Recurring concern

Unreliable on-site emergency medical and first-aid response arrangements

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First reported 25 Feb 2014•Latest report 20 Feb 2026

Definition

What this concern includes

Includes lack of required on-site medical or first-aid cover and failures of the dedicated procedure, access route or mechanism for obtaining that urgent assistance.

Not included

  • Ambulance attendance or hospital treatment delays after assistance has been summoned
  • Routine clinical care unrelated to an on-site emergency-response arrangement
  • Generic staffing or training deficiencies that do not impair on-site urgent assistance
Reports
33

Distinct published reports

Individual concerns
40

A report can raise multiple concerns

Date range
2014–2026

First to latest report issue date

Stated actions
35

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.

Care Quality Commission2
Department of Health and Social Care2
Health and Safety Executive2
HM Prison and Probation Service2
Ministry of Defence2
NHS England2
ABTA Ltd1
AITO - The Specialist Travel Association Ltd1
Blatchington Mill School1
Bourne Leisure Limited1
Brighton and Hove City Council1
Brunswick Gardens Village1
Capita Business Services Ltd1
Capita PLC1
Church Inn, Cheadle Hulme1

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. Inner North London

    AI-generated summary

    Sean Perry WILLIAMS · 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

    Sean Williams died in the back of a Serco van outside Thames Magistrates’ Court after suffering a fit during transport and then a cardiac arrest. Concerns included gaps in his custody healthcare assessment and treatment, inadequate Serco first-aid training and competence assessment, failure to provide timely first aid, unclear emergency procedures, and insufficient emphasis on preserving life.

    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

    Delays in opening a detainee cell and administering emergency first aid

    Wider context from the report

    “For the MPS The MPS had already recognised before inquest that, following Mr Williams’ detention, he was not seen by a custody nurse for 23 hours. However, there was another sub optimal element of his care that did not appear to have been identified. The custody nurse who reviewed Mr Williams on two separate occasions in the twelve hours immediately before he attended court, did not on the second occasion take any observations of Mr Williams’ vital signs before (or after) prescribing dihydrocodeine, and did not record any part of Mr Williams’ clinical picture. Despite having prescribed dihydrocodeine for drug withdrawal, when giving evidence in court the nurse was unable to describe the signs and symptoms of withdrawal. For Serco By 18.11 hours, the Serco van that was transporting Mr Williams had returned to the court car park entrance and the driver had got out of the cab and into the back of the van. At that point, neither the escort nor the driver opened the door to Mr Williams’ cell to administer first aid - at the very least to relieve his slumped, squashed position to try to deal with any potential airway obstruction. At 18.15 hours when he stopped showing any signs of life, they still did not open his door. They only opened his door at 18.23 hours, removing him from the cell at 18.24 hours, and administering chest compressions at 18.25 hours. The driver did not press the emergency button in the cab to alert the operations control centre of the situation. The Serco crew did call the London Ambulance Service from the van, but were unable to give the postcode of their location. I put it to the Serco driver that the focus of the two Serco crew members seemed to be on talking to the three other prisoners in their cells, on phone calls, in fact on anything except getting Mr Williams out of his cell to see if the crew could help him. The driver agreed. The Serco driver eventually administered chest compressions but could not face giving rescue breaths. He seemed to have forgotten that he had a face guard hanging from his belt. Despite evidence from Serco that they were satisfied with the first aid training that was given to the two officers, the jury found that: - the Serco first aid training was inadequate; - it did not include a video of a seizure; - it did not sufficiently emphasise the urgency of potentially life saving measures such as use of the recovery position; - the Serco assessment of the first aid knowledge and competence of its staff was inadequate; - Serco failed to provide clear guidance on the emergency button procedures; - Serco’s policy appeared to conflict with its training slides about whether staff should or are even permitted to drive a casualty direct to hospital; - Serco gave insufficient emphasis on urgency and the paramount importance of preserving life. ”

    Source location

    Sean Perry WILLIAMS · 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

    Revise relevant prisoner welfare, vehicle escort, death-in-custody and associated procedures, and align corresponding training materials.

