaemic encephalopathy caused by the arrest. The concerns included that emergency services did not instruct the caller to begin chest compressions, and that public-house staff may lack CPR training needed to provide lifesaving treatment when appropriate.

    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 staff with CPR training

    Wider context from the report

    “3. Whilst the primary responsibility of staff is to comply with EMD directions they are deprived of the opportunity to provide lifesaving treatment in circumstances that warrant it if that training is not offered 4. Staff would not know the circumstances that warrant it without the benefit of CPR training. ”

    Source location

    Christopher James Locke · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Existing policy of calling emergency services and relying on qualified medical professionals is considered sufficient; CPR training will not be added.

    Verbatim wording from the response

    “Wetherspoon have a policy that if any customers or staff get into a medical emergency, care is provided by appropriately trained medical professionals. It is therefore Wetherspoon’s policy that for any injury or medical incident that requires immediate attention, emergency services are called and an ambulance is requested. Wetherspoon does not provide or offer medical training (which would include CPR training) to its staff as it feels a qualified medical professional is best place to provide it. This policy has been in place for 25 years and has been reviewed by and assured advice has been received from Wetherspoon’s Primary Authority.”

    Source location

    Response from JD Wetherspoon PLC
    Page 1 · response
    Published 7 September 2023

    Open published response
  8. Essex

    AI-generated summary

    Michael Brian Waite · 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

    Michael Brian Waite, who had learning difficulties and lived in supported accommodation, collapsed after vomiting and drinking water on 19 August 2022. An ambulance was called after a delay, and he was confirmed dead by an attending paramedic. The report raised concerns that Peabody Support Workers providing 24-hour solo support were not required to complete certificated First Aid and Basic Life Support training before undertaking their duties.

    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 require certificated First Aid and Basic Life Support training before solo support duties

    Wider context from the report

    “1. Although the SW involved in this case had received Basic Life Support training, the evidence of senior witnesses for Peabody, including the Assistant Head of Service and the Director of Care, confirmed that there is presently no requirement for Support Workers, employed by Peabody to provide 24-hour solo support to clients in supported living accommodation, to undergo certificated First Aid Training including Basic Life Support training, prior to assuming their role. 2. Whilst it is recognised that residents in supported living accommodation have varying capabilities and varying abilities to care for themselves, as in this case, many will require help and support and, as such, will have varying - including significant - degrees of vulnerability. In my view, for those who are solo providers of support in such circumstances (ie are working alone in providing the support required) to not have received formal, certificated First Aid training, including Basic Life Support training, prior to assuming their duties gives rise to the risk of future deaths. ”

    Source location

    Michael Brian Waite · 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

    Introduce a revised training programme featuring certified Emergency First Aid training, including Basic Life Support, and additional in-house training.

    Verbatim wording from the response

    “However, upon careful consideration of the risks raised by the Coroner and having reviewed the risks inherent with our supported living customers, we have put in place additional measures to improve our training and quality of service.”

    Source location

    Response from Peabody
    Page 2 · response
    Published 12 February 2024

    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 new care workers to complete enhanced Emergency First Aid training within their first month and prohibit lone working until completion.

    Verbatim wording from the response

    “All our new care workers will complete the enhanced training programme as part of their induction process. They will be required to complete the Emergency First Aid training”

    Source location

    Response from Peabody
    Page 2 · response
    Published 12 February 2024

    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

    Roll out the revised Emergency First Aid training course to more than 420 existing care workers within one year.

    Verbatim wording from the response

    “Our existing care workers will also be required to complete the new course. This affects over 420 employees. We have given ourselves a target of one year to complete the roll out of this training programme, which has already commenced. This is on top of the basic life support training that our existing care workers who provide solo support have already completed.”

    Source location

    Response from Peabody
    Page 3 · response
    Published 12 February 2024

    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

    Update and republish Core and Mandatory training guidance to reflect the CQC Single Assessment Framework.

    Verbatim wording from the response

    “Our guidance and advice include:”

    Source location

    Response from Skill for Care
    Page 1 · response
    Published 12 February 2024

    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

    Host Care Certificate resources, including the Basic Life Support standard, for adult social care employers and workers.

    Verbatim wording from the response

    “Care Certificate”

    Source location

    Response from Skill for Care
    Page 2 · response
    Published 12 February 2024

    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

    Develop a specification for a new Level 2 Adult Social Care Certificate qualification based on existing Care Certificate standards.

