Recurring concern

Failure to provide adequate first aid where emergency assistance may be needed

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First reported 5 Dec 2014•Latest report 20 Feb 2026

Definition

What this concern includes

Includes failures in arrangements specifically intended to provide first aid to people who may require emergency assistance at sites or organised activities, including consideration of visitors, availability of appropriate first-aid personnel and equipment, and the ability to deliver first aid during incidents.

Not included

  • Excludes staff competence, training or certification deficiencies where first-aid provision is otherwise adequate; those belong to competence-specific concerns.
  • Excludes failures of ambulance dispatch, emergency-service attendance or hospital treatment after appropriate first aid has been provided or requested.
  • Excludes condition-specific emergency systems, such as choking response or defibrillator readiness, when that narrower control is the supported concern.
  • Excludes generic staffing, supervision or emergency-planning deficiencies without a direct first-aid provision failure.
Reports
19

Distinct published reports

Individual concerns
22

A report can raise multiple concerns

Date range
2014–2026

First to latest report issue date

Stated actions
17

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.

Health and Safety Executive4
Blatchington Mill School1
Bourne Leisure Limited1
Brighton and Hove City Council1
Care Quality Commission1
Children's Commissioner for Wales1
Church Inn, Cheadle Hulme1
Department for Education1
East Sussex Healthcare NHS Trust1
Hamilton Community Homes Limited1
Hibiscus House Domiciliary Care Agency1
Hibiscus Housing Association Limited1
Home Office1
Leeds City Council1
Leicestershire Partnership NHS Trust1

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

    Emiel Ariel Malinski · 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

    Emiel Ariel Malinski attended a miniature rifle range on 2 November 2020, where he fired a rifle in the direction of his right temple and later died in hospital. The report recorded that he died as a consequence of suicide and raised concerns about the limited regulation of miniature rifle ranges, including the absence of requirements for supervision, secure weapons, ammunition control and first-aid provision.

    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 first-aid-trained staff and a first-aid kit

    Wider context from the report

    “It is a matter of concern that the continued existence and operation of s11 (4) Firearms Act 1968 enables miniature rifle ranges to operate with no minimal regulation, with attendees able to fire miniature rifles and ammunition not exceeding .23 calibre and air weapons in a largely unregulated environment. In addition, it is a matter of particular concern that the following specific requirements do not currently apply to miniature rifle ranges: 1) Requirement for the user to sign a prohibited person (Section 21) declaration on each and every visit; 2) Requirement for the weapon to be securely tethered so that any projectile discharged from it can only be ‘down range’; 3) Requirement for a competent Range Conducting Officer (“RCO”) to be present on the range at all times to enable effective supervision of the shooter; 4) Requirement for the weapon to be loaded for the customer by the RCO or other member of staff so ammunition may be accounted for; 5) Requirement for the RCO or other member of staff present to be first aid trained with a first aid kit present; 6) Requirement for any weapon or ammunition used on the range to be kept secure, controlled and supervised by a member of staff at all times. ”

    Source location

    Emiel Ariel Malinski · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Brighton and Hove

    AI-generated summary

    David Alexander MOBS​​BY · 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

    David Alexander MOBS​​BY fell while working at Blatchington Mill School on 3 August 2018 and was found unconscious after working alone. The report raises concerns about inadequate health and safety arrangements for work at height, lack of training, supervision and risk assessment, and delays in providing CPR, including the absence of a first aider or designated person 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

