Recurring concern

Inadequate staff training and familiarisation in defibrillator use

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First reported 6 Mar 2014•Latest report 8 May 2026

Definition

What this concern includes

Includes missing, inadequate or irregular training and familiarisation for staff expected to operate an automated or other defibrillator.

Not included

  • Physical absence, inaccessibility or equipment failure where operator competence is adequate
  • General resuscitation training that does not concern defibrillator use
  • Clinical decisions about whether defibrillation is indicated
Reports
8

Distinct published reports

Individual concerns
9

A report can raise multiple concerns

Date range
2014–2026

First to latest report issue date

Stated actions
25

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.

NHS England3
HM Prison and Probation Service2
Ministry of Justice2
Alternative Futures Group Limited1
Care Quality Commission1
Choice Support1
Department of Health and Social Care1
Greater Manchester Mental Health NHS Foundation Trust1
NHS South West London Integrated Care Board1
Nottinghamshire Healthcare NHS Foundation Trust1
Partnerships in Care Limited1
Prisons and Probation Ombudsman1
Ranby Prison1
Safety Matters (Legal) Limited1
Safety Matters Ltd1

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. West London

    AI-generated summary

    Jake Daniel Taylor · 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

    Jake Daniel Taylor, aged 19, suffered a cardiac arrest at his care home on 16 January 2025 and died in Kingston hospital on 20 January 2025. The report identified delays in first aid and concerns about the lack of individual emergency planning, staff training, immediately available equipment, and airway training and equipment.

    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

    Staff misunderstanding of defibrillator function

    Wider context from the report

    “No planning for this foreseeable emergency. Inadequate staff training (to always conduct CPR if no decision to the contrary) No defibrillator on site and staff misunderstanding of the function of a defibrillator. No airway training and equipment although Registered Nursing staff have this within their competencies. I consider that individual emergency planning for those service users with recognised high tier needs and life-threatening risk profiles is essential to ensure best possible outcomes and care tailored to their needs. Medical emergencies in this cohort of patients are predictable but are likely to happen suddenly and unexpectedly. In this case the staff were not able to respond and their evidence to the court demonstrated that they felt unprepared and uncertain about what to do. This is a situation that could be replicated throughout the services that care for individuals such as Jake. Those commissioning the services should consider if the individual emergency care planning is comprehensive and complete and reviewed where appropriate. ”

    Source location

    Jake Daniel Taylor · 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

    Require providers to assess AED need and provide, maintain and govern AED equipment with appropriate staff training.

    Verbatim wording from the response

    “c. Availability and Use of Defibrillators All commissioned providers will be required to:”

    Source location

    Response from NHS South West London ICB
    Page 3 · response
    Published 2 July 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

    Reinforce CPR and safe AED-use training for Roy Kinnear House staff.

    Verbatim wording from the response

    “First Aid training already includes training and practical competency of CPR and safe use of AEDs in line with national guidance. This will be reinforced for the staff at Roy Kinnear House.”

    Source location

    Response from Choice Support
    Page 4 · response
    Published 2 July 2026

    Open published response
  2. West Yorkshire Eastern

    AI-generated summary

    Lewis Steven Johnson · 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

    Lewis Steven Johnson was found unresponsive with a neck ligature at HMP Wealstun on 12 December 2019 and later died in hospital following a further cardiac arrest. The report raised concerns about the absence of overnight healthcare staff and the prison officers’ delayed and inadequate response, including lack of CPR, defibrillator use and consideration of the recovery 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

    Failure to provide annual refresher training in CPR and defibrillator use for night patrol staff

    Wider context from the report

    “(8) The value of all night patrol staff (particularly in a prison without 24 hour healthcare provision) being trained to provide effective CPR and use a defibrillator competently was recognised at the inquest, along with the wisdom of this being refreshed annually. ”

    Source location

    Lewis Steven Johnson · 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

    Outdated defibrillator training for prison officers

    Wider context from the report

    “(5) The officer acting as ████████ attended the cell but did not think about CPR, believing Mr Johnson to be already dead (notwithstanding that none of the discipline officers present had any medical qualifications to certify death). He had undertaken defibrillator training “many years ago”. ”

    Source location

    Lewis Steven Johnson · 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

    Update the emergency-response training video and distribute it to training centres and prisons for staff training.

