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. Inner North London

    AI-generated summary

    Sean Perry WILLIAMS · Prevention of Future Deaths report

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

    Report summary

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

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Delays in opening a detainee cell and administering emergency first aid

    Wider context from the report

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

    Source location

    Sean Perry WILLIAMS · Prevention of Future Deaths report
    Page 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

    Revise relevant prisoner welfare, vehicle escort, death-in-custody and associated procedures, and align corresponding training materials.

    Verbatim wording from the response

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

    Source location

    Response from Serco
    Page 1 · response
    Published 24 February 2026

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Create and require staff to complete a separate online medical-emergency vehicle course covering emergency response, basic life support and related vehicle incidents, with an 80% pass threshold.

    Verbatim wording from the response

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

    Source location

    Response from Serco
    Page 3 · response
    Published 24 February 2026

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Develop and display laminated emergency-response flowcharts in escort vehicles to clarify required actions and support consistent responses.

    Verbatim wording from the response

    “As outlined by Serco’s Head of Professional Standards and Security in his evidence, and to support staff on scene in following the correct process, Serco has developed a flowchart for escort officers following the death of Mr Williams. A copy appears in the Inquest bundle. This has since been incorporated into training, and laminated copies are now displayed within all escort vehicles in a position visible from the escort seat. The intention is that this readily accessible guide will reinforce existing training, clarify the required steps, and support escort officers in responding with confidence and consistency during suspected medical emergencies.”

    Source location

    Response from Serco
    Page 4 · response
    Published 24 February 2026

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Develop and display an OCC emergency flowchart with structured prompt questions at controller desks to standardise alarm-activation responses.

    Verbatim wording from the response

    “Serco has also developed a corresponding flowchart for the OCC to reflect that provided to PCOs, together with structured prompt questions to assist OCC controllers in identifying the nature of an emergency and providing appropriate support and direction to PCOs when an incident occurs. A copy of the OCC flowchart has also been provided.”

    Source location

    Response from Serco
    Page 4 · response
    Published 24 February 2026

    Open published response

  2. Inner North London

    AI-generated summary

    Gabriella Omolabake Torisheju JAYIESIMI · 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

    Gabriella Omolabake Torisheju Jayiesimi suffered seizures and a cardiac arrest at a Tesco supermarket on 24 January 2025 and died a month later from the hypoxic brain injury sustained during the arrest. The concerns included the absence of effective first aid and CPR, failure to recognise that she had stopped breathing, failure to check her pulse or use a defibrillator, and inadequate first-aid training and preparedness among relevant Tesco and security 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 recognise breathing difficulty and place an unresponsive person in the recovery position

    Wider context from the report

    “When Ms Jaiyesimi was on the floor having suffered several fits, no person put her in the recovery position. They were apparently unaware that her present position could be causing an airway obstruction preventing her breathing. Then when Ms Jaiyesimi stopped breathing, nobody recognised this, though they were looking at her and made one inadequate attempt to feel for breathing (by placing a single finger somewhere near her nose). No person ever attempted to check Ms Jaiyesimi’s pulse to see if her heart was still beating. Even if they had identified her cardiac arrest, there was nobody present who would have started CPR. Nobody thought of fetching one of the store defibrillators. Lack of CPR notwithstanding, the failure to understand the situation properly meant that nobody relayed the crucial information of the arrest to the ambulance service. ”

    Source location

    Gabriella Omolabake Torisheju JAYIESIMI · 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

    Unavailability of a Tesco first aider at Colney Hatch

    Wider context from the report

    “When Gabriella Jaiyesimi suffered a cardiac arrest – Tesco 1. There was no Tesco first aider working at Colney Hatch. 2. The TSS security officer was first aid trained, but none of the Tesco staff knew that. 3. All staff, including the TSS security officer, properly understood the Tesco policy of calling the duty manager to assess such an emergency and decide upon the correct course of action, but the duty manager charged with this responsibility had no CPR or first aid training. She told me that most of the Tesco duty managers were not CPR or first aid trained. ”

    Source location

    Gabriella Omolabake Torisheju JAYIESIMI · Prevention of Future Deaths report
    Page 3 · 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

    Tesco’s own store first-aider provision is considered sufficient; T.S.S officers are not contractually required to provide first aid.

