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
Individual concerns: 40
Date range: 2014–2026
Stated actions: 35

Reports 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 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.

24 Oct2022
Birmingham and Solihull
Concerns raised2
1. Lack of a mechanism to broadcast a medical emergency by tannoy at the base
2. Lack of a system for obtaining urgent medical attention at the Lichfield base
This report raised 17 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Issue revised Standing Operating Instruction 20 governing responses when candidates become unwell during assessment-centre events.
  Stated by Capita PLC and Ministry of DefenceStated completed
2. Action
  Maintain generic exertional-collapse clinical policy and review it annually for coherence with Sickle Cell Trait guidance.
  Stated by Capita PLC and Ministry of DefenceStated completed
3. Action
  Incorporate exertional-collapse scenarios into Defence Medic training to support early differential diagnosis and appropriate intervention.
  Stated by Capita PLC and Ministry of DefenceStated in progress
AI-generated summary

Kamil Iddrisu and Youngson Nkhoma · 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

Kamil Iddrisu and Youngson Nkhoma collapsed during separate military selection runs at Whittington Barracks and later died after being taken to hospital. Both were found to have metabolic acidosis, acute kidney injury, rhabdomyolysis and sickle cell trait; the final causes of death remained under investigation, with the most likely cause of collapse described as sickle cell trait combined with military exercise. The principal concern was the risk of death or harm to non-UK selection candidates, including the need to consider screening for sickle cell trait.