    Verbatim wording from the response

    “Since the death of Mr Williams we have revised Standard Operating Procedure (SOP) 038 Prisoner Welfare on a Vehicle, SOP 009 Duties of a Vehicle Escort Officer and SOP 047 Death or attempted suicide of a prisoner in custody, to improve the clarity of the steps to be taken where a medical emergency is suspected and I understand copies of the updated SOPs have been provided to you. The changes have also been reflected in other SOPs and training documents to ensure consistency.”

    Source location

    Response from Serco
    Page 1 · response
    Published 24 February 2026

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Create and require staff to complete a separate online medical-emergency vehicle course covering emergency response, basic life support and related vehicle incidents, with an 80% pass threshold.

    Verbatim wording from the response

    “In addition, in order to remind staff of the required process and aid their retention of the information provided during the training, in March 2025 we created a new online course on Serco’s LMS. This is a mandatory course for all staff members and includes what to do in an emergency medical incident, basic life support, self-harm incidents, vehicle breakdown, fire and anything deemed a vehicle emergency. The content provides a refresher of the training covered in the ITC course, to reinforce learning and gives additional prominence by being a separate module and links together the concepts that staff have learned during their Highfield First Aid training.”

    Source location

    Response from Serco
    Page 3 · response
    Published 24 February 2026

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Develop and display laminated emergency-response flowcharts in escort vehicles to clarify required actions and support consistent responses.

    Verbatim wording from the response

    “As outlined by Serco’s Head of Professional Standards and Security in his evidence, and to support staff on scene in following the correct process, Serco has developed a flowchart for escort officers following the death of Mr Williams. A copy appears in the Inquest bundle. This has since been incorporated into training, and laminated copies are now displayed within all escort vehicles in a position visible from the escort seat. The intention is that this readily accessible guide will reinforce existing training, clarify the required steps, and support escort officers in responding with confidence and consistency during suspected medical emergencies.”

    Source location

    Response from Serco
    Page 4 · response
    Published 24 February 2026

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Develop and display an OCC emergency flowchart with structured prompt questions at controller desks to standardise alarm-activation responses.

    Verbatim wording from the response

    “Serco has also developed a corresponding flowchart for the OCC to reflect that provided to PCOs, together with structured prompt questions to assist OCC controllers in identifying the nature of an emergency and providing appropriate support and direction to PCOs when an incident occurs. A copy of the OCC flowchart has also been provided.”

    Source location

    Response from Serco
    Page 4 · response
    Published 24 February 2026

    Open published response

  2. South Yorkshire (Western)

    AI-generated summary

    Mark Townsend · 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

    Mark Townsend attended a football match at Hillsborough Stadium on 28 September 2024, suffered a cardiac arrest, and later died at Northern General Hospital; the medical cause of death was acute myocardial infarction due to coronary artery disease. The Court found that stewards took additional time to summon medical assistance because they did not know where to find the nearest staff member with a radio. It found that this delay did not cause or contribute to Mark’s death, but raised concerns that similar delays could contribute to future deaths.

    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 of stewards to know the location of the nearest radio

    Wider context from the report

    “Accepting staff are required to roam to deal with their duties, this position was not in line with those outlined on a map of radio locations produced to the Court. The CCTV footage shows the following events: • A West Bromwich Albion supporter spoke to a steward to raise the alarm. The steward initially climbed up the stairs to speak to supporters. • That steward signalled to a second steward to raise the alarm. • The second steward began to descend the stairs. • The first steward then began to descend the stairs. • Stewards one and two conversed with a group of other stewards at the bottom of the stairs leading to the W vomitory. • A steward then moved from the group of stewards the bottom of the stairs leading to the W vomitory and ran towards the group of stewards and steward supervisors at the bottom of the stairs leading to the X vomitory following which the call for medical assistance was made by a supervisor. The Court found that the actions of the stewards in moving to the bottom of the stairs leading to the W vomitory, before running towards the group of stewards and supervisors at the bottom of the stairs leading to the X vomitory, demonstrated that they did not know where to find a member of staff with a radio. The time between the second steward arriving at the group of people at the bottom of the stairs leading to the W vomitory, and the time the steward arrives at the group of stewards and supervisors at the bottom of the stairs leading to the X vomitory, was 20 seconds with the radio call being made 11 seconds later. The Court found this period of time did not cause or contribute to Mark’s death, but has concerns that delays caused by stewards not being aware where the nearest radio is could cause delays in summoning medical help in the future, and that may give rise to a risk of future deaths. ”

