Recurring concern

Unreliable access to barrier devices for emergency resuscitation

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First reported 29 Nov 2017•Latest report 7 Jun 2023

Definition

What this concern includes

Includes failures to design, provide, carry, maintain, replace or require suitable barrier devices for use during emergency resuscitation by police, custodial or comparable responders.

Not included

  • Excludes general CPR, first-aid or resuscitation competence failures where barrier-device availability or suitability is not the deficient control.
  • Excludes defective or unavailable clinical equipment unrelated to barrier devices used during emergency resuscitation.
  • Excludes infection-control, personal-protective-equipment and respiratory-protection concerns unrelated to providing a resuscitation barrier device.
  • Excludes failures occurring after a suitable barrier device was available and used, including the quality of subsequent clinical treatment.
Reports
2

Distinct published reports

Individual concerns
2

A report can raise multiple concerns

Date range
2017–2023

First to latest report issue date

Stated actions
4

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

HM Prison and Probation Service2
HM Prison Service1
Ministry of Justice1
Preston Prison1

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. Lancashire and Blackburn with Darwen

    AI-generated summary

    Anthony George Smith · 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 George Smith was found hanging in his cell at HMP Preston on 4 May 2022 while suffering an acute relapse of schizophrenia, and officers commenced resuscitation. The report raised concerns that mouth-to-mouth resuscitation was performed without available mouth protection, creating risks of blood-borne virus transmission and potentially discouraging rescue breaths, and noted the need for readily accessible protection masks.

    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 available mouth protection for resuscitation

    Wider context from the report

    “(1) An officer attempting resuscitation carried out mouth to mouth resuscitation without the safeguard of mouth protection which was not available in the prison at the time. Mr Smith was a regular drug user who on occasions injected drugs. Performing mouth to mouth resuscitation carried with it the risk of transmission of blood born viruses with possible fatal consequences. (2) The lack of available protection not only carried with it a risk to those who performed resuscitation but potentially also to the person suffering a cardiac arrest in that without protection the would-be resuscitator might decline to provide rescue breaths ”

    Source location

    Anthony George Smith · 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

    Reissue the First Aid Policy Framework with face-shield requirements for prison first-aid kits and related CPR guidance.

    Verbatim wording from the response

    “As you are aware, the First Aid Policy Framework is currently under review and is due to be re-issued by August 2023. The revised policy document will include instructions on the use of face shields including the requirement for all first aid kits in prisons to contain resuscitation face shields and for these to be monitored and replenished when required. The policy also emphasises the training requirements for Emergency First Aid and First Aid at Work, including the importance of using the face masks correctly and of these being available at all times.”

    Source location

    Response from HM Prison and Probation Service
    Page 1 · response
    Published 13 June 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Provide resuscitation face shields in first-aid boxes across all HMP Preston residential units.

    Verbatim wording from the response

    “At HMP Preston, face shields have been purchased and added to the existing first aid boxes on all residential units and will be monitored by the Health and Safety Team. A Notice to Staff was also issued in June 2023 to advise staff of the location of the face shields and the importance of using these when administering CPR.”

    Source location

    Response from HM Prison and Probation Service
    Page 1 · response
    Published 13 June 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Monitor HMP Preston face shields and replenish them when required.

    Verbatim wording from the response

    “As you are aware, the First Aid Policy Framework is currently under review and is due to be re-issued by August 2023. The revised policy document will include instructions on the use of face shields including the requirement for all first aid kits in prisons to contain resuscitation face shields and for these to be monitored and replenished when required. The policy also emphasises the training requirements for Emergency First Aid and First Aid at Work, including the importance of using the face masks correctly and of these being available at all times.”

    Source location

    Response from HM Prison and Probation Service
    Page 1 · response
    Published 13 June 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Issue staff guidance explaining face-shield locations and the importance of using them during CPR.

    Verbatim wording from the response

    “At HMP Preston, face shields have been purchased and added to the existing first aid boxes on all residential units and will be monitored by the Health and Safety Team. A Notice to Staff was also issued in June 2023 to advise staff of the location of the face shields and the importance of using these when administering CPR.”

    Source location

    Response from HM Prison and Probation Service
    Page 1 · response
    Published 13 June 2023

    Open published response

  2. Preston and West Lancashire

    AI-generated summary

    Christopher Talbot · Prevention of Future Deaths report

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

    Report summary

    Christopher Talbot, a prisoner at Preston Prison, was found with a plastic bag over his head after being identified as vulnerable and at risk of suicide. Resuscitation initially restored breathing and cardiac output, but he later died in hospital. Concerns included inadequate reception training, the absence of a breathing guard during resuscitation, insufficient sharing of information about similar deaths, and failures to request immediate assistance and maintain constant observation.

    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 breathing guards for senior officers during resuscitation

    Wider context from the report

    “(2) A Senior Officer gave mouth to mouth resuscitation to Mr Talbot without the use of a guard. It is understood that although mandatory for more junior officers at HMP Preston, carrying a breathing guard at all times is discretionary for certain senior grades. Lack of such a guard might put an officer in personal danger when attempting to revive a prisoner or dissuade that officer from intervening, with potential adverse consequences for the prisoner. ”

    Source location

    Christopher Talbot · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026