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 mechanism to broadcast a medical emergency by tannoy at the base
Wider context from the report
“Sickle cell trait (SCT) screening process and identifying SCT in candidates: 1. The Inquest heard evidence that since these tragedies there had be 12 (13 as one incident includes 2 people) near misses where the process that had been put in place following these tragedies had not be followed. This resulted in 3 candidates at High Risk for SCT according to their family origins questionnaire undertaking the 2km run. 1 of these had self-identified to a Group Leader prior to the exercise but was directed to complete the RFT(E) run element in any case. This raises a concern about the screening process may be safe and effective. 2. The inquest was told that the Air force and Navy are not screening any candidates for SCT. The Army are. Both services are recruiting from the Commonwealth. Medical evidence at the inquest confirmed screening was the only way to safely identify candidates at risk. This raises a concern that the recruitment process is not safe and effective. Training and Education 1. The near miss incidents lead to a concern that staff involved in the selection process and RFT assessments are still not aware of the risk associated with SCT given that in one case the person was directed to undertake the run despite knowing he was at high risk of developing exertional rhabdomyolysis associated with SCT. 2. The lack of screening in the Navy and Air Force leads to a further concern about the level of understanding regarding the risks associated with SCT – the evidence at the inquest said this risk was unpredictable . 3. The inquest heard evidence that there is no standardised way to identify SCT candidates who are going through the selection process as the different services were considering using different colours wrist bands in different services. The raises a concern about the ability to identify those candidates who have SCT. 4. There should be a review of the wording used and rationale for including questions for candidates regarding ‘cola coloured urine’ in the PMSA. Dr Gupta, an expert haematologist at the inquest, informed the court that this is not always a sign of SCT as an individual can get cola urine from hepatitis. This raises a concern about the level of understanding of the significant of "cola coloured urine" and what it might indicate. Reporting and investigation 1. The inquest heard how Capita have set up a clinical oversight board to review any incidents. First this board did not appear to have reviewed or audited any of the near misses referred to above and second it does not include a representative from the Army. This raises concerns about the lack of joined up thinking for an incident between Capita and the army and the safety of the new process. 2. Reporting of incidents: the majority of the 12 near misses were not investigated at the time they occurred which indicates the present process is not safe and effective. 3. There is no system to audit whether incidents are being correctly processed and investigated. 4. The reporting system continues to use two parallel reporting forms for Capita (Casper) and the Army (Durals). These are on separate IT systems. This raises a concern that there is no "one version of the truth". The inquest heard evidence that Capita were unclear if they had resolved the issue in their Casper system associated with the drop down menu options and the fact that non work related incidents close investigations automatically. 5. It was unclear from the evidence whether the Recruiting Group has a clear identifiable person to take responsibility for the review health and safety incidents and to ensure adequate investigation is undertaken. Specifically it was still not clear that any oversight of the medical incidents fell within the remit of the Capita Head of Health and Safety. 6. It was unclear from the evidence whether the Recruiting Group act as one entity regarding health and safety issues with a clear lines of responsibility for global risk assessment (and promoting information gathering & investigation) of incidents of any nature. The Inquest heard evidence that ‘H&S at work’ is considered differently to any medical risk, which is supported by the lack of investigation of the near misses. Medical response: 1. Inquest heard how Lichfield had specialist medical staff on site in the medical training unit but there was no system for getting urgent medical attention on the base if needed. There was no mechanism to put a tannoy out for a medical emergency but the Inquest heard evidence that this could be done for a cake sale. 2. All the services should consider whether there should be a generic policy for the treatment of exertional collapse (of any cause) as per US Army where during training there is a clear medical plan with availability of essential medical treatment (eg oxygen and fluids) before hospitalisation. ”
Source location
Kamil Iddrisu and Youngson Nkhoma · 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
Lack of a system for obtaining urgent medical attention at the Lichfield base
Wider context from the report
“Sickle cell trait (SCT) screening process and identifying SCT in candidates: 1. The Inquest heard evidence that since these tragedies there had be 12 (13 as one incident includes 2 people) near misses where the process that had been put in place following these tragedies had not be followed. This resulted in 3 candidates at High Risk for SCT according to their family origins questionnaire undertaking the 2km run. 1 of these had self-identified to a Group Leader prior to the exercise but was directed to complete the RFT(E) run element in any case. This raises a concern about the screening process may be safe and effective. 2. The inquest was told that the Air force and Navy are not screening any candidates for SCT. The Army are. Both services are recruiting from the Commonwealth. Medical evidence at the inquest confirmed screening was the only way to safely identify candidates at risk. This raises a concern that the recruitment process is not safe and effective. Training and Education 1. The near miss incidents lead to a concern that staff involved in the selection process and RFT assessments are still not aware of the risk associated with SCT given that in one case the person was directed to undertake the run despite knowing he was at high risk of developing exertional rhabdomyolysis associated with SCT. 2. The lack of screening in the Navy and Air Force leads to a further concern about the level of understanding regarding the risks associated with SCT – the evidence at the inquest said this risk was unpredictable . 3. The inquest heard evidence that there is no standardised way to identify SCT candidates who are going through the selection process as the different services were considering using different colours wrist bands in different services. The raises a concern about the ability to identify those candidates who have SCT. 4. There should be a review of the wording used and rationale for including questions for candidates regarding ‘cola coloured urine’ in the PMSA. Dr Gupta, an expert haematologist at the inquest, informed the court that this is not always a sign of SCT as an individual can get cola urine from hepatitis. This raises a concern about the level of understanding of the significant of "cola coloured urine" and what it might indicate. Reporting and investigation 1. The inquest heard how Capita have set up a clinical oversight board to review any incidents. First this board did not appear to have reviewed or audited any of the near misses referred to above and second it does not include a representative from the Army. This raises concerns about the lack of joined up thinking for an incident between Capita and the army and the safety of the new process. 2. Reporting of incidents: the majority of the 12 near misses were not investigated at the time they occurred which indicates the present process is not safe and effective. 3. There is no system to audit whether incidents are being correctly processed and investigated. 4. The reporting system continues to use two parallel reporting forms for Capita (Casper) and the Army (Durals). These are on separate IT systems. This raises a concern that there is no "one version of the truth". The inquest heard evidence that Capita were unclear if they had resolved the issue in their Casper system associated with the drop down menu options and the fact that non work related incidents close investigations automatically. 5. It was unclear from the evidence whether the Recruiting Group has a clear identifiable person to take responsibility for the review health and safety incidents and to ensure adequate investigation is undertaken. Specifically it was still not clear that any oversight of the medical incidents fell within the remit of the Capita Head of Health and Safety. 6. It was unclear from the evidence whether the Recruiting Group act as one entity regarding health and safety issues with a clear lines of responsibility for global risk assessment (and promoting information gathering & investigation) of incidents of any nature. The Inquest heard evidence that ‘H&S at work’ is considered differently to any medical risk, which is supported by the lack of investigation of the near misses. Medical response: 1. Inquest heard how Lichfield had specialist medical staff on site in the medical training unit but there was no system for getting urgent medical attention on the base if needed. There was no mechanism to put a tannoy out for a medical emergency but the Inquest heard evidence that this could be done for a cake sale. 2. All the services should consider whether there should be a generic policy for the treatment of exertional collapse (of any cause) as per US Army where during training there is a clear medical plan with availability of essential medical treatment (eg oxygen and fluids) before hospitalisation. ”
Source location
Kamil Iddrisu and Youngson Nkhoma · 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
Issue revised Standing Operating Instruction 20 governing responses when candidates become unwell during assessment-centre events.

Verbatim wording from the response
“Following the request, Recruiting Group has issued revised guidance (Standing Operating Instructions 20), which details how to respond if a candidate becomes unwell during an Assessment Centre event. The document details that Recruiting Group Doctors (Capita staff) should assist in an emergency as a ‘Good Samaritan’ drawing upon paragraph 26 of the General Medical Council’s ‘Good Medical