    Source location

    Mark Townsend · 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

    Continue steward training on radio locations and immediate communication during medical emergencies.

    Verbatim wording from the response

    “Stewards receive advance briefing information in the days prior to any match with information sent to them via an app. On matchdays stewards receive stand briefings from their supervisor/stand managers which are in turn informed by briefings given to those leaders by the Chief Steward, Safety Officers and medical leads. Briefings include ‘How to get help’ incorporating locations of radios, location of emergency phones, location of first aid responders and location of Fire Marshals.”

    Source location

    Response from Sheffield Wednesday Football Club
    Page 4 · response
    Published 20 October 2025

    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

    Continue enhanced pre-match briefings addressing radio accessibility and how to obtain help.

    Verbatim wording from the response

    “Stewards receive advance briefing information in the days prior to any match with information sent to them via an app. On matchdays stewards receive stand briefings from their supervisor/stand managers which are in turn informed by briefings given to those leaders by the Chief Steward, Safety Officers and medical leads. Briefings include ‘How to get help’ incorporating locations of radios, location of emergency phones, location of first aid responders and location of Fire Marshals.”

    Source location

    Response from Sheffield Wednesday Football Club
    Page 4 · response
    Published 20 October 2025

    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

    Regularly review radio positioning and distribution using operational experience.

    Verbatim wording from the response

    “The location of radio holders is planned and mapped. The location of radio holders is disseminated to stewards through their training, briefings and during emergency training scenarios.”

    Source location

    Response from Sheffield Wednesday Football Club
    Page 3 · response
    Published 20 October 2025

    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

    Continue testing and exercising emergency procedures, including radio and communications systems.

    Verbatim wording from the response

    “As a club we host and participate in large scale multi-agency emergency response training including large scale emergency incident scenarios. As part of this training radio and communications systems are trialled and tested.”

    Source location

    Response from Sheffield Wednesday Football Club
    Page 4 · response
    Published 20 October 2025

    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 brief delay was non-causative and does not indicate that the stadium’s radio arrangements are unsafe or unsuitable.

    Verbatim wording from the response

    “SWFC respectfully notes that the substantive findings of the inquest were positive in relation to the Club's safety arrangements and response to this incident and that there were no causative failings on the part of the Club. The inquest’s findings demonstrated that a radio call was made 63 seconds after a steward was first notified of the medical incident and a paramedic arrived with Mr Townsend approximately 3 minutes later, 1 minute 20 seconds after Mr Townsend’s cardiac arrest. The speed of the resultant medical response was found to have been in line with what might be expected had Mr Townsend suffered a cardiac arrest in a clinical hospital setting.”

    Source location

    Response from Sheffield Wednesday Football Club
    Page 1 · response
    Published 20 October 2025

    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 radio provision, training, procedures, inspections and emergency telephones are considered an effective and adequate response to communications risks.

    Verbatim wording from the response

    “The location of radio holders is planned and mapped. The location of radio holders is disseminated to stewards through their training, briefings and during emergency training scenarios.”

    Source location

    Response from Sheffield Wednesday Football Club
    Page 3 · response
    Published 20 October 2025

    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

    Leaving static unattended radios around the stand is not considered practical or safe; the emergency telephone is the static contact method.

    Verbatim wording from the response

    “incidents that might occur and so that radios can be moved into position to deal with developing situations. Stand Managers and Steward Supervisors liaise with one another to ensure that a radio holder presence is always maintained on the lateral walkway even if one of them is called away to attend to an incident. It is not considered practical or safe to leave static unattended radios around the stand. The emergency telephone serves as the static means of contacting the control room.”