    Unavailability of first-aid or designated emergency personnel on site

    Wider context from the report

    “(1) Brighton and Hove City Council were “advising” Blatchington Mill School (BMS) on health and safety. They were apparently using a template which made no mention of work at height when considering the health and safety of the facilities (caretaking/cleaning) department at BMS. This is dangerous and may have led to the fact that neither of their audits of 2014 or 2018 made any mention of the risks associated with and training requirements regarding working at height. (2) Although Mr MOBS​​BY was employed either by Brighton and Hove City Council or BMS or a combination of the two, he was not monitored or instructed in his work. He was allowed to choose how, when and where he worked. Even though anyone who knew his job description or knew Mr MOBS​​BY was aware that he was using ladders and step ladders he was untrained with regard to working at height. • On the 3rd August 2018 he was unchallenged when he announced his work programme for the day. • His line manager’s did not instruct him with regard to the jobs he did, even though those jobs were considered to be unnecessary by the managers. • No methodology was explored when he announced his job for the day, there was no discussion about the equipment that he was going to use. • There was no risk assessment undertaken in respect of any of the jobs that he did. • He was allowed to work alone and unsupervised. He lay alone and unconscious for 9-10 minutes before he was spotted. It was over 20 minutes before CPR was started. There was no first aider or designated person on the school site that day. • His working environment on the 3rd August 2018 meant that he was working with ambient temperatures of around 26 degrees centigrade. • He was not wearing a hat and he worked in the heat initially and then in direct sunlight latterly, from 0848 hrs until his fall at 1255 hrs having taken one forty minute break at 1100 hrs. • It seems clear that working at BMS formed a huge part of Mr MOBS​​BY’s life. He had been there for many years and was probably set in his ways and not amenable to being managed. • Those managing him were all relatively new to their managerial posts and yet none of them had received any management training. It was clear they had no idea how to deal with him. • They were not assisted by the fact that it was supposed to be the case that every employee was appraised annually. • There was no evidence at all to suggest that Mr MOBS​​BY had ever been appraised. I am concerned that this situation which was demonstrated to be in existence at BMS could well be replicated, not only throughout Brighton and Hove, but throughout England and Wales and this is the reason why this Report has been sent to the Department of Education and I think the matters raised in it should have wider discussion throughout the Country. ”

    Source location

    David Alexander MOBS​​BY · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. Leicester City and South Leicestershire

    AI-generated summary

    Margery Annie Astill · 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

    Margery Annie Astill was admitted to the Evington Centre under Section 2 of the Mental Health Act. On 2 September 2016, she collided with another agitated patient, fell, and was diagnosed with unsurvivable head injuries; she died three days later. Concerns included ineffective referral and incident-reporting systems, inadequate communication with family members, and delays in providing first aid after falls. The inquest also found that there was no care plan, the ward was understaffed, and not all patient observations were completed.

    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

    Delays in immediate post-fall attendance, examination and basic observations

    Wider context from the report

    “(3) Mrs Astill had two unwitnessed falls during her time in the unit, both were recorded on CCTV and both were due to interaction with other patients. The first fall was quickly attended by numerous nursing staff members, but there was a considerable delay in actually physically attending to the patient, examining her or taking basic observations. In a professional nursing environment this delay in first aid provision was of concern and the Trust should consider enhanced training to ensure immediate effective interventions ”

    Source location

    Margery Annie Astill · 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 CCTV footage to determine whether Basic Life Support and Immediate Life Support training requires organisational or individual changes.

    Verbatim wording from the response

    “The Trust resuscitation lead has the responsibility for the Resuscitation Councils (UK) Basic Life Support and Immediate Life Support training. As part of their review they will analyse the CCTV footage to understand if there are any organisational changes required to the training, or if this is purely an individual training requirement.”

    Source location

    2017-0440-Leicestershire-Partnership-NHS-Trust
    Page 3 · response
    Published 11 July 2017

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Implement clinical emergency drills with immediate reflection and feedback for participating staff.

    Verbatim wording from the response

    “In addition to the above, I can confirm that the Trust Resuscitation Committee is overseeing the implementation of clinical drills. These drills re-enact patient emergency situations in the clinical setting in which staff on duty will participate in and will then be offered immediate practice reflection and feedback with regard to how they have responded to and managed this in practice.”

    Source location

    2017-0440-Leicestershire-Partnership-NHS-Trust
    Page 3 · response
    Published 11 July 2017

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Schedule further experiential learning and practice-development training on person-centred responses to emergency medical situations.

