30 Mar 2017 Ondrej SUHA · Prevention of Future Deaths report Staffordshire South
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Concerns raised 1
Failure to ensure responding staff have basic resuscitation training View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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Ondrej SUHA · 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
Ondrej Suha, a serving prisoner, was found hanging in his cell on 21 December 2015 and died in hospital on 25 December 2015. Concerns included the lack of specific night-shift training for the responding prison officer and the absence of first-aid training enabling initial staff to attempt resuscitation.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to ensure responding staff have basic resuscitation training
Wider context from the report “(2) The initial staff responding to the incident did not have first aid training to enable them to attempt resuscitation . Subsequently many staff at HMPOI Brinsford have had this training. However I wonder if basic resuscitation should form part of a Prison Officer's training or indeed if the quotas for staff on duty at any one time in a prison with such training should be reviewed.
” Source location Ondrej SUHA · Prevention of Future Deaths report
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23 Mar 2017 Antony Miles Abbott · Prevention of Future Deaths report Manchester West
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Concerns raised 1
Lack of cardiopulmonary resuscitation training for custody officers in Spain View source
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Antony Miles Abbott · 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
Antony Miles Abbott was arrested on 23 October 2015 and held in a cell at Benidorm Police Station, Spain, where he was found with a soft loose ligature around his neck after no officer presence was observed for 18 minutes. The jury concluded that he died by hanging and recorded misadventure, with his death contributed to by neglect. Concerns included the lack of CCTV and an audible means of attracting attention in the cell, the failure to implement prior recommendations for custody surveillance and cell safety, and the absence of CPR training for custody officers.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of cardiopulmonary resuscitation training for custody officers in Spain
Wider context from the report “In addition evidence was given at the Inquest that whilst Custody Officers in Spain must be trained to administer first aid to detained persons, that training does not include training in the administration of Cardio Pulmonary Resuscitation (CPR) . These matters are reported in order that they can be brought to the attention of the relevant Authorities in Spain through the appropriate channels.
” Source location Antony Miles Abbott · Prevention of Future Deaths report
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5 Sep 2016 Benjamin Thomas Brown · Prevention of Future Deaths report North London
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Concerns raised 1
Insufficient staff training for resuscitation when a patient collapses View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Benjamin Thomas Brown · 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 Thomas Brown was a patient detained under section 2 of the Mental Health Act who was found unresponsive at 8.45am after gaps and inaccurate entries in the required 15-minute observation records. He was recognised as having died at 10.06, and the inquest recorded natural causes, with sudden cardiac death due to cardiac arrhythmia. The substantive concerns related to auditing 15-minute observations, staff resuscitation training, and auditing the prescription and management of clozapine.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Insufficient staff training for resuscitation when a patient collapses
Wider context from the report “2. Training of staff for resuscitation in the event that a patient collapses .
” Source location Benjamin Thomas Brown · Prevention of Future Deaths report
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15 Jul 2016 Sydney Mya Neil · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 1
Insufficient resuscitation expertise in GP practices View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Birmingham South Central CCG NHS England Wychall Lane Surgery
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 5
NHS England
Ask the CQC to ensure inspections check that primary care services have equipment and skills to address respiratory emergencies.
View source
Birmingham South Central CCG
Conduct contract visits to ensure GP practices adhere to emergency equipment, training and protocol guidance.
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Birmingham South Central CCG
Assist the practice involved in the incident to identify and address issues highlighted by the incident.
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Birmingham South Central CCG
Circulate learning from the incident to all commissioned GP practices.
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Birmingham South Central CCG
Circulate incident learning to surrounding clinical commissioning groups for dissemination to their practices.
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Sydney Mya Neil · 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
Sydney Mya Neil suffered from severe brittle asthma and died at Birmingham Children's Hospital after collapsing at a GP surgery following breathing difficulties. The report raised concerns about inadequate ventilation, lack of suction and lack of oxygen during resuscitation, and whether GP practices have sufficient expertise and equipment for emergencies.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Insufficient resuscitation expertise in GP practices
Wider context from the report “Once Sydney collapsed in the GP surgery there was inadequate ventilation for 8 minutes. No suction was used nor was oxygen provided. I am concerned about the level of expertise in GP practices when resuscitation is required and whether they have sufficient equipment to deal with emergency situations.
