Recurring concern

Failure to ensure staff competence in resuscitation

First to latest report 16 Dec 2013 — 20 Feb 2026

Reports that mention this concern: 30
Times this concern has been raised: 32
Stated actions linked to this concern: 51

What this concern includes

Includes failures of resuscitation-specific training, competence assessment, refresher provision, guidance alignment, practical preparation and supporting aids where these affect staff ability to recognise when resuscitation is required and deliver it safely across healthcare and comparable care settings.

What is not included

Excludes general first-aid or emergency-response training deficiencies where resuscitation competence is not the identified unsafe condition.
Excludes failures of resuscitation equipment availability, serviceability or deployment where staff competence is not deficient.
Excludes clinical errors during resuscitation where the responsible staff had appropriate resuscitation competence and the problem lies in another control.
Excludes generic training, staffing or communication deficiencies not specifically tied to resuscitation competence.

Trends

Reports over time

Reports mentioning this concern, over time

Reports about this concern issued each year.

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

Most frequent recipients

Reports about this concern sent to each recipient.

Care Quality Commission4

HM Prison and Probation Service4

NHS England3

Department of Health and Social Care2

Wandsworth Prison2

Barons Park Care1

Birmingham and Solihull Mental Health NHS Foundation Trust1

Bupa Care Homes (GL) Limited1

Camino Healthcare Limited1

College of Policing1

East Kent Hospitals University NHS Foundation Trust1

East London NHS Foundation Trust1

Edgware Community Hospital1

Father of the deceased1

Foreign, Commonwealth & Development Office1

Reports and published responses 30 reports

See individual reports that have raised this concern, and the actions taken in response

25 Aug2022
Black Country
Concerns raised1
1. Lack of staff training in CPR
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses

Hibiscus Housing Association Limited
Wolverhampton City Council
Stated actions 2
1. Wolverhampton City Council
  Review staff training, including mandatory training and emergency-response skills and competences.
2. Hibiscus Housing Association Limited
  Provide CPR training to all employees and refresh it annually.
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
Lack of staff training in CPR
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
Review staff training, including mandatory training and emergency-response skills and competences.

Verbatim wording from the response
“The plan includes a review of staff training to ensure all staff have completed mandatory and/or relevant training. This includes assurances that staff have the right skills and competences to react appropriately in an emergency situation.”

Source location
Response from Wolverhampton City Council
Page 1 · 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
Provide CPR training to all employees and refresh it annually.

Verbatim wording from the response
“Hibiscus have engaged Delphi to assist in creating a planned programme of training. All employees of Hibiscus have now undertaken CPR training. CPR Awareness training commenced 29 July 2022 and was complete by 5 August 2022. This will be refreshed every year.”

Source location
Response from Hibiscus House
Page 2 · response
Published 4 November 2022
Open published response
18 Aug2022
West Yorkshire Eastern
Concerns raised1
1. Failure to establish whether bank and agency staff hold current resuscitation training
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

Leeds Teaching Hospitals NHS Trust
Stated actions 1
1. Leeds Teaching Hospitals NHS Trust
  Check for new temporary staff at every shift start and complete a signed first-shift induction covering emergency and resuscitation procedures, equipment locations and reporting processes.
Respondent positions 3
1. Leeds Teaching Hospitals NHS Trust
  The Trust disputes that the bank nurse lacked appropriate resuscitation training, stating that she had completed current mandatory Level 1 resuscitation training.
  Disputes the concern
1. Leeds Teaching Hospitals NHS Trust
  Existing qualification, training, induction, audit and spot-check arrangements are considered sufficient to ensure temporary ED staff understand emergency procedures.
  Existing arrangements considered sufficient
2. Leeds Teaching Hospitals NHS Trust
  Additional checks for substantive staff joining the bank are considered unnecessary because mandatory training compliance is regularly reported and reviewed through their substantive roles.
  Existing arrangements considered sufficient
AI-generated summary