    Verbatim wording from the response

    “In respect of the EFAW training all prison officers receive during their entry level training, all first aid training certificates are valid for three years and although not mandatory, staff are encouraged to undertake refresher training to maintain their basic skills and keep up to date with any changes to first-aid procedures. The initial training for staff includes an HMPPS video which shows how to respond to an emergency situation where a prisoner has attempted suicide. This is currently being updated to reflect changes to policy and equipment available since the original video was produced. This video covers the use of prison issue ligature tools, emergency response codes, placing someone in the recovery position and considerations such as when to initiate first aid and the use of defibrillators.”

    Source location

    Response from HM Prison & Probation Service
    Page 2 · response
    Published 19 December 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

    Resume local FAW and EFAW training, prioritising night-group staff and extending training to Custodial Managers and other officers.

    Verbatim wording from the response

    “While the delivery of staff training has been severely impacted as a result of restrictions put in place due to the COVID-19 pandemic, with prisons only being able to deliver limited safety critical training, from April 2023 HMP Wealstun will be able to resume the delivery of FAW and EFAW training locally, and will prioritise all those on the dedicated night group, which includes Operation Support Grade staff. The intention is also for all Custodial Managers to receive this training, as well as a significant proportion of the wider officer group, to ensure that an effective emergency response can be provided when required.”

    Source location

    Response from HM Prison & Probation Service
    Page 2 · response
    Published 19 December 2022

    Open published response
  3. Manchester City

    AI-generated summary

    Shona Christine Michaela Campbell · 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

    Shona Christine Michaela Campbell, a detained psychiatric patient with a history of self-harm and repeated ligature incidents, was found in cardiac arrest after using a ligature on 12 January 2019 and died in hospital on 14 February 2019. The principal concerns included incomplete and inaccurate clinical and observation records, inadequate communication, patients’ access to ligatures, insufficiently developed risk-management plans, training and staffing deficiencies, and shortcomings in the serious incident investigation.

    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 regular training in automated external defibrillator use

    Wider context from the report

    “6. Regular training on all the applicable policies/procedures and use of an Automated Electronic Defibrillator. ”

    Source location

    Shona Christine Michaela Campbell · Prevention of Future Deaths report
    Page 6 · concerns

    Open source report
  4. Milton Keynes

    AI-generated summary

    William VICKERS · 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 Vickers was found collapsed in his cell at HMP Woodhill on 19 July 2018, was resuscitated and taken to hospital after suffering hypoxic brain damage, and died there on 26 July 2018. The report raised concern about delays in prison staff gaining access and, in particular, the 11-minute delay escorting the ambulance through five sets of gates to reach him.

    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 AEDs within the prison

    Wider context from the report

    “During the course of the evidence I was concerned that not all staff within the prison, including those within healthcare, were confident in using the AED (Automatic External Defibrillator) and believe that the training of all staff should be reviewed so all are both familiar and confident in its use. ”

    Source location

    William VICKERS · 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

    Hold AED training sessions for CNWL Offender staff to develop competence and confidence in AED use.

    Verbatim wording from the response

    “In July 2019, with the introduction of the new AEDs there have been a number of training sessions held to ensure CNWL Offender staff are competent and confident in their use.”

    Source location

    2019-0255-Response-by-CNWL-NHS-Trust
    Page 2 · response
    Published 9 September 2019

    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

    Add AED verbal-instruction meanings, including “shock cancelled”, to emergency response training.

    Verbatim wording from the response

    “The Trust Resuscitation Lead has confirmed that all emergency response training (BLS, ELS, ILS) includes information on the verbal instructions (and their meaning) that is given by an AED. The meaning of the wording ‘shock cancelled’ has been added with immediate effect to the training delivered.”

    Source location

    2019-0255-Response-by-CNWL-NHS-Trust
    Page 2 · response
    Published 9 September 2019

    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 monthly local AED and emergency-equipment refreshers, quarterly clinical attendance, attendance monitoring and signed competence statements.

    Verbatim wording from the response

    “We have, with immediate effect, ensured that all Offender Care Services including Woodhill will have:”

    Source location

    2019-0255-Response-by-CNWL-NHS-Trust
    Page 2 · response
    Published 9 September 2019

    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

    Display “Know your AED” posters and distribute a “How to use the AED” guide for refresher training.

    Verbatim wording from the response

    “‘Know your AED’ posters have been developed and are displayed throughout HMP Woodhill to maintain familiarisation with it.”