    Verbatim wording from the response

    “Level 2 Adult Social Care Certificate Qualification”

    Source location

    Response from Skill for Care
    Page 3 · response
    Published 12 February 2024

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The body cannot mandate or enforce adult social care training because it is an independent charitable organisation without regulatory authority.

    Verbatim wording from the response

    “Whilst Skills for Care is committed to influencing improvements in the standards and the quality of personalised care across the adult social care sector, as an independent charitable body, we are not able to mandate or enforce what training is undertaken.”

    Source location

    Response from Skill for Care
    Page 4 · response
    Published 12 February 2024

    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

    Employers are responsible for determining required training, ensuring mandatory training, and assessing when workers can work unsupervised.

    Verbatim wording from the response

    “In line with HSE guidance, it further states that ‘Establishments must provide adequate personnel to respond if someone is taken ill or injured at work. It’s the employer’s responsibility to determine how many people need training and to what level.’ We note that this HSE guidance applies to First Aid and First Aid at Work, not specifically to Basic Life Support.”

    Source location

    Response from Skill for Care
    Page 1 · response
    Published 12 February 2024

    Open published response
  9. Black Country

    AI-generated summary

    Charles Evans · 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

    Charles Evans, a resident at Hibiscus House, choked on food in the communal dining room on 29 May 2022, suffered cardiac arrest and severe hypoxic brain injury, and died in hospital the following day. The concerns included inadequate CPR and first-aid provision, absence of a defibrillator and emergency communication arrangements, insufficient staffing and emergency procedures in the dining room, and weaknesses in risk assessment and reporting processes.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of staff training in CPR

    Wider context from the report

    “During the course of the inquest I heard evidence from Faye Cadogan Registered Manager Hibiscus House and Norma Chambers Catering Assistant at Hibiscus House. 1. None of the Carers employed at Hibiscus House had any training in CPR. The carer on duty was qualified to Level 2 Diploma in Health & Social care which does not include any training in first aid; 2. At the time of the incident there were no staff members trained in CPR (Coroner was told this had been rectified post Mr Evans death); 3. There was no Registered First Aider at the premises; 4. There was no defibrillator on site; 5. There was no requirement for any staff to be on duty in the communal dining room during mealtimes despite the fact the Hibiscus House could cater for residents with special dietary requirements; 6. There was no emergency bell/alarm or telephone in the residents’ dining room. Staff were expected to use their mobile phone to call for help; 7. There was no procedure for what should happen in an emergency situation (in this instance the catering staff member who found Mr Evans located a carer instead of calling 999 themselves; 8. Staff did not know who else was on duty at any given time; 9. There was no proper procedure in place for staff to report concerns about residents; 10. No further risk assessments were being conducted if a resident returned to Hibiscus House after a hospital admission to ensure the facility could still meet the needs of the resident (Coroner was told staff relied on a discharge summary and/or the GP); 11. Post inquest, the Coroner noted the CQC Inspection report for Hibiscus House Domiciliary Care Agency dated July 2019 which rated the facility as ‘requiring improvement’. The Coroner is concerned to establish whether the service provider put forward an action plan following the CQC Inspection setting out what they would do to improve the standards of quality and safety and whether the CQC monitored any progress towards said plan. ”

    Source location

    Charles Evans · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Review staff training, including mandatory training and emergency-response skills and competences.

    Verbatim wording from the response

    “The plan includes a review of staff training to ensure all staff have completed mandatory and/or relevant training. This includes assurances that staff have the right skills and competences to react appropriately in an emergency situation.”

    Source location

    Response from Wolverhampton City Council
    Page 1 · response
    Published 4 November 2022

    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 CPR training to all employees and refresh it annually.

    Verbatim wording from the response

    “Hibiscus have engaged Delphi to assist in creating a planned programme of training. All employees of Hibiscus have now undertaken CPR training. CPR Awareness training commenced 29 July 2022 and was complete by 5 August 2022. This will be refreshed every year.”

    Source location

    Response from Hibiscus House
    Page 2 · response
    Published 4 November 2022

    Open published response
  10. South Yorkshire (Western)

    AI-generated summary

    Brian Parry · 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

    Brian Parry died at Brunswick Retirement Village on 3 November 2021 after choking on food. The report identified delays in calling emergency services, an emergency cord system that did not alert nearby staff, limited confidence in first-aid training, and no advanced first aider available on site.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of staff confidence in using basic first aid training

    Wider context from the report

    “I am concerned that despite all staff having basic first aid training, evidence was given at the inquest that not all staff are confident using their training ”

    Source location

    Brian Parry · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026