John Francis Heffron · 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

John Francis Heffron, a 50-year-old wheelchair user, was found confused in his flat and later suffered a cardiac arrest while alone in an A&E cubicle. There was a delay in initiating CPR, including delays in making a crash call and ascertaining his DNAR status; he was resuscitated but sustained a hypoxic brain injury and died in hospital. The concerns included bank and agency nursing staff’s familiarity with emergency procedures, training and induction, and the adequacy and independence of the Trust’s 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
Failure to establish whether bank and agency staff hold current resuscitation training
Wider context from the report
“(6) It was unclear what steps had been taken by the Trust prior to 12 December 2021 to establish: (i) the nursing qualifications of bank and/or agency staff permitted to work in the ED (ii) whether bank and/or agency staff hold appropriate and current training in resuscitation procedures (iii) whether a suitable induction system was in place to ensure bank and/or agency staff were familiar with the crash call system ”
Source location
John Francis Heffron · 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
Check for new temporary staff at every shift start and complete a signed first-shift induction covering emergency and resuscitation procedures, equipment locations and reporting processes.

Verbatim wording from the response
“Following the patient’s death, and during the investigation into the care provided before it, the Trust identified deficiencies in the training provided for bank and agency staff about the crash call process used by the ED teams and action has been taken to address these.”

Source location
Response from The Leeds Teaching Hospital
Page 3 · response
Published 3 October 2022
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 Trust disputes that the bank nurse lacked appropriate resuscitation training, stating that she had completed current mandatory Level 1 resuscitation training.

Verbatim wording from the response
“We have considered these carefully and our response is set out below.”

Source location
Response from The Leeds Teaching Hospital
Page 2 · response
Published 3 October 2022
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
Existing qualification, training, induction, audit and spot-check arrangements are considered sufficient to ensure temporary ED staff understand emergency procedures.

Verbatim wording from the response
“(6) In December 2021 the Trust followed a framework employment checklist for temporary workers on temporary assignments, to establish their qualifications and training prior to them starting work in the ED. This still remains the case. Staff allocated by the preferred provider to work in the EDs should only be staff with prior ED experience. Checks made cover the individual’s qualifications, skills and experience, their DBS status and completion of the Trust’s mandatory and priority training (including refresher training and updating); resuscitation training forms part of this. A CV is received for each candidate in order to verify skills and experience based on previous employment history.”

Source location
Response from The Leeds Teaching Hospital
Page 3 · response
Published 3 October 2022
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
Additional checks for substantive staff joining the bank are considered unnecessary because mandatory training compliance is regularly reported and reviewed through their substantive roles.

Verbatim wording from the response
“In this case the nurse involved in caring for the patient on 12th December 2021 was a substantive Trust employee. For these staff their substantive skill set holds true, as does their mandatory and priority training requirements. Currently there are no additional checks on completion of mandatory and priority training or DBS when substantive staff apply for the staff bank. This is because compliance with all mandatory and priority training elements is a requirement of their substantive position and is subject to regular reporting and review. As highlighted in response (2) above, the bank nurse in question was up to date with all her training requirements including resuscitation training.”

Source location
Response from The Leeds Teaching Hospital
Page 3 · response
Published 3 October 2022
Open published response
11 May2022
Inner North London
Concerns raised1
1. Lack of frequent appropriate emergency resuscitation training
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

Bupa
Stated actions 4
1. Bupa
  Provide and competency-assess Basic Life Support and DNACPR training, including practical choking and CPR assessment.
2. Bupa
  Have the Internal Lead Inspector attend Basic Life Support training to assess its quality and efficacy.
3. Bupa
  Retrain remaining Highgate staff and ensure they are competent and confident to manage future choking, cardiac arrest and CPR incidents.
1. Bupa
  Consider implementing more frequent competency checks or opportunities to practise chest compressions.
Respondent positions 2
1. Bupa
  Existing evidence indicates Highgate BLS delegates passed competency assessments, disputing that training competence was absent.
  Disputes the concern
1. Bupa
  Annual BLS training frequency is not out of step with other social care providers.
  Disputes the concern
AI-generated summary

Cristofaro PRIOLO · 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

Cristofaro Priolo, an 80-year-old man with progressive Alzheimer’s dementia who lived in a nursing home, choked on cauliflower cheese on 25 November 2020 and died. The report identifies concerns that his food was not prepared or fed in accordance with his assessed needs, and that staff failed to provide appropriate first aid, recognise cardiac arrest, and attempt effective CPR.