    Source location

    Response from Sheffield Wednesday Football Club
    Page 4 · response
    Published 20 October 2025

    Open published response

  3. Inner North London

    AI-generated summary

    Gabriella Omolabake Torisheju JAYIESIMI · 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

    Gabriella Omolabake Torisheju Jayiesimi suffered seizures and a cardiac arrest at a Tesco supermarket on 24 January 2025 and died a month later from the hypoxic brain injury sustained during the arrest. The concerns included the absence of effective first aid and CPR, failure to recognise that she had stopped breathing, failure to check her pulse or use a defibrillator, and inadequate first-aid training and preparedness among relevant Tesco and security staff.

    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 identify and deploy the available trained first aider

    Wider context from the report

    “I heard that it was the duty manager’s choice not to be first aid trained. She said that she did not like blood and was afraid of the responsibility of a paramedic. However, on further exploration she said that she would like to be able to recognise a person not breathing and she would like to be able to administer basic first aid. TSS 4. The TSS security officer was first aid trained, but did not tell anyone that he was first aid trained. He told me repeatedly that his job was simply to do whatever the duty manager told him to do. Despite being the only first aider present, he took no responsibility at scene. He failed to offer Ms Jaiyesimi or the duty manager any meaningful support at all. ”

    Source location

    Gabriella Omolabake Torisheju JAYIESIMI · Prevention of Future Deaths report
    Page 3 · 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

    Unavailability of a Tesco first aider at Colney Hatch

    Wider context from the report

    “When Gabriella Jaiyesimi suffered a cardiac arrest – Tesco 1. There was no Tesco first aider working at Colney Hatch. 2. The TSS security officer was first aid trained, but none of the Tesco staff knew that. 3. All staff, including the TSS security officer, properly understood the Tesco policy of calling the duty manager to assess such an emergency and decide upon the correct course of action, but the duty manager charged with this responsibility had no CPR or first aid training. She told me that most of the Tesco duty managers were not CPR or first aid trained. ”

    Source location

    Gabriella Omolabake Torisheju JAYIESIMI · Prevention of Future Deaths report
    Page 3 · 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

    Tesco’s own store first-aider provision is considered sufficient; T.S.S officers are not contractually required to provide first aid.

    Verbatim wording from the response

    “Regarding the relationship between Tesco PLC and T.S.S security officers, we consider it important to clarify that the security officer was not employed as a first-aider and there has never been, nor is there currently, a contractual requirement by Tesco PLC for T.S.S security officers to provide first aid to Tesco employees or members of the public in Tesco stores. This is on the basis that Tesco has its own provision for first-aiders within its stores who are called to any medical emergency. There are no current T.S.S employees who hold a role as a Tesco first-aider.”

    Source location

    Response from Total Security Services
    Page 2 · response
    Published 5 September 2025

    Open published response

  4. Teesside and Hartlepool

    AI-generated summary

    Gary Lee JAMES · 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 Lee James died at James Cook University Hospital on 11 January 2019 from injuries sustained when metal frames fell on him while he was trying to move them at Ward Bros. The report identified concerns including inadequate risk assessment, training, equipment, supervision and first-aid provision, as well as failures to address employees’ safety concerns and unsafe working 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

    Unavailability of trained first aider assistance before emergency services arrive

    Wider context from the report

    “9. No first aid assistance was provided by a trained first aider before the arrival of the emergency services. ”

    Source location

    Gary Lee JAMES · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  5. Manchester South

    AI-generated summary

    Nathan Harry 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

    Nathan Harry Shepherd died in hospital on 16 January 2024 after being found suspended from a ligature in his room at approved premises, following an unsuccessful attempt to gain immediate entry because the room had been barricaded. The inquest concluded that the death was suicide, with medical cause of death recorded as hypoxic brain injury and hanging. Concerns included the lack of policies and training for barricaded-room incidents, movable furniture that enabled barricading, ligature points, inadequate assurance of agency staff first-aid and CPR capability, and ineffective sharing of risk information.