    Source location

    2019-0255-Response-by-CNWL-NHS-Trust
    Page 2 · response
    Published 9 September 2019

    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

    Offer AED training to HMP Woodhill officers through scheduled monthly refresher sessions.

    Verbatim wording from the response

    “It has been agreed with the Governor that CNWL will offer AED training sessions to officers at HMP Woodhill. Officers will be able to attend the refresher sessions scheduled each month.”

    Source location

    2019-0255-Response-by-CNWL-NHS-Trust
    Page 2 · response
    Published 9 September 2019

    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 role-appropriate annual e-learning and biennial face-to-face emergency response training for all CNWL Offender Care staff.

    Verbatim wording from the response

    “In addition to the above, all CNWL Offender Care staff are required to complete mandatory emergency response training (e-learning annually and face to face bi-annually) at a level appropriate to their role.”

    Source location

    2019-0255-Response-by-CNWL-NHS-Trust
    Page 2 · response
    Published 9 September 2019

    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 new HMP Woodhill CNWL staff with local induction covering emergency-equipment locations and use.

    Verbatim wording from the response

    “All new CNWL staff at HMP Woodhill complete a detailed local induction which includes location of emergency equipment and its use.”

    Source location

    2019-0255-Response-by-CNWL-NHS-Trust
    Page 3 · response
    Published 9 September 2019

    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

    Establish a Resuscitation Review Group to share best practice, standardise emergency equipment and response, and review staff training needs.

    Verbatim wording from the response

    “In December 2018, the Offender Care Directorate established a Resuscitation Review Group with the purpose of sharing best practice, standardising emergency equipment and response and to review the training needs of staff. The review group is led by the Lead Nurse for Offender Care and includes senior clinicians from services and the Trust Resuscitation Lead.”

    Source location

    2019-0255-Response-by-CNWL-NHS-Trust
    Page 3 · response
    Published 9 September 2019

    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

    Complete Train the Trainer preparation for the HMP Woodhill Primary Care Lead to deliver regular local emergency-response and refresher training.

    Verbatim wording from the response

    “On 27 June 2019, the CNWL Primary Care Lead at HMP Woodhill, who is a senior paramedic, completed a ‘Train the Trainer’ course which will enable local emergency response and refresher training detailed above to be carried out on a regular basis within the Woodhill Team.”

    Source location

    2019-0255-Response-by-CNWL-NHS-Trust
    Page 3 · response
    Published 9 September 2019

    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

    Commission an independent external review of emergency-response practice in Offender Care to inform recommendations for policy, practice and training.

    Verbatim wording from the response

    “An external independent review has been commissioned to review the practice of emergency response within Offender Care and make recommendations for policy, practice and training. The findings will form the basis of a detailed action plan to ensure staff are equipped by the training provided and equipment available to respond to a medical emergency according to their role and expertise. These actions are expected to improve patient safety and outcomes.”

    Source location

    2019-0255-Response-by-CNWL-NHS-Trust
    Page 3 · response
    Published 9 September 2019

    Open published response
  5. Inner North London

    AI-generated summary

    Kamal Yahyia AL-HIRSI · 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

    Kamal Yahyia AL-HIRSI, a cleaner at a London health club, suffered a cardiac arrhythmia and slipped beneath the water while cleaning the swimming pool on 10 October 2017. Resuscitation attempts were too late to change the outcome. Concerns included dangerous pool-cleaning practices, inadequate water-safety and defibrillator training, ineffective emergency alarms and communication, limited CCTV coverage, and procedures that remained substantially unchanged ten months after his 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 staff defibrillator location and use training

    Wider context from the report

    “7. There seemed a lack of meaningful awareness of the defibrillator location and function. The first person trained in CPR (cardiopulmonary resuscitation) to respond to the calls for help was a freelance personal trainer who was not a member of Bannatyne staff. Although he was trained, he did not take the defibrillator (there was only one and it was located in the gym) with him, because at that stage he did not know that Mr Al-Hirsi had suffered a cardiac arrest. Some staff members had not received defibrillator training. When the personal trainer reached Mr Al-Hirsi and realised the exact nature of the emergency, the only other person on poolside at that point who seemed confident of the location of the defibrillator, was a club member who happened to be a retired doctor. ”

    Source location

    Kamal Yahyia AL-HIRSI · 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

    Require documented Workplace Induction Checklists covering emergency and lifesaving equipment locations and use.