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 frequent appropriate emergency resuscitation training
Wider context from the report
“A BUPA internal investigation has already taken place and identified some learning points. However, there are matters outstanding around training and audit. Obviously, the cauliflower for Mr Priolo should have been prepared properly for him by the catering staff, but quite apart from that, Mr Priolo’s carers were never assessed when they were feeding him. Whilst the carer who was feeding him when he choked knew that he needed small, soft mouthfuls that he should be allowed to swallow completely before offering the next, that is not what happened. He was fed a large quantity of cauliflower cheese, it seems relatively quickly, that was undercooked to the point of being almost raw, making it much too hard for him to swallow safely. Staff, including qualified nursing staff, then failed to give appropriate first aid. Even 18 months after the event when they were giving evidence in court this week – the inquest had been delayed to allow a police investigation – some staff were unable to describe the correct treatment for choking. Most significantly, nursing staff failed to recognise that Mr Priolo had suffered a cardiac arrest. They then failed to attempt CPR. After the arrival of paramedics, one member of nursing staff did attempt to give chest compressions, but these were ineffective. That is likely to be the result of panic and distress. These are common feelings in an emergency situation, but the risk of them overwhelming resuscitation efforts may be reduced by frequent appropriate training. ”
Source location
Cristofaro PRIOLO · 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
Provide and competency-assess Basic Life Support and DNACPR training, including practical choking and CPR assessment.

Verbatim wording from the response
“• Training around Basic Life Support (“BLS” – the content of which includes addressing and dealing with choking incidents and CPR) and DNACPRs. This training involved an online/classroom based training session, as well as a practical session, where learners are practically assessed, and are not deemed competent until the trainer is satisfied that a learner is competent. We are mindful of your on-going concerns in relation to those nurses who gave evidence during the inquest, and we have said more on this point below – see “concerns 3, 4 & 5”, below.”

Source location
Response from BUPA Care Services
Page 1 · response
Published 12 May 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
Have the Internal Lead Inspector attend Basic Life Support training to assess its quality and efficacy.

Verbatim wording from the response
“9. Our Internal Lead Inspector will attend training in Basic Life Support (BLS) to assess the quality and efficacy of the training provided internally by Bupa. To reassure you, our BLS and Emergency First Aid at Work trainers are all qualified and trained by external training providers. During this training our staff are evaluated and leave the classroom assessed as competent. This includes a practical assessment of delivery of chest compressions.”

Source location
Response from BUPA Care Services
Page 4 · response
Published 12 May 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
Retrain remaining Highgate staff and ensure they are competent and confident to manage future choking, cardiac arrest and CPR incidents.

Verbatim wording from the response
“10. Given the concerns raised at inquest regarding the competence of some of The Highgate staff, we will ensure that those who remain within The Highgate are retrained, competent and confident to manage any further incidents in the future.”

Source location
Response from BUPA Care Services
Page 4 · response
Published 12 May 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
Consider implementing more frequent competency checks or opportunities to practise chest compressions.

Verbatim wording from the response
“We will, however, consider whether or not to implement more frequent competency checks, or opportunities to practice chest compressions. It should be kept in mind though that nurses have a professional obligation to take responsibility and ensure that they feel confident to carry out their role and maintain their competencies in line with NMC requirements.”

Source location
Response from BUPA Care Services
Page 4 · response
Published 12 May 2022
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
Existing evidence indicates Highgate BLS delegates passed competency assessments, disputing that training competence was absent.