    Verbatim wording from the response

    “Regarding the relationship between Tesco PLC and T.S.S security officers, we consider it important to clarify that the security officer was not employed as a first-aider and there has never been, nor is there currently, a contractual requirement by Tesco PLC for T.S.S security officers to provide first aid to Tesco employees or members of the public in Tesco stores. This is on the basis that Tesco has its own provision for first-aiders within its stores who are called to any medical emergency. There are no current T.S.S employees who hold a role as a Tesco first-aider.”

    Source location

    Response from Total Security Services
    Page 2 · response
    Published 5 September 2025

    Open published response

  3. Teesside and Hartlepool

    AI-generated summary

    Gary Lee JAMES · 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

    Gary Lee James died at James Cook University Hospital on 11 January 2019 from injuries sustained when metal frames fell on him while he was trying to move them at Ward Bros. The report identified concerns including inadequate risk assessment, training, equipment, supervision and first-aid provision, as well as failures to address employees’ safety concerns and unsafe working conditions.

    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 trained first aider assistance before emergency services arrive

    Wider context from the report

    “9. No first aid assistance was provided by a trained first aider before the arrival of the emergency services. ”

    Source location

    Gary Lee JAMES · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. Inner North London

    AI-generated summary

    Student A · 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

    Student A was found unresponsive in his student accommodation on 28 July 2024 and paramedics verified his death shortly thereafter; the medical cause was asphyxiation and the inquest conclusion was suicide. The principal concerns were delays in carrying out the welfare check and calling emergency services, limited assessment of Student A’s condition, failure to provide basic assistance or first aid, and possible inadequacy or ineffectiveness of staff training and procedures.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to render basic assistance or first aid to an unresponsive student

    Wider context from the report

    “2. When attending Student A’s room at about 10:50 on 28 July 2024, the member of staff knocked repeatedly on the door and asked for Student A to come to the door. The staff member then used their staff pass to open the door, on account of getting no response. In their statement, the staff member sets out that they remained in the doorway and could see Student A’s legs (from the knees down) on the bed within the room. The statement continues, ‘I called out to the student and stated that it was reception and asked if they were okay. At this time I was scared so I closed the door and went to the stairwell.’ The staff member spoke to the ECC and explained the circumstances to them and the ECC advised the staff member to call an ambulance ‘and to also get someone from one of the other buildings that is run by the university.’ Following the call with the ECC, the staff member sent a text message to their ‘general manager’ explaining the situation and requesting that a receptionist from another building be sent to assist. The staff member’s statement then says, ‘At approximately 1134 I called my manager and whilst on the phone returned to the room and knocked on the door repeatedly. I shouted out and knocked twice. The student did not answer the door.’ The staff member then returned to reception and telephoned for a colleague in another building to come and assist. Assistance from a colleague arrived at approximately 12 noon. Both members of staff then made their way to Student A’s room where, upon entering they found Student A unresponsive on his bed in the manner already described at section 4 of this report. As a result, the staff left the room, returned to reception and ‘called our managers and emergency services and we waited for their arrival.’ The concerns here are numerous: • It was obvious to staff that Student A was, at the very least, unresponsive / difficult to rouse at about 10:50, which on any view would be regarded as a serious / emergency situation. However, it appears that no positive or definitive action was taken to assist for over an hour. • The ECC advised the staff member to call an ambulance at about 10:50, yet this was not done until approximately 12 noon. • The staff member who first checked on Student A at 10:50, went no further than threshold (seeing no more than his legs) and therefore did little, if anything, to satisfy themselves about the true welfare status of Student A. • The staff members who attended Student A’s room at approximately 12 noon, did not attempt to render basic assistance or first aid to Student A. • In the particular circumstances of Student A’s case, he was highly likely to have been deceased for hours prior to his death being verified by paramedics at 12:27. However, that fact was not known to staff at the material time and, therefore, they would have been expected to act in accordance with any protocols or policy in place at that time. Given these matters, I am concerned that there may be a lack of appropriate training in place for staff or, if there is such training in place, that it may not be effective. Nothing in the evidence available to me has suggested that the future risks posed by my concerns have been addressed. ”

    Source location

    Student A · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  5. North Wales (East and Central)