    Verbatim wording from the response

    “The MHSOP Clinical Education Lead is also scheduling in further experiential learning and practice development training opportunities to reflect on the immediate person centred approach to support emergency medical situations.”

    Source location

    2017-0440-Leicestershire-Partnership-NHS-Trust
    Page 3 · response
    Published 11 July 2017

    Open published response

  4. Manchester South

    AI-generated summary

    William Joseph WILSON · 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

    William Joseph WILSON choked on a piece of steak, suffered hypoxic brain damage and remained in a coma before receiving end-of-life care and dying in hospital on 2 February 2017. Concerns included that the designated first aider was not called, there was no clear system for alerting the first aider, and staff attending Mr Wilson were unfamiliar with all life-saving first-aid techniques.

    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 a system for alerting the first aider to problems

    Wider context from the report

    “[BRIEF SUMMARY OF MATTERS OF CONCERN] (1) I was informed in evidence by the manager of the Church Inn that the designated first aider was the Chef who was not called to the scene. (2)The Manager of the Church Inn was unable to inform me of the system for alerting the first aider to any problem to ensure he attended the scene. (3)The manager and his colleague who attended upon the deceased were unfamiliar with all of the first aid life saving techniques when dealing with Mr Wilson. ”

    Source location

    William Joseph WILSON · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to call the designated first aider to the scene

    Wider context from the report

    “[BRIEF SUMMARY OF MATTERS OF CONCERN] (1) I was informed in evidence by the manager of the Church Inn that the designated first aider was the Chef who was not called to the scene. (2)The Manager of the Church Inn was unable to inform me of the system for alerting the first aider to any problem to ensure he attended the scene. (3)The manager and his colleague who attended upon the deceased were unfamiliar with all of the first aid life saving techniques when dealing with Mr Wilson. ”

    Source location

    William Joseph WILSON · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  5. West Yorkshire Eastern

    AI-generated summary

    Paul David Whitehead · Prevention of Future Deaths report

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

    Report summary

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

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Lack of immediately available First Aid provision

    Wider context from the report

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

    Source location

    Paul David Whitehead · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Introduce appointed persons across factory departments and train production charge hands in basic first aid and initial emergency response.

    Verbatim wording from the response

    “It is proposed to introduce a number of ‘Appointed Persons’ within the factory departments. Production Charge Hands across the manufacturing facility will be trained in basic first aid skills and will be able to provide initial and first response aid to a person in the event of an accident or injury in the immediate vicinity. The existing first aiders (First Aid at Work qualification) would then take over once arriving at the scene of an incident. We would expect this to enable a more immediate response in the event of a future incident. We are targeting this to be implemented and training provided as suggested above by 31 March 2016.”

    Source location

    Paul-Whitehead-Response
    Page 1 · response
    Published 14 December 2015

    Open published response

  6. Inner North London

    AI-generated summary

    Codrut IEDERAN · 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

    Codrut Iederan died after pushing an unstable wall at a construction site, which collapsed on him. The report raised concerns that the site’s first aider was absent, the remaining workers were not first-aid trained, and some workers did not know how to summon an ambulance.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Unavailability of a trained first aider on site

    Wider context from the report

    “I heard at inquest that the site manager for the Anchor and Hope Public House construction was the site first aider, but he was off site at the time of the fatal accident. The remaining four workers were all Romanian non native English speakers, and none was first aid trained. Mr Iederan had the best English of the four, but of course after the accident he was not in a position to help himself. When one of his colleagues tried to call an ambulance, he realised that he did not know the number. He asked a passer by and so no time was lost in this case. However, when I asked him in court if he now knew the number, some eleven months after Mr Iederan’s death, he did not, despite still being employed by Zelltec. I am conscious that many construction sites in London are heavily supported by foreign workers. It seems to me that it would be of great assistance if employers and site managers were to ensure that all members of their workforce were able to summon help in an emergency. In addition to signs (perhaps in languages other than English) with the 999 number displayed clearly, this could be covered in toolbox talks – of course how it is done is of course a matter for you. ”

    Source location

    Codrut IEDERAN · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  7. Suffolk

    AI-generated summary

    ANTHONY STEPHEN CLEVELAND · 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

    Anthony Stephen Cleveland collapsed after exercising unsupervised at a gym on 11 June 2013 and died some days later in intensive care following a cardiac arrest and hypoxic injury associated with severe coronary artery stenosis. Concerns included inadequate supervision and resuscitation, inadequate risk assessment, a lack of qualified first aiders, and the absence of formalised national guidance for risk assessment in fitness centres and gyms.