    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 verify agency staff competence to deliver CPR and First Aid

    Wider context from the report

    “5. Agency staff were used under a national contract. The evidence before the inquest was that at the time of Mr Shepherd’s death there was no policy for ensuring they could deliver CPR / First Aid. It was part of the national contract that they should be so trained but there were no checks to ensure that this part of the contract was being followed. The evidence at the inquest was that the agency worker in place on the night did not appear able to deliver CPR. ”

    Source location

    Nathan Harry SHEPHERD · 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

    Bring Approved Premises night shifts in house when the external Double Waking Night Cover contract ends in March 2026.

    Verbatim wording from the response

    “The Double Waking Night Cover contract with external agencies is due to come to an end in March 2026 and thereafter night shifts at Approved Premises will no longer be contracted out and will be brought in house. This will ensure that all staff will be trained in accordance with HMPPS requirements, which includes First Aid, CPR and use of the defibrillator. There are already pilots in place across the country looking to this new arrangement. Where this service is still being delivered by external agencies, it will be part of the contract management process to monitor compliance with the contractual term that requires the agency staff to be fully trained to the standard required by HMPPS.”

    Source location

    Response from HMPPS
    Page 2 · response
    Published 22 January 2025

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Monitor external agency compliance with contractual requirements for HMPPS-standard training, including First Aid, CPR and defibrillator use.

    Verbatim wording from the response

    “The Double Waking Night Cover contract with external agencies is due to come to an end in March 2026 and thereafter night shifts at Approved Premises will no longer be contracted out and will be brought in house. This will ensure that all staff will be trained in accordance with HMPPS requirements, which includes First Aid, CPR and use of the defibrillator. There are already pilots in place across the country looking to this new arrangement. Where this service is still being delivered by external agencies, it will be part of the contract management process to monitor compliance with the contractual term that requires the agency staff to be fully trained to the standard required by HMPPS.”

    Source location

    Response from HMPPS
    Page 2 · response
    Published 22 January 2025

    Open published response

  6. Inner North London

    AI-generated summary

    Nonie Atshiki · 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

    Nonie Atshiki, aged 35, was found dead in the stairwell of the hostel where she lived shortly after 4am on 13 July 2024. Her medical cause of death was acute cardiac failure associated with cocaine use and long-term alcohol excess. The report raised concerns that the hostel’s night concierge had no first aid training from St Mungo’s, there was no defibrillator, and no cardiopulmonary resuscitation was attempted after her discovery.

    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 night staffing to support resuscitation while maintaining other essential duties

    Wider context from the report

    “I heard evidence at inquest that the night concierge who found Ms Atshiki had not had any first aid training from St Mungo’s. He said that he had undergone first aid training elsewhere in the past, but he did not know whether the hostel had a defibrillator. It did not. Whilst not relevant in this case, I was told that the hostel does stock naloxone (used in the emergency treatment of opiate/opioid toxicity), but that the night concierge is not trained in its use. The evidence at inquest was that there are only ever two members of staff working at the hostel at night, of which the night concierge is one. After Ms Atshiki’s discovery, the night concierge stayed with her as she lay across the stairs, while the other member of staff stayed by the front door to open it when the ambulance service arrived. Nobody at the hostel attempted to perform cardiopulmonary resuscitation on Ms Atshiki. There is no evidence that if CPR had been performed it would have changed the outcome for Ms Atshiki. However, in another situation it might. And in another situation it might be the second member of staff who falls ill. That would only leave the night concierge to attempt resuscitation. ”

    Source location

    Nonie Atshiki · Prevention of Future Deaths report
    Page 2 · 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

    Existing staffing models are considered sufficient to run services safely, with at least two waking night staff in many high-support services.