Verbatim wording from the response
“We did, however, make enquiries with our Learning and Development team as to the training provided to staff at Highgate, including some of those who gave evidence at the inquest. We wanted to be sure that there had been no issue with their engagement or competency checks. The feedback from our trainer on the BLS training delivered at Highgate was that all delegates (which would include some of those who gave evidence during the inquest) had all passed first time and had a completed competency assessment on file, which confirmed, amongst other things, competent to deliver CPR and how to respond to a choking incident. However, the relevant staff will attend further training to ensure competency.”

Source location
Response from BUPA Care Services
Page 4 · response
Published 12 May 2022
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
Annual BLS training frequency is not out of step with other social care providers.

Verbatim wording from the response
“11. We also note your comments in relation to the frequency of training. At present, BLS is scheduled on an annual basis, although during the pandemic, there was a time during which practical assessments by trainers could not take place, due to measures put in place to comply with government guidance and infection prevention control measures. To the best of our knowledge, the frequency of our training is not out of step with other social care providers and our focus will be as outlined above, which is ensuring the quality and competency of our trainers, the content of our training and the competency checks, to ensure staff leave training confident and competent.”

Source location
Response from BUPA Care Services
Page 4 · response
Published 12 May 2022
Open published response
18 Mar2022
Inner North London
Concerns raised1
1. Inadequate resuscitation training and emergency-equipment familiarity among the only available doctor
This report raised 7 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.
AI-generated summary

Gary OTTWAY · 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 Ottway, aged 41, died after being found in cardiac arrest while detained alone in a seclusion room under constant nursing observation during a severe mental health episode. The report raised concerns about whether observation was constant or effective, delays in entering the room and obtaining emergency equipment, gaps in available medical training and resources, and ineffective chest compressions. The inquest determined that he died from natural causes involving two heart 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
Inadequate resuscitation training and emergency-equipment familiarity among the only available doctor
Wider context from the report
“7. The junior (and only) doctor called to assist in the attempted resuscitation was not familiar with the contents of the emergency grab bag, told me that it would not have occurred to him to ask for any equipment to assist with ventilations other than a pocket mask, and explained that he was not trained in giving adrenaline or any other medicines for resuscitation. As he was the only medical resource available in the case of an emergency, these seem significant gaps. ”
Source location
Gary OTTWAY · Prevention of Future Deaths report
Page 3 · concerns
Open source report
2 Dec2021
Inner North London
Concerns raised1
1. Lack of cardiopulmonary resuscitation training for school teaching assistants
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response

Swiss Cottage School - Development & Research Centre
Stated actions 1
1. Swiss Cottage School - Development & Research Centre
  Deliver Basic Life Support and CPR training to 70 staff on 12 and 14 January 2022 as part of regular training.
AI-generated summary

Alaynah Khadija AHMED · 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

Khadija suffered a cardiac arrest at school on 1 July 2021 and died a week later from a hypoxic brain injury. The principal concern was that the teaching assistant had not been trained in CPR and no staff member attempted CPR when Khadija became unresponsive; frequent CPR training was identified as needing consideration.

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 cardiopulmonary resuscitation training for school teaching assistants
Wider context from the report
“I heard that the teaching assistant looking after Khadija was not trained by the school in cardiopulmonary resuscitation and that, when Khadija became unresponsive, CPR was not attempted by any staff member. It is highly unlikely that CPR would have changed the outcome for Khadija. The cause of her cardiac arrest was an airway compromised by mucous plugging, that even a highly trained paramedic crew was unable to clear. However, CPR might make a difference for another child, or even for a staff member. To put the lack of CPR in context, the care that Khadija received from the school before the arrest seemed to be of a very high standard, even drawing comment from a paediatric intensive care consultant giving evidence at inquest. He told me that many nurses at Great Ormond Street Hospital would not have been able to administer the treatment that Khadija’s teaching assistant did on 1 July 2021. She was quick to recognise that something was wrong and quick to act appropriately. However, it seems to me that the school would benefit from consideration being given to frequent CPR training. ”
Source location
Alaynah Khadija AHMED · 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
Deliver Basic Life Support and CPR training to 70 staff on 12 and 14 January 2022 as part of regular training.

Verbatim wording from the response
“I am writing to confirm that the school is completing this recommendation on 12th January, 14th January, and within our annual training cycle.”