” Source location Sydney Mya Neil · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Ask the CQC to ensure inspections check that primary care services have equipment and skills to address respiratory emergencies.
Verbatim wording from the response “I have asked ████████ Head of Primary Care Commissioning, NHS” Source location 2016-0256-Response-by-NHS-England
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct contract visits to ensure GP practices adhere to emergency equipment, training and protocol guidance.
Verbatim wording from the response “All organisations providing primary care should also have appropriate equipment and drugs for managing other life-threatening emergencies (e.g. anaphylaxis). The CCG would expect all GP staff to be trained to deliver basic CPR to patients, to have this training updated on a regular basis and have appropriate protocols in place to deal with such emergencies. The CCG has a programme of contract visits where we will ensure that practices are adhering to the guidance provided above” Source location 2016-0256-Response-by-Birmingham-South-Central-Clinical-Commissioning-Group
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Assist the practice involved in the incident to identify and address issues highlighted by the incident.
Verbatim wording from the response “The CCG has been assisting the practice involved in this incident to identify and address issues that have been highlighted by this unfortunate incident and it is the intention of the CCG to circulate any learning from this incident across all GP practices that we are responsible for commissioning. We will also circulate this learning to surrounding CCGs so that they may also disseminate these lessons to their practices.” Source location 2016-0256-Response-by-Birmingham-South-Central-Clinical-Commissioning-Group
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Circulate learning from the incident to all commissioned GP practices.
Verbatim wording from the response “The CCG has been assisting the practice involved in this incident to identify and address issues that have been highlighted by this unfortunate incident and it is the intention of the CCG to circulate any learning from this incident across all GP practices that we are responsible for commissioning. We will also circulate this learning to surrounding CCGs so that they may also disseminate these lessons to their practices.” Source location 2016-0256-Response-by-Birmingham-South-Central-Clinical-Commissioning-Group
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Circulate incident learning to surrounding clinical commissioning groups for dissemination to their practices.
Verbatim wording from the response “The CCG has been assisting the practice involved in this incident to identify and address issues that have been highlighted by this unfortunate incident and it is the intention of the CCG to circulate any learning from this incident across all GP practices that we are responsible for commissioning. We will also circulate this learning to surrounding CCGs so that they may also disseminate these lessons to their practices.” Source location 2016-0256-Response-by-Birmingham-South-Central-Clinical-Commissioning-Group
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Except in remote or inaccessible locations, practices may rely on rapid access to emergency services when determining appropriate equipment and training.
Verbatim wording from the response “The Care Quality Commission (CQC) as the regulator of general practice needs to be assured that practices are able to immediately respond to the needs of a person who becomes seriously ill. The CQC does not have explicit guidance around emergency equipment; however does state that if the practice does not have oxygen they are unlikely to be able to demonstrate they are equipped for dealing with emergencies.²” Source location 2016-0256-Response-by-NHS-England
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The CQC is responsible for using its inspection regime to ensure primary care services carry necessary equipment and skills for respiratory emergencies.
Verbatim wording from the response “The Care Quality Commission (CQC) as the regulator of general practice needs to be assured that practices are able to immediately respond to the needs of a person who becomes seriously ill. The CQC does not have explicit guidance around emergency equipment; however does state that if the practice does not have oxygen they are unlikely to be able to demonstrate they are equipped for dealing with emergencies.²” Source location 2016-0256-Response-by-NHS-England
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation General practice is not an emergency service and is not contracted, equipped or organised to deliver team-based emergency care.