    Verbatim wording from the response

    “Response: In terms of staffing levels, it should be noted that we, St Mungo’s, develop and review our staffing models within each of our service contracts at the start and before any extension of a contract. In many of our high support services, we have a minimum of two staff members working at night, who undertake waking night shifts (on site and awake at all times), and who”

    Source location

    Response from St Mungo's
    Page 12 · response
    Published 18 December 2024

    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

    Financial constraints in commissioned contracts prevent adding a third night worker where preferable but not considered essential.

    Verbatim wording from the response

    “support the safe running of the service. We always ensure that our proposed staffing model will allow the service to be run safely, before bidding, accepting or delivering any service contract. However, it is also important to note that due to the nature of the financial environment within which we are commissioned, and the significant financial pressures that Local Authorities who often commission us face, there are significant and growing pressures to meet financial envelopes dictated by those commissioning our services. This sometimes means that in services where it might be preferable, but not necessarily essential, to have a third staff member on shift in the rota, we are unable to do so due to the financial constraints of the contract.”

    Source location

    Response from St Mungo's
    Page 13 · response
    Published 18 December 2024

    Open published response

  7. Inner North London

    AI-generated summary

    Nimo OSMAN · 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

    Nimo Osman was in state detention under a Hospital Order and receiving psychiatric inpatient care when she collapsed on the ward on 21 April 2022. She was unresponsive for over half an hour before an ambulance was called and died in hospital on 23 April 2022 from hypoxic ischaemic brain injury. The principal concerns were delays in recognising the emergency and calling an ambulance, whether learning had been embedded among staff, completion of venous thromboembolism assessments, and ambiguity in the Trust’s venous thromboembolism policy.

    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 activate the emergency alarm system to summon the rapid response team promptly

    Wider context from the report

    “Following the discovery of Ms Osman’s collapse on Rosebank Ward on 21 April 2022, it took staff a significant number of minutes to recognise that instead of just lying on the floor, Ms Osman was actually unrousable. A few minutes later a nurse arrived on the scene, who decided to summon the duty senior nurse (DSN) by radio, rather than activating the alarm system, which would have summoned the rapid response team sooner. The DSN contacted the duty doctor to inform them that there was a medical emergency, prior to calling an ambulance. In total, Ms Osman had been on the floor and unresponsive for over half an hour before an ambulance was called. I also viewed the CCTV evidence covering this course of events. I heard evidence from a consultant neurosurgeon and a consultant neuroradiologist. Their evidence was such that, in Ms Osman’s case this delay would not have made a difference because she had suffered a catastrophic brain injury and her condition was likely to have been unsalvageable from the moment she was found unresponsive on the floor. However, I consider that a delay of circa 30 minutes in calling an emergency ambulance raises a considerable risk, if repeated in the case of another patient requiring emergency treatment at hospital. I was initially reassured by the evidence of a very senior member of nursing staff (Nurse A) about the work that has been done to educate all staff that anyone can call 999 for an ambulance if they consider it necessary, without seeking the advice of colleagues or the specific approval of a doctor. I was told by Nurse A that they were confident that the education and training undertaken with staff had had a positive impact and that a delay of this kind was unlikely to be repeated in the future. However, a senior nurse (Nurse B) who was on duty at the time of Ms Osman’s collapse told me in their evidence (over two years after Ms Osman’s death) that nursing staff cannot and would not call an ambulance of their own volition. Nurse B told me that she would only ever call an ambulance if told to do so by a more senior clinician. Nurse B went on to tell me that it was often the case that by the time an ambulance had been called and arrived, a patient would die; the manner in which this evidence was given led me to form the view that the Nurse B seemed to think that this was ‘just one of those things that happens’. While I was told by Nurse A (who seemed genuinely concerned) that this matter would be escalated and addressed, I was concerned that over two years since Ms Osman’s death this view was still held by a senior and experienced member of the nursing team who led a team of more junior nurses. My concern was such that I am not reassured that sufficient steps have been taken to prevent the recurrence of such a risk in the future. ”

    Source location

    Nimo OSMAN · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  8. Central and South East Kent

    AI-generated summary

    Oliver Steeper · 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

    Oliver Steeper choked on finely chopped pasta bolognaise at a nursery on 23 September 2021 and died on 29 September 2021 after suffering a hypoxic/ischaemic brain injury. The report raises concerns about the number and validity period of paediatric first-aid qualifications available at nurseries, the standard of first aid provided, and staff education and systems for assessing and recording babies’ weaning stages.