    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 qualified first aiders

    Wider context from the report

    “It is possible and entirely foreseeable that significant medical problems may arise in an environment where people are exercising and may have underlying medical problems that could predispose them to collapse. Given the severity of the underlying coronary artery disease and subsequent cardiac arrest here it is not possible to say in this particular situation whether this tragic outcome could have been avoided with an earlier and more effective response, but the evidence here was that there was not a level of supervision that enabled the problem to be recognised immediately, and neither was there an adequate attempt to resuscitate once it had been established that a person had collapsed. There was also evidence of absence of adequate risk assessment in respect of gym users, a lack of qualified first aiders, and an absence of formalised national guidance on risk assessment in fitness centres and gyms. There was evidence that there was HSE guidance on swimming pool operations, but there is not for other facilities and it was felt that this would help the industry, particularly given the proliferation of such gymnasia in recent years, if there was formalised national guidance on risk assessment in fitness centres and gyms. ”

    Source location

    ANTHONY STEPHEN CLEVELAND · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  8. West Yorkshire Eastern

    AI-generated summary

    Alison Dawn Evers · 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

    Alison Dawn Evers, who was dependent on care staff and had swallowing difficulties, suffered hypoxia and cardiac arrest after choking on a sweet given contrary to her dietary support plan. The principal concerns were the lack of a written no-treats policy, the absence of a policy ensuring first-aid-trained staff on every shift, and the level of first-aid training among healthcare support workers.

    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 a policy ensuring first-aid-trained staff on duty for each shift

    Wider context from the report

    “(2) The lack of a policy ensuring a first aid trained member of staff is on duty for each shift. ”

    Source location

    Alison Dawn Evers · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  9. Buckinghamshire

    AI-generated summary

    Peter Harry Mackie · 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

    Peter Harry Mackie, a prisoner at HMP Springhill, was found hanging in the prison chapel on 28 December 2013 and was declared deceased. The inquest concluded that he took his own life while the balance of his mind was disturbed. Concerns included the availability and deployment of first aiders and healthcare staff across the prison sites, and a lack of clarity about when CPR should be commenced and what action untrained staff should take.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Insufficient availability of trained first aiders across the site, including at night

    Wider context from the report

    “(1) Despite improvements during 2014 concerns remain as to the overall numbers of first aiders available on the Springhill site at any time including at night. A first aider on the Grendon site is unlikely to be able to respond in time due necessary security moving from a closed estate to an open prison. This applies in respect of those trained to “First aid at work (FAW) and Emergency First aid at work (EFAW). Operational needs may deplete numbers with FAW and/or EFAW by transferring them to the closed part of the overall site. ”

    Source location

    Peter Harry Mackie · 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

    Increase trained first-aid staffing and establish 24-hour cover at Springhill.

    Verbatim wording from the response

    “HMP Grendon and Springhill are currently working on increasing the number of trained first aid staff at both establishments to First Aid at Work (FAW) and Emergency First Aid at Work (EFAW) level. A number of staff were trained to these levels during 2014 but it is recognised that more are needed at the Springhill site to provide cover, especially at night when healthcare staff are located at Grendon. A new risk assessment is being completed to ensure appropriate levels of staff are identified to provide 24 hour cover. This system will be fully operational within 12 months.”

    Source location

    2014-0528-Response-by-NOMS
    Page 1 · response
    Published 5 December 2014

    Open published response
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Data last updated 7 September 2026