    Verbatim wording from the response

    “The Company also now requires all of its new and existing employees to undertake a documented Workplace Induction Checklist, where they will be given a guided tour of their site to ensure that they are aware of the location and use of the building’s emergency and life saving apparatus. The Company will ensure that all existing employees complete this by 15 November 2018.”

    Source location

    2018-0265-Response-by-Bannatyne-Fitness-Limited
    Page 2 · response
    Published 11 October 2018

    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

    Ensure all existing employees complete the documented Workplace Induction Checklist.

    Verbatim wording from the response

    “The Company also now requires all of its new and existing employees to undertake a documented Workplace Induction Checklist, where they will be given a guided tour of their site to ensure that they are aware of the location and use of the building’s emergency and life saving apparatus. The Company will ensure that all existing employees complete this by 15 November 2018.”

    Source location

    2018-0265-Response-by-Bannatyne-Fitness-Limited
    Page 2 · response
    Published 11 October 2018

    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

    Relocate defibrillators to reception areas across all sites.

    Verbatim wording from the response

    “At the time of Kamal’s death there was signage at the Club’s reception stating the whereabouts of the defibrillator. This was standard at all of the Company’s sites; defibrillators were not encased or hidden away in offices, but were located in a bracket on gym floors clearly signed in prominent locations and visible to employees, members and visitors. However, following the inquest and your Regulation 28 Report, the Company has taken the decision to relocate defibrillators to sites’ reception area, where they can be readily seen and accessed by all. The Company can confirm that this has been completed across all of its sites.”

    Source location

    2018-0265-Response-by-Bannatyne-Fitness-Limited
    Page 4 · response
    Published 11 October 2018

    Open published response
  6. Nottinghamshire

    AI-generated summary

    Steven James May · 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

    Steven James May died by hanging at HMP Ranby on 25 May 2015 at 01:45, after previously expressing suicidal intent and being placed on the ACCT programme. The report identified concerns about failures in reception health screening, ACCT documentation and reviews, information handovers, staff training and involvement, emergency first aid, cell-entry procedures, and access to health and mental health care.

    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

    Selective emergency First Aid training among prison staff

    Wider context from the report

    “(7) The selective training of prison staff in emergency First Aid (namely the first member of prison staff on the scene of the death was not trained in the administration of CPR and was ignorant of the location of and method of use of defibrillators); ”

    Source location

    Steven James May · 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 the bands, grades and numbers of staff requiring first-aid training.

    Verbatim wording from the response

    “The PSI becomes effective on 16 May 2016, and in preparation for its implementation, the Governor of HMP Ranby is reviewing the band/grade and numbers of staff who need to be trained in first aid. The prison currently has 61 staff trained in FAW and 73 in EFAW. 86 staff have received training in the use of defibrillators, and all staff have been provided with information on the location and use of defibrillators through a staff information notice issued on 16 July 2015.”

    Source location

    Steven-May-Response
    Page 2 · response
    Published 16 March 2016

    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 staff information on defibrillator locations and use.

    Verbatim wording from the response

    “The PSI becomes effective on 16 May 2016, and in preparation for its implementation, the Governor of HMP Ranby is reviewing the band/grade and numbers of staff who need to be trained in first aid. The prison currently has 61 staff trained in FAW and 73 in EFAW. 86 staff have received training in the use of defibrillators, and all staff have been provided with information on the location and use of defibrillators through a staff information notice issued on 16 July 2015.”

    Source location

    Steven-May-Response
    Page 2 · response
    Published 16 March 2016

    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

    Ensure first-aid training is delivered by competent, approved or currently certificated instructors.

    Verbatim wording from the response

    “PSI 29/2015 is clear that all training provided to NOMS staff must be delivered by competent instructors, either by external providers from an approved list or trained and currently certificated NOMS trainers.”

    Source location

    Steven-May-Response
    Page 3 · response
    Published 16 March 2016

    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

    Healthcare concerns are assigned to NHS England and Nottinghamshire Healthcare NHS Foundation Trust, which addressed them separately.