    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 numbers of qualified paediatric first aiders present on site

    Wider context from the report

    “1. Paediatric First Aid (PFA) Requirements I have heard evidence during the course of the inquest that the Early Years Foundation Stage Statutory Framework For Group and School-Based Providers stated that of all the staff on site “at least one” member of staff must have a valid paediatric first aid certificate. Whilst I accept that providers could potentially have more, there is a risk that there is only one PFA certified member of staff on site, and that this would still be compliant within the framework mandate. If there is only one PFA certified staff member, they may be solely responsible for providing first aid for all the children on site. If that one staff member is unavailable or indisposed when an emergency situation arises, or simply is unable to render the required first aid by nature of the traumatic events unfolding, this may in turn have a serious and detrimental effect on the child requiring assistance. Other staff members, who perhaps have not had recent PFA training, or staff with no PFA training at all, may have to urgently deal with the evolving situation. There is always a risk that young children, particularly weaning babies like Oliver, will require emergency first aid due to sudden choking. In the 20 years between 2001 and 2021, the Office for National statistics recorded 40 deaths due to choking in infants (children aged less than one year) in England and Wales. I am concerned that the Framework does not mandate an increased number of qualified paediatric first aiders to be present on site. I have reviewed the current EYFS statutory framework, published 8th December 2023 and updated 4th January 2024. This contains the same provision as that which was in force at the time of Oliver’s death in 2021. See paragraph 3.29. ”

    Source location

    Oliver Steeper · 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

    Complete the EYFS safeguarding consultation and use its findings to develop proposed safer-eating requirements.

    Verbatim wording from the response

    “12. The requirements outlined above when implemented together should ensure that there is a PFA member of staff available and ready to respond to incidents quickly. However, the Department recognises the importance of staff members being PFA trained, especially whilst children are eating, which is why in the recent EYFS safeguarding consultation which closed on 17 June 2024, we have put forward the following proposals:”

    Source location

    Response from Department for Education
    Page 4 · response
    Published 31 May 2024

    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 staffing, supervision and paediatric first-aid requirements should ensure a trained responder is available quickly during emergencies.

    Verbatim wording from the response

    “‘3.30. Providers should take into account the number of children, staff, and layout of premises to ensure that a paediatric first aider is able to respond to emergencies quickly.’”

    Source location

    Response from Department for Education
    Page 3 · response
    Published 31 May 2024

    Open published response

  9. Derby and Derbyshire

    AI-generated summary

    Thomas Roy LANGLEY · 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

    Thomas Roy Langley was found collapsed in a hotel room and died at the hotel on 22 May 2019 after taking toxic levels of MDMA. The report raised concerns about the absence of a fully trained first-aid employee on site overnight and the lack of basic first-aid training and refresher courses for all staff.

    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 a fully trained first-aid employee on site throughout the day and night

    Wider context from the report

    “1. There is no fully trained First aid trained employee on site at a Travel Lodge hotel premises for 24 hours of the day; at present there is a fully trained first aid employee on site from only 7am to 7pm. Emergency medical situations could present themselves between after 7pm and 7am and when there is only 1 Travel Lodge employee on the premises. 2. All staff employees do not presently have basic first aid training with regular follow up refresher courses. i.e. they do not have both online AND face to face practical training to assess and handle emergency medical situations that may present themselves day or night - situations that may cause an employee and residents staying at a Travel Lodge to panic. It may be the case that they have a lack of understanding of the present first aid training. This training is key at night when there is only 1 member of staff on site at a Travel Lodge hotel premises. ”

    Source location

    Thomas Roy LANGLEY · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Extend basic first-aid training to all reception team members, including night-shift staff, by working through delivery logistics and implementing the training.