Source location
2021-0410-Response-from-Swiss-Cottage-School_Published
Page 1 · response
Published 8 December 2021
Open published response
2 Mar2020
North East Kent
Concerns raised1
1. Inadequate neonatal resuscitation training
This report raised 19 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

Department of Health and Social Care
Respondent positions 1
1. Department of Health and Social Care
  The Trust is responsible for setting out and implementing actions to address the identified maternity-service safety risks.
  Redirects responsibility
AI-generated summary

HARRY RICHFORD · 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

Harry Richford was born at QEQM on 2 November 2017 and died at William Harvey Hospital on 9 November 2017 after being transferred there. The report describes delays in delivery, shortcomings in the caesarean delivery and neonatal resuscitation, and subsequent hypoxia and brain injury. Substantive concerns included locum recruitment, assessment and supervision; clarity about escalation to consultants; neonatal resuscitation training; record keeping and adherence to guidelines; and inaccurate death notifications and reporting.

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
Inadequate neonatal resuscitation training
Wider context from the report
“Concern 7 The evidence of ████████ raised substantial concerns about the quality of training and learning in respect of neonatal resuscitation at the East Kent Trust. His evidence was that it would be desirable for middle grade doctors to attend the ARNI course (the advanced resuscitation of the new born infant). He also recommended that there should be simulated drills in neo natal resuscitation. ”
Source location
HARRY RICHFORD · Prevention of Future Deaths report
Page 13 · 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
The Trust is responsible for setting out and implementing actions to address the identified maternity-service safety risks.

Verbatim wording from the response
“I am advised that the Trust Board is taking these matters very seriously and has welcomed the national support being provided. I expect the Trust to set out in its response to your report the actions it is taking to address the important safety risks you have outlined.”

Source location
Response from Department of Health and Social Care
Page 2 · response
Published 11 October 2022
Open published response
6 Sep2019
Black Country
Concerns raised1
1. Minimal training for care staff in performing patient resuscitation
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses

Camino Healthcare Limited
Care Quality Commission
Stated actions 2
1. Camino Healthcare Limited
  Evaluate staff training requirements and provision.
2. Camino Healthcare Limited
  Provide staff with further Intensive Life Support and, where required, Basic First Aid training including CPR.
Respondent positions 1
1. Care Quality Commission
  Regulations do not prescribe specific staff training content or format, limiting the ability to require a particular training approach.
  Unable to act
AI-generated summary

Ms Shannon Quinn · 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

Ms Shannon Quinn, a 24-year-old woman with a complex mental health history and repeated self-harm, was found hanging in her room at Oak House on 9 January 2019 and was pronounced deceased shortly afterwards. The report identified concerns including inadequate information sharing and joint care planning, insufficient staff training, escalating ligature risk without sufficient environmental measures, and failure to adhere to five-minute observations.

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
Minimal training for care staff in performing patient resuscitation
Wider context from the report
“6. Evidence emerged during the inquest that there had been minimal training for Oak House staff in performing resuscitation on patients. The training received included general first aid training by e-learning. ”
Source location
Ms Shannon Quinn · 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
Evaluate staff training requirements and provision.

Verbatim wording from the response
“We have also evaluated all of our training and our staff have received further training in Intensive Life Support and also Basic First Aid (where required) which includes CPR. The Intensive Life Support which is mandatory for our staff exceeds the regulatory requirements of the service.”

Source location
2019-0499-Response-from-Camino-Healthcare-Redacted
Page 1 · response
Published 25 March 2020
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 with further Intensive Life Support and, where required, Basic First Aid training including CPR.

Verbatim wording from the response
“We have also evaluated all of our training and our staff have received further training in Intensive Life Support and also Basic First Aid (where required) which includes CPR. The Intensive Life Support which is mandatory for our staff exceeds the regulatory requirements of the service.”

Source location
2019-0499-Response-from-Camino-Healthcare-Redacted
Page 1 · response
Published 25 March 2020
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
Regulations do not prescribe specific staff training content or format, limiting the ability to require a particular training approach.