Verbatim wording from the response “We have taken advice from the Local Medical Committee and General Practice Committee (GPC) of the BMA who commissioned ████████ who is a senior GP who has held roles including provision of and teaching of immediate care, now known as Pre-Hospital Emergency Medicine and is chair of BASICS Education Ltd, who aim to improve emergency care outside hospital, to comment on the care the Practice provided to Miss Neil and provide his general thoughts on this incident. He states general practice and general practitioners are not an emergency service…… General practitioners who very, very infrequently have to deal with life threatening emergencies and are neither equipped, contracted nor organised to deliver such team based emergency care.” Source location 2016-0256-Response-by-Wychall-Lane-Surgery
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14 Dec 2015 Paul David Whitehead · Prevention of Future Deaths report West Yorkshire Eastern
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Concerns raised 1
Failure of First Aid provision to maintain effective resuscitation capability View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 1
W.E.Rawson Limited
Refresh all first aiders’ first-aid training regularly in line with HSE guidance.
View source
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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.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of First Aid provision to maintain effective resuscitation capability
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
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Refresh all first aiders’ first-aid training regularly in line with HSE guidance.
Verbatim wording from the response “We will prepare all of our first aiders so far as possible by refreshing their first aid training on a regular basis in line with HSE guidance. The First Aider in question has already been provided with refresher training following the incident.” Source location Paul-Whitehead-Response
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation It is difficult to prepare non-medical first aiders to avoid freezing from shock during incidents as severe as this one.
Verbatim wording from the response “3) The First Aider was unable to perform mouth to mouth resuscitation.” Source location Paul-Whitehead-Response
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17 Sep 2015 FIONA MARGARET PATRICIA LEWIS · Prevention of Future Deaths report Suffolk
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Concerns raised 1
Inadequate resuscitation training for health care professionals involved in patient care View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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FIONA MARGARET PATRICIA LEWIS · 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
Fiona Margaret Patricia Lewis was admitted to Ipswich Hospital after three weeks of symptoms and died there on 13 September 2014. The cause of death was found to be disseminated carcinoma, with no primary mass identified at post-mortem examination. Concerns were raised about delayed resuscitation following her collapse and whether the healthcare professionals involved had adequate resuscitation knowledge and ability, although it was considered unlikely that this would have altered the outcome.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Inadequate resuscitation training for health care professionals involved in patient care
Wider context from the report “Although, in the very sad circumstances of the death of Fiona Luis, any problems in respect of resuscitation at the time of the collapse are unlikely to have affected the outcome for the reasons given above, it is clearly important that there is confidence that health care professionals involved with patient care are adequately trained in resuscitation and able to respond appropriately in the event of a collapse occurring.
” Source location FIONA MARGARET PATRICIA LEWIS · Prevention of Future Deaths report
Open source report
5 Dec 2014 Peter Harry Mackie · Prevention of Future Deaths report Buckinghamshire
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Concerns raised 1
Lack of guidance for CPR-trained staff on when to commence CPR View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
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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.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of guidance for CPR-trained staff on when to commence CPR
Wider context from the report “(3)It appears that there is not currently any guidance to staff as to when CPR should be commenced . This applies to CPR trained staff . For those without such training there is a lack of clarity as to what if any action they should undertake.
” Source location Peter Harry Mackie · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issue interim First Aid Guidance for staff during consultation on the revised policy instruction.
Verbatim wording from the response “All first aid trained staff will be aware of how and when to apply CPR following the training they receive. A new First Aid at Work PSI is currently taking place. Once the period of consultation is complete, a revised PSI will be published. During the interim period, NOMS has issued the old First Aid Guidance for staff to use, as attached.” Source location 2014-0528-Response-by-NOMS
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish a revised First Aid at Work policy instruction after consultation.
Verbatim wording from the response “All first aid trained staff will be aware of how and when to apply CPR following the training they receive. A new First Aid at Work PSI is currently taking place. Once the period of consultation is complete, a revised PSI will be published. During the interim period, NOMS has issued the old First Aid Guidance for staff to use, as attached.” Source location 2014-0528-Response-by-NOMS
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide all Grendon and Springhill staff with written advice on responding to a non-breathing person through a booklet, induction and the local intranet.