    Verbatim wording from the response

    “However, in light of your concerns, we have decided to extend the level of training given to all reception team members, including those who cover the night shift, to include the basic level of first aid training currently provided to our management teams. This will result in over 3,500 extra Travelodge team members being provided with basic first aid training, and will ensure that there will always be a team member on duty that has had a basic level of first aid training 24hrs a day. We are currently working through the logistics of providing”

    Source location

    Response from Travelodge
    Page 2 · response
    Published 25 January 2024

    Open published response

  10. Essex

    AI-generated summary

    Sharon Elizabeth Langley · 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

    Sharon Elizabeth Langley, an inpatient with Severe Depressive Disorder and Psychosis, died by immersion in water while unsupervised in an assisted bathroom at Princess Alexandra Hospital on 10 August 2019. The principal concerns included failures in the immediate emergency response, inadequate communication and coordination, shortcomings in bathroom and high-risk-area safety measures, confusion about bath-plug controls, unreliable investigation and learning processes, and inadequate record keeping and risk documentation.

    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 of trained staff to provide basic life support assistance

    Wider context from the report

    “(1) Essex Partnership NHS Foundation Trust staff immediate emergency response was not followed: a. pinpoint alarms were not activated immediately on finding Sharon Langley unresponsive b. there was a delay calling the ambulance and basic key information about the type of the emergency was not relayed: i. by qualified nurses who made the 999 calls, or ii. to paramedics on attendance c. there was a delay informing the site co-ordinator of the emergency even though she was based on the ward and there was a lack of co-ordination of the emergency resulting in the ambulance being called a second time by the site co-ordinator d. staff trained in basic life support did not assist the two nurses who were attempting to resuscitate Sharon Langley ”

    Source location

    Sharon Elizabeth Langley · 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 drop-in refresher life-support training for clinical and administrative staff, emphasizing immediate help-seeking and pinpoint-alarm use.

    Verbatim wording from the response

    “- EPUT’s Head of Deteriorating Patient Pathways and Resuscitation Training Officer is working closely with mental health wards to facilitate drop-in ‘refresher’ life support training for clinical and administrative staff dealing with emergency situations. During”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 1 · response
    Published 7 March 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Conduct a medical-emergency simulation with Derwent Centre staff and share incident learning for incorporation into current training.

    Verbatim wording from the response

    “- The issue of calling for help as soon as possible is also shared during the weekly ‘virtual’ drop-in sessions which focus on the deteriorating patient. Head of Deteriorating Patient Pathways and Resuscitation Training Officer will continue to work with staff at the Derwent Centre to conduct a medical emergency simulation with the team and the importance of calling for help at the earliest possible opportunity is relayed during the post simulation feedback. In addition, the Trust’s training team have shared details of the learning from this incident and request for incorporation and sharing within the current training programme (1b, 1c).”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 2 · response
    Published 7 March 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Share emergency-response learning through basic-life-support and grab-bag training, including prompt notification of the Site Coordinator and Doctor.

    Verbatim wording from the response

    “- The importance of informing the Site Coordinator and Doctor, at the time of the medical emergency, will be shared and highlighted by our colleagues who currently deliver the basic life support and grab bag training. In addition, any learning (examples of good practice or areas for improvement) which derives from a medical emergency, can be shared as part of the training (1c).”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 2 · response
    Published 7 March 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Review the business case for creating an in-house faculty to deliver Immediate Life Support training and consider faculty development system-wide.

    Verbatim wording from the response

    “- A business case, for the creation of an in-house faculty, to deliver the gold standard Resuscitation Council UK ‘Immediate Life Support’ (RCUK ILS) training to EPUT staff has recently been presented to the Executive Team for their approval. The business case will be reviewed again in June 2023 in order to explore the faculty development as part of the system wide consideration. The RCUK ILS training focuses on leadership and task allocation during a medical emergency (1b, 1c, 1d).”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 2 · response
    Published 7 March 2023

    Open published response
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Data last updated 7 September 2026