Verbatim wording from the response
“As you may be aware the fundamental standards regulations we inspect against do not prescribe what particular training providers must provide to their staff, nor in what format. However, registered providers must ensure that:”

Source location
2019-0499-Response-from-CQC-Redacted
Page 6 · response
Published 25 March 2020
Open published response
12 Apr2019
West Sussex
Concerns raised1
1. Inconsistent understanding of when to commence CPR for abnormal or distressed breathing
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

Sussex Police
Respondent positions 3
1. Sussex Police
  Changes to nationally agreed police training packages require approval through national policing bodies rather than unilateral force action.
  Redirects responsibility
1. Sussex Police
  Basic first-aid training provides officers with knowledge and skills suitable for their policing role.
  Existing arrangements considered sufficient
2. Sussex Police
  Officers cannot reasonably be expected to possess medical professionals’ knowledge because attempting untrained interventions could pose excessive risks.
  Unable to act
AI-generated summary

Duncan Tomlin · 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

Duncan Tomlin died on 29 July 2014 after cardiac arrest following the use of drugs and police prone restraint, including handcuffs, leg restraints and incapacitant spray. The report identified concerns about insufficient emphasis on the heightened breathing risks of multiple factors, delayed opportunities to assess and reposition him, inadequate guidance on monitoring, the timing of CPR, and understanding atypical or post-seizure behaviour.

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
Inconsistent understanding of when to commence CPR for abnormal or distressed breathing
Wider context from the report
“Commencing CPR 4. The evidence relating to current training and training at the time of the death concerned in this inquest indicates that CPR should commence when a person is not breathing normally (described as in 2-3 breaths in 10 seconds for an adult and 3-5 in 10 seconds for small children) or if breathing is distressed (snoring, rasping) known as agonal breathing. The evidence in the inquest was that individual officers of some experience understood CPR should commence when breathing had stopped. Whilst that may be a misunderstanding on the part of individual officers, owing to the importance of commencing CPR at the earliest opportunity when time is critically of the essence, the timing of when CPR should start should be a central point of when training CPR and when reacting to situations akin to that seen in this inquest. ”
Source location
Duncan Tomlin · Prevention of Future Deaths report
Page 4 · 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
Changes to nationally agreed police training packages require approval through national policing bodies rather than unilateral force action.

Verbatim wording from the response
“We are currently delivering nationally agreed training packages and any alteration to these should be agreed nationally with approval of all parties. The benefit in delivering training packages (for all mandatory training, not just Personal Safety Training) is they are consistent across the UK, all police officers are trained in the most current, relevant and up to date thinking which is designed using the latest research and learning from all Forces. We are aware this is currently being reviewed by NPCC and any alterations passed onto Forces in order for them to include in their training. It would be expected these alterations would be completed by the end of 2020.”

Source location
2019-0135-Response-by-Sussex-Police
Page 2 · response
Published 14 June 2019
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
Basic first-aid training provides officers with knowledge and skills suitable for their policing role.

Verbatim wording from the response
“Police officers are not trained to the level of medical practitioners. All police officers have basic first aid training (First Aid – Module 2 of the College of Policing curriculum which includes conducting CPR and managing a casualty who is convulsing) which gives them the knowledge and skills suitable for their role. It is the expectation that they recognise signs and symptoms of a wide variety of medical conditions. It is unrealistic to expect officers to have the knowledge of medical professionals, as the risks posed to themselves and others in trying to take action in which they are not trained is too great. Officers will carry out a dynamic risk assessment of any risk posed by a violent individual – whether the violence is caused by a medical condition or otherwise – and make a decision based on that risk assessment at that time”

Source location
2019-0135-Response-by-Sussex-Police
Page 3 · response
Published 14 June 2019
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
Officers cannot reasonably be expected to possess medical professionals’ knowledge because attempting untrained interventions could pose excessive risks.