    AI-generated summary

    Benjamin David Leonard · 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

    Benjamin David Leonard, aged 16, died after slipping and falling from a cliff while descending the Great Orme during an Explorer Scout trip in North Wales. The report identifies concerns about inadequate planning, risk assessment, briefing, supervision, training, safeguarding, first-aid provision, oversight and the Scouts Association’s response to the 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

    Failure to plan and provide appropriate first aid kits

    Wider context from the report

    “32. I did not receive any evidence to suggest that, following an appropriate risk assessment for the Great Orme trip, there was a plan as to what type of first aid kit was required. None of the leaders had a first aid kit with them when they embarked on the walk up the Great Orme or on a 3-hour hike on the Saturday. ”

    Source location

    Benjamin David Leonard · Prevention of Future Deaths report
    Page 11 · 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 and update first-aid-kit guidance, linking kit requirements to activity type, terrain and risk assessments, with example assessments.

    Verbatim wording from the response

    “1. We have confirmed that the current information is fully in line with current Health & Safety Executive advice and updated our guidance in line with industry standards (action completed).”

    Source location

    Response from Scouts
    Page 26 · response
    Published 26 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

    Enhance online training with guidance on first-aid-kit suitability and terrain.

    Verbatim wording from the response

    “3. We will enhance our online training to provide specific guidance on first aid kit suitability and specifically to support the issues identified around terrain guidance (to be completed by September 2024).”

    Source location

    Response from Scouts
    Page 26 · response
    Published 26 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

    Include first-aid-kit guidance and contents in the First Aid Working Group’s annual review cycle.

    Verbatim wording from the response

    “4. We will review our governance approach and ensure that our First Aid Working Group has a review of the guidance relating to first aid kits as part of its annual review cycle. Our First Aid Working Group has a remit to provide a single focal point for all national level first aid decisions and actions, and to seek ways to improve the relevance and quality of first aid support and training across Scouts (to be completed by May 2024).”

    Source location

    Response from Scouts
    Page 26 · response
    Published 26 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 Department cannot comment on the Scout Association’s internal structure, workings, or implementation of internal policies and procedures.

    Verbatim wording from the response

    “6. Finally, we would note that various matters identified in your report concern the internal structure and workings of the Scout Association (for example their internal FAIP process). Where feasible, we have sought to address all matters of concern, but unfortunately we cannot comment on the internal set-up and structure of individual organisations, or charities in the case of the Scout Association. We understand that the Scout Association will provide a response to your report which we expect will address these issues. Similarly, we understand that the Charity Commission will provide a response which we expect will address matters relating to charity trustees’ legal duties and responsibilities in managing their charity.”

    Source location

    Response from Department for Education
    Page 4 · response
    Published 26 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 Scout Association and the Charity Commission are expected to address matters concerning internal operations and charity trustees’ legal duties, respectively.

    Verbatim wording from the response

    “6. Finally, we would note that various matters identified in your report concern the internal structure and workings of the Scout Association (for example their internal FAIP process). Where feasible, we have sought to address all matters of concern, but unfortunately we cannot comment on the internal set-up and structure of individual organisations, or charities in the case of the Scout Association. We understand that the Scout Association will provide a response to your report which we expect will address these issues. Similarly, we understand that the Charity Commission will provide a response which we expect will address matters relating to charity trustees’ legal duties and responsibilities in managing their charity.”

    Source location

    Response from Department for Education
    Page 4 · response
    Published 26 February 2024

    Open published response

  6. 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

    Lack of a fully trained first-aid employee on site throughout the day and night

    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

    Open published response

  7. 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

  8. 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

    Unavailability of a registered first aider on the premises

    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

    Provide formal first-aider training to four employees.

    Verbatim wording from the response

    “On 17 October 2022 all employees of Hibiscus undertook First Aid Workplace Awareness training provided by High Speed Training. Additionally, four employees of Hibiscus will undertake First Aider Training via St John’s Ambulance which is scheduled for the end of October.”

    Source location

    Response from Hibiscus House
    Page 2 · 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

    Introduce a formal first-aid duty rota after the four employees complete first-aider training.