    Verbatim wording from the response

    “You will be aware that healthcare at HMP Ranby is commissioned by NHS England and provided by Nottinghamshire Healthcare NHS Foundation Trust, and I understand that the matters of concern that you have raised at points 1, 2 and 10 have been addressed separately by the Chief Executive of the Trust in a letter dated 13 April 2016, and by the Clinical Quality Manager at NHS England in a letter dated 5 May 2016. This response therefore addresses the matters of concern at points 3 to 9.”

    Source location

    Steven-May-Response
    Page 1 · response
    Published 16 March 2016

    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 remaining seven concerns were matters for HM Prison Service and other parties, so the Trust could not respond to them.

    Verbatim wording from the response

    “The Trust cannot respond to the other 7 concerns highlighted in the Prevent Future Death report as they are matters for HM Prison Service and/or other parties.”

    Source location

    2016-0109-Response-by-Nottingham-Healthcare-NHS-Trust
    Page 4 · response
    Published 16 March 2016

    Open published response
  7. Surrey

    AI-generated summary

    Keith John MURPHY · 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

    Keith John Murphy became physically ill in prison after using SPICE and was later found on his cell floor, where he was pronounced dead on 18 July 2013. The report raises concerns about basic first aid, CPR and defibrillator training for prison staff, and the availability of Healthcare staff outside the hours of 7am to 6.30pm.

    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 defibrillator-use familiarisation for prison officers and staff with direct access to prisoners

    Wider context from the report

    “1. Action is required to ensure that Prison Officers and Staff with direct access to prisoners have basic first aid training, CPR training and familiarisation with the use of a defibrillator. ”

    Source location

    Keith John MURPHY · 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

    Train all Custodial Managers in first aid to ensure trained staff are always available.

    Verbatim wording from the response

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

    Source location

    2015-0120-Response-by-NOMS
    Page 1 · response
    Published 25 March 2015

    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 wider staff instruction on CPR and defibrillator use during monthly prisoner-regime closedowns.

    Verbatim wording from the response

    “This policy is being implemented at HMP Coldingley. In order to ensure that a trained member of staff is always available, all Custodial Managers (CMs) are being trained. At present, all but two of the CMs at the prison have been trained, and those two members of staff will be provided with training as soon as they return to duty. HMP Coldingley also uses a monthly closedown of the prisoner regime to provide opportunities for training for the wider staff group and this includes instruction on CPR and on the use of defibrillators.”

    Source location

    2015-0120-Response-by-NOMS
    Page 1 · response
    Published 25 March 2015

    Open published response
  8. West Sussex

    AI-generated summary

    Natasha Raghoo · 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

    Natasha Raghoo was admitted to The Dene Hospital in April 2012 for treatment related to bipolar disorder and was later detained under section 2 of the Mental Health Act. She was found unresponsive in bed on 5 May 2012 and died from anaphylactic shock caused by an unknown allergen. Concerns included inconsistent physical observations, lack of ECG assessment, staff training in resuscitation and defibrillator use, and communication and handover problems.

    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 cardiopulmonary resuscitation and defibrillator use

    Wider context from the report

    “1. During the course of the evidence, concern was expressed concerning the training that staff had received in the techniques of cardio pulmonary resuscitation and the use of the defibrillator. The latter was reported not to have been used by hospital staff although available on the ward. ”

    Source location

    Natasha Raghoo · 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

    Implement monthly emergency incident drills to practise CPR and related emergency skills.

    Verbatim wording from the response

    “Lessons Learned and changes made”

    Source location

    2014-0100-Response-by-Partnership-in-Care
    Page 2 · response
    Published 6 March 2014

    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

    Deliver company-wide Immediate Life Support training, including defibrillator use, to qualified nurses and doctors.

    Verbatim wording from the response

    “In 2013, and subsequent to the death, PiC implemented a company-wide training programme to move from the provision of Basic Life Support to Immediate Life Support. This training has been delivered to all qualified nurses and doctors across PiC. This training specifically includes the use of the defibrillator.”

    Source location

    2014-0100-Response-by-Partnership-in-Care
    Page 2 · response
    Published 6 March 2014

    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 and defibrillator training with competency sign-off and repeat training where staff do not meet the required standard.

    Verbatim wording from the response

    “Cardio Pulmonary Resuscitation (CPR) and Defibrillator Training”

    Source location

    2014-0100-Response-by-Partnership-in-Care
    Page 1 · response
    Published 6 March 2014

    Open published response
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Data last updated 7 September 2026