Verbatim wording from the response
“Police officers are not trained to the level of medical practitioners. All police officers have basic first aid training (First Aid – Module 2 of the College of Policing curriculum which includes conducting CPR and managing a casualty who is convulsing) which gives them the knowledge and skills suitable for their role. It is the expectation that they recognise signs and symptoms of a wide variety of medical conditions. It is unrealistic to expect officers to have the knowledge of medical professionals, as the risks posed to themselves and others in trying to take action in which they are not trained is too great. Officers will carry out a dynamic risk assessment of any risk posed by a violent individual – whether the violence is caused by a medical condition or otherwise – and make a decision based on that risk assessment at that time”

Source location
2019-0135-Response-by-Sussex-Police
Page 3 · response
Published 14 June 2019
Open published response
23 Oct2018
West Yorkshire Eastern
Concerns raised1
1. Lack of cardiopulmonary resuscitation training for some prison staff
Linked response

HM Prison and Probation Service
Respondent positions 1
1. HM Prison and Probation Service
  Risk-assessed staffing levels provide sufficient emergency first-aid response, and CPR training for all prison staff is not mandated.
  Existing arrangements considered sufficient
AI-generated summary

Nicola Jayne Lawrence · 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

Nicola Jayne Lawrence was an inmate at HMP New Hall who was found unresponsive on 24 September 2016 and died despite efforts by prison, healthcare and ambulance staff. The report raised concerns that healthcare staff had not considered the anti-respiratory or depressant effects of her medication, and that some prison staff had not received cardiopulmonary resuscitation 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
Lack of cardiopulmonary resuscitation training for some prison staff
Wider context from the report
“(1) Some Prison staff had not received any cardiopulmonary resuscitation training. Either as part of initial training or any refresher training. Evidence was received that good quality CPR within the first few minutes of those who stopped breathing or heart stopped was critical. ”
Source location
Nicola Jayne Lawrence · Prevention of Future Deaths report
Page 1 · 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
Risk-assessed staffing levels provide sufficient emergency first-aid response, and CPR training for all prison staff is not mandated.

Verbatim wording from the response
“You may be aware that our approach is set out in PSI 29/2015 First Aid, which does not mandate first aid training for all staff, but requires Governors of public sector prisons to ensure that there are at all times sufficiently trained first aiders available. The appropriate number must be determined by conducting a first aid risk assessment, and first aiders must be trained to levels which are appropriate to the circumstances - to either First Aid at Work (FAW) level or Emergency First Aid at Work (EFAW) level.”

Source location
2018-0318-Response-by-HM-Prison-Probation-Service
Page 2 · response
Published 23 February 2019
Open published response
20 Nov2017
Inner West London
Concerns raised1
1. Inadequate medical staff training in resuscitation
This report raised 14 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.
AI-generated summary

Robert John Richards · 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

Robert John Richards died by suicide after being found hanging by a sheet in his cell at HMP Wandsworth on 29 July 2014. The report identified concerns about bullying, extortion, inadequate risk management and communication, unsuitable cell allocation, staffing and training, and failings in resuscitation equipment 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
Inadequate medical staff training in resuscitation
Wider context from the report
“5. That training of medical staff in relation to Resuscitation is inadequate. ”
Source location
Robert John Richards · Prevention of Future Deaths report
Page 3 · concerns
Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

Data last updated 7 September 2026

What this concern includes

Trends

Reports mentioning this concern, over time

Concerns raised1

Lack of staff training in CPR

Linked responses

Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Concerns raised1

Failure to establish whether bank and agency staff hold current resuscitation training

Linked response

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3

Concerns raised1

Lack of frequent appropriate emergency resuscitation training

Linked response

Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Concerns raised1

Inadequate resuscitation training and emergency-equipment familiarity among the only available doctor

Concerns raised1

Lack of cardiopulmonary resuscitation training for school teaching assistants

Linked response

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

Concerns raised1

Inadequate neonatal resuscitation training

Linked response

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Minimal training for care staff in performing patient resuscitation

Linked responses

Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Stated actions 2

Stated actions 1

Respondent positions 3

Stated actions 4

Respondent positions 2

Stated actions 1

Respondent positions 1

Stated actions 2

Respondent positions 1