Verbatim wording from the response “HMP Grendon and Springhill have sought additional advice from the Resuscitation Council UK on when CPR should be commenced and will be providing staff who work at HMP Grendon and Springhill with written advice on what to do should they find somebody not breathing. This will be provided to all staff in the form of a booklet by 31 January 2015, to ensure staff receive this information. The information will form part of the induction for new staff and will be made available on the local intranet at HMP Grendon and Springhill.” Source location 2014-0528-Response-by-NOMS
Open published response
Concerns raised 1
Failure to maintain effective and current first aid training and competence View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Barons Park Nursing Home Ltd
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 5
Barons Park Nursing Home Ltd
Review and strengthen the staff training system using a skills matrix and training plan.
View source
Barons Park Nursing Home Ltd
Allocate staff to scheduled training sessions rather than relying on open attendance.
View source
Barons Park Nursing Home Ltd
Require employees to keep training current through an employment-contract clause.
View source
Barons Park Nursing Home Ltd
Provide key-area training to all nursing and care staff.
View source
Barons Park Nursing Home Ltd
Review training effectiveness through staff feedback and course-participant evaluation.
View source See 2 more actions
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Christopher John Royal · 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 John Royal suffered a cardiac event on 25 January 2013 and was found collapsed in the en-suite bathroom of Baron’s Park Nursing Home; CPR was unsuccessful. Concerns included unreliable 15-minute observation records, inadequate emergency response and first-aid training, and the potential impact of lengthy staff shifts on care.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to maintain effective and current first aid training and competence
Wider context from the report “2) Evidence was taken that the Matron did not have a valid First Aid Certificate at the time of this event; it had expired in 2011 . There was evidence that the nursing home staff response to this medical emergency was inadequate and insufficient. One member of staff said although First Aid trained she did not feel competent to carry out CPR . First Aid training is essential in a Nursing Home environment, and there should be in place a proper system to ensure training is provided, updated, effective and understood . An annual system of review and/or appraisal may assist in the monitoring process and allow staff feedback and concerns reporting.
” Source location Christopher John Royal · Prevention of Future Deaths report
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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 strengthen the staff training system using a skills matrix and training plan.
Verbatim wording from the response “a) After the death of Mr Royal in January 2013, and upon finding at this time that Matron’s first aid training had lapsed, we immediately reviewed our training system and the implementation of such, and deployed our skills matrix to highlight an overview of staff training. Since February 2013, we have developed a more robust training matrix which focuses on some of the key training of staff within a nursing environment. The matrix enclosed (appendix C), shows our progress to date and shows that the majority of our nursing and care staff have (during the past 18 months), undertaken training in many mandatory courses. This is an ongoing process and we enclose (appendix D) a copy of our training plan which shows our program for this year. We will continue to monitor staff training records.” Source location Royal-2014-0354-Response
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Allocate staff to scheduled training sessions rather than relying on open attendance.
Verbatim wording from the response “As part of this development, we now also allocate staff to attend sessions as opposed to our previous process of “open attendance requirements”. We have also added a clause to employment contracts which makes a requirement to keep training “in-date” and allows us to take further action if this is not the case.” Source location Royal-2014-0354-Response
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require employees to keep training current through an employment-contract clause.
Verbatim wording from the response “As part of this development, we now also allocate staff to attend sessions as opposed to our previous process of “open attendance requirements”. We have also added a clause to employment contracts which makes a requirement to keep training “in-date” and allows us to take further action if this is not the case.” Source location Royal-2014-0354-Response
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide key-area training to all nursing and care staff.
Verbatim wording from the response “b) We are now ensuring that all nursing/care staff receive training in key areas. To monitor the effectiveness of this, we will be reviewing training sessions with staff to find out how effective the session has been and to find out if there are any remaining shortcomings. From our findings, we can arrange further training if needed, source an alternative provider or continue to implement if all received. We are commencing this program of monitoring and review with effect from 1st September 2014.” Source location Royal-2014-0354-Response
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review training effectiveness through staff feedback and course-participant evaluation.