    Verbatim wording from the response

    “There is no formal first aid duty rota in place, however with all staff being trained and the overlap of shifts which cover the week, there will always be at least one person who has first aid awareness on site. After the four employees have undertaken First Aider Training with St John’s Ambulance, a formal rota will be put in place.”

    Source location

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

    Open published response

  9. West Sussex

    AI-generated summary

    James Joseph MANNING · 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 Joseph Manning, aged two, choked on a piece of sausage at Butlins, Bognor Regis, on 6 June 2018, suffered a cardiac arrest and hypoxic ischaemic brain injury, and died in hospital on 20 June 2018. The concerns included delays and weaknesses in healthcare referral, follow-up and information-sharing systems, and shortcomings in the management of health and safety, incident reporting, first-aid provision and emergency procedures at Bourne Leisure sites.

    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 written procedure for obtaining first aid help quickly

    Wider context from the report

    “e) Witnesses confirmed that there was no written standard operating procedure setting out how staff can get first aid help quickly as well as when and how to make a 999-emergency call especially if a trained first aider is not immediately available. ”

    Source location

    James Joseph MANNING · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to provide adequately for visitors' first aid needs across sites

    Wider context from the report

    “c) I am concerned that the Health & Safety Executive’s strong recommendation in the First Aid Regulations to consider the first aid of visitors and what will be offered in terms of provision across each site was not sufficiently reflected in company practices. ”

    Source location

    James Joseph MANNING · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  10. Leicester City and South Leicestershire

    AI-generated summary

    Jane Louise SHILTON · 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

    Jane Louise Shilton, who had severe and enduring mental health difficulties and lived in a residential care home, was found unresponsive in her bedroom and was pronounced dead at the scene. The report raises concerns about the failure to check on her after missed medication, dinner and cigarettes, the absence of overnight proactive checks, and the staff’s response to the medical emergency, including not checking breathing or pulse and not attempting CPR. It also raises concerns about the quality and frequency of first-aid training.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to provide first aid during incidents

    Wider context from the report

    “I was told during the inquest that Hamilton House First Aid Training was outdate at the point Jane died and I have since been provided with the First Aid Training Certificates which evidence that First Aid Training was provided to staff once every 3 years, and this was in 2018 and staff had received updated training in 2021, within the 3 year time frame. I remain concerned and that concern is heightened when having heard the evidence of the support workers on shift that evening to learn that updated first aid training was only undertaken 5 days prior to this incident. I understand that the first aid training in 2021 was delivered online given the Cv19 restrictions. I further understand that whilst yearly first aid refresher training can be undertaken Hamilton House have not required staff to undergo such training. As I have found in this inquest sadly for Jane the failure to attempt to deliver any first aid would not have made any difference in her case as she had been sadly passed away for some time. However, the way in which the incident was handled which is evident from the 999 call which gave rise to a safeguarding alert does deeply trouble me especially in the context of learning that refresher training had been received by the individuals engaged with the incident only 5 days prior. This causes me to question quality of that training in the context of an online setting given the pandemic. I am further concerned that first aid training is only undertaken at the minimum requirement of every 3 years, given that Hamilton House is charged with the responsibility of looking after some of society’s most vulnerable individuals who I am told have co-existing difficulties of both mental health but also substance misuse. ”

    Source location

    Jane Louise SHILTON · 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

    Mandate annual First Aid training instead of training every three years.

    Verbatim wording from the response

    “• First Aid training is now mandated annually instead of the previous 3 year requirement and in light of Covid-19 restrictions coming to an end this training will be carried out face-to-face. We are communicating with our training provider to accommodate this training as we can not complete the training in one session. We hope to complete this by the end of April 2022.”

    Source location

    2022-0053-Response-from-Hamilton-Community-Homes-Ltd_Published
    Page 2 · response
    Published 24 February 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

    Arrange face-to-face First Aid training with the training provider.

    Verbatim wording from the response

    “• First Aid training is now mandated annually instead of the previous 3 year requirement and in light of Covid-19 restrictions coming to an end this training will be carried out face-to-face. We are communicating with our training provider to accommodate this training as we can not complete the training in one session. We hope to complete this by the end of April 2022.”

    Source location

    2022-0053-Response-from-Hamilton-Community-Homes-Ltd_Published
    Page 2 · response
    Published 24 February 2022

    Open published response
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Data last updated 7 September 2026