Recurring concern

Failure to reliably recognise hypostasis and rigor mortis

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First reported 29 Apr 2021•Latest report 10 May 2024

Definition

What this concern includes

Includes failures of staff knowledge, training, assessment or operational application specifically concerning recognition of hypostasis or rigor mortis when determining death or deciding whether resuscitation should continue or be initiated.

Not included

  • Excludes general death-verification or resuscitation-procedure failures where recognition of hypostasis or rigor mortis is not the identified deficiency.
  • Excludes recognition of other signs of death unless the report explicitly connects them to the same hypostasis or rigor-mortis recognition concern.
  • Excludes generic clinical, nursing, prison or first-aid training deficiencies that are not specifically tied to recognising hypostasis or rigor mortis.
  • Excludes failures occurring after death has been reliably established, including post-death investigation, certification or coronial processes.
  • Excludes the existing prison-specific concern about the overall reliability of prison death-verification procedures where the assertion does not specifically concern recognition of hypostasis or rigor mortis.
Reports
2

Distinct published reports

Individual concerns
3

A report can raise multiple concerns

Date range
2021–2024

First to latest report issue date

Stated actions
2

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.

Ministry of Justice1
Practice Plus Group1
Resuscitation Council UK1

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. Derby and Derbyshire

    AI-generated summary

    Paul Edward DAY · 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 Edward Day was found collapsed and unresponsive in a prison toilet cubicle on 22 March 2017 after exposure to cold running water from a broken pipe. Prison officers did not attempt CPR because they believed he was in rigor mortis; CPR was started about 15 minutes later, but he subsequently died in hospital in the early hours of 23 March. The principal concern was that national prison CPR guidance included rigor mortis as an exclusion, despite prison officers not being trained to recognise it, creating a risk that CPR could be withheld in prisons without 24-hour healthcare staffing.

    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 train prison officers to assess and recognise rigor mortis for CPR decisions

    Wider context from the report

    “1. I understand that the prison guidance re CPR which I have referenced, is in effect guidance provided nationally to all prisons. The inclusion of rigor mortis in the exclusions for CPR is something of an outlier as compared to the other reasons which would clearly and obviously evidence that death had occurred, even to someone without first aid training. In those prisons without 24-hour healthcare staffing prison officer staff are operating under guidance that they are not trained to be able to follow (re rigor mortis). In prisons with 24-hour healthcare staffing it is likely that healthcare staff would attend a resuscitation incident. 2. Given the current guidance, in those prisons without 24-hour healthcare staffing, and where prison officer staff attend a prisoner in a state of collapse who is not breathing and is pulseless, there is the clear potential to mistakenly assess the person to be in a state of rigor mortis, and thus miss the opportunity to undertake CPR and potentially prevent death, because quite clearly they have not been trained to assess for and recognise rigor mortis. This was very clearly illustrated in Mr Day’s inquest. 3. The current CPR guidance does not appear to be appropriate for those prisons without 24-hour healthcare staffing, and in my view presents the real risk that future deaths could occur unless action is taken. ”

    Source location

    Paul Edward DAY · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. South Yorkshire (Eastern)

    AI-generated summary

    Darren Adams · 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

    Darren Adams was transferred between prisons and, within 24 hours of arrival, experienced a deterioration in his mental health. He was found ligatured in his cell on 12 November 2017 and was declared dead at hospital on 13 November 2017; the inquest concluded that he died by suicide. Concerns included nursing staff misdiagnosing hypostasis and rigor mortis, insufficient training in identifying these conditions, and potentially confusing definitions in CPR guidance.

    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

    Insufficient nursing staff understanding of identifying hypostasis and rigor mortis

    Wider context from the report

    “1. The Nursing Staff misdiagnosed hypostasis. It was apparent in evidence that they did not have a sufficient understanding of the process and how to identify it. 2. The Nursing Staff misdiagnosed rigor mortis. It was apparent in evidence that they did not have a sufficient understanding of the process and how to identify it. ”

    Source location

    Darren Adams · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Insufficient life support training coverage of hypostasis and rigor mortis identification

    Wider context from the report

    “3. Management of the nurses accepted in evidence that more focus on the identification of those conditions should have been covered in better depth during the nurse’s life support training. ”

    Source location

    Darren Adams · 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

    Introduce mandatory ILS teaching on hypostasis, lividity and rigor mortis, including mandatory decision-making scenarios, through the revised curriculum from July 2021.

    Verbatim wording from the response

    “• Practice Plus Group mandates annual Intermediate Life Support Training (ILS) for all clinical staff in recognition of their critical role in providing pre hospital life support. Non clinical staff are trained in Basic Life Support and agency staff are required to have undertaken ILS training and can access the training provided by Practice Plus Group. The curriculum for PPG’s ILS training has been adapted by our training provider to include prison specific scenarios. The training is delivered by Resuscitation Council accredited trainers. Following this request, the training provider has spoken to staff who have been involved in resuscitation decision-making scenarios to hear their experiences and understand the issues that are faced, including the challenges of diagnosing hypostasis. Our training provider has amended the content of the previously provided ILS course to include:”

    Source location

    Response from Practice Plus Group
    Page 2 · response
    Published 4 May 2021

    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

    Teach clinical staff how to diagnose death.

    Verbatim wording from the response

    “Response: This guidance was issued by the National Offender Management Service (NOMS), Royal College of Nursing (RCN) and the Royal College of General Practitioners (RCGP) in March 2016. Therefore, the terminology sits outside the control of Practice Plus Group. For Practice Plus Group we will:”

    Source location

    Response from Practice Plus Group
    Page 3 · response
    Published 4 May 2021

    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

    Detailed training in recognising rigor mortis and hypostasis falls outside the scope of RCUK training courses.

    Verbatim wording from the response

    “6. Training and clinical experience are required to be able to reliably diagnose irreversible death based on the presence of rigor mortis and hypostasis. Detailed training in the recognition of rigor mortis and hypostasis is outside the scope of RCUK training courses.”

    Source location

    2021-0125-Response-from-Resuscitation-Council-UK_Published
    Page 2 · response
    Published 4 May 2021

    Open published response
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Data last updated 7 September 2026