Verbatim wording from the response “b) We are now ensuring that all nursing/care staff receive training in key areas. To monitor the effectiveness of this, we will be reviewing training sessions with staff to find out how effective the session has been and to find out if there are any remaining shortcomings. From our findings, we can arrange further training if needed, source an alternative provider or continue to implement if all received. We are commencing this program of monitoring and review with effect from 1st September 2014.” Source location Royal-2014-0354-Response
Open published response
6 Mar 2014 Natasha Raghoo · Prevention of Future Deaths report West Sussex
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Concerns raised 1
Lack of staff training in cardiopulmonary resuscitation and defibrillator use View source
This report raised 12 other concerns. They are not shown here because they do not form part of this recurring concern.
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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.
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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
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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
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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
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation 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
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16 Dec 2013 Sarah Anne Shepherd · Prevention of Future Deaths report Surrey
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Concerns raised 3
Unclear alignment of resuscitation training with current guidance View source Failure to initiate resuscitation when a patient is not breathing normally View source Misleading resuscitation aide memoires in staff resuscitation bags View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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Sarah Anne Shepherd · 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
Sarah Anne Shepherd, a patient detained under the Mental Health Act, was found in her room with a plastic bin liner over her head on 12 September 2011 and died in hospital the following day. The report identified concerns about unclear referral processes to the Psychiatric Intensive Care Unit, failures to attempt resuscitation in accordance with guidance, and uncertainty and misleading materials concerning resuscitation training.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Unclear alignment of resuscitation training with current guidance
Wider context from the report “(2) It was apparent from the evidence that the nursing staff who found the Deceased in an unresponsive state on the 12th September 2011 did not attempt to resuscitate her in accordance with the guidelines of the Resuscitation Council. They understood that resuscitation should be started if the patient was not “breathing” whereas the Council states that it should be started if the patient is not “breathing normally”.
The evidence heard as to what training the nursing staff had been given concerning when resuscitation should be started was unclear and confusing. It remains unclear whether the resuscitation training now being given to clinical staff (a) is fully and clearly in accordance with the current guidance of the Resuscitation Council and (b) includes training as to what observations should be taken and recorded.
Further, it was apparent from the evidence that the resuscitation bags used by staff contain a laminated aide memoire which is itself misleading as it refers to the use of resuscitation when the patient is not “breathing” rather than “breathing normally”.
” Source location Sarah Anne Shepherd · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to initiate resuscitation when a patient is not breathing normally
Wider context from the report “(2) It was apparent from the evidence that the nursing staff who found the Deceased in an unresponsive state on the 12th September 2011 did not attempt to resuscitate her in accordance with the guidelines of the Resuscitation Council . They understood that resuscitation should be started if the patient was not “breathing” whereas the Council states that it should be started if the patient is not “breathing normally” .
The evidence heard as to what training the nursing staff had been given concerning when resuscitation should be started was unclear and confusing. It remains unclear whether the resuscitation training now being given to clinical staff (a) is fully and clearly in accordance with the current guidance of the Resuscitation Council and (b) includes training as to what observations should be taken and recorded.
Further, it was apparent from the evidence that the resuscitation bags used by staff contain a laminated aide memoire which is itself misleading as it refers to the use of resuscitation when the patient is not “breathing” rather than “breathing normally”.
” Source location Sarah Anne Shepherd · Prevention of Future Deaths report
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 Misleading resuscitation aide memoires in staff resuscitation bags
Wider context from the report “(2) It was apparent from the evidence that the nursing staff who found the Deceased in an unresponsive state on the 12th September 2011 did not attempt to resuscitate her in accordance with the guidelines of the Resuscitation Council. They understood that resuscitation should be started if the patient was not “breathing” whereas the Council states that it should be started if the patient is not “breathing normally”.
The evidence heard as to what training the nursing staff had been given concerning when resuscitation should be started was unclear and confusing. It remains unclear whether the resuscitation training now being given to clinical staff (a) is fully and clearly in accordance with the current guidance of the Resuscitation Council and (b) includes training as to what observations should be taken and recorded.
Further, it was apparent from the evidence that the resuscitation bags used by staff contain a laminated aide memoire which is itself misleading as it refers to the use of resuscitation when the patient is not “breathing” rather than “breathing normally” .
” Source location Sarah Anne Shepherd · Prevention of Future Deaths report
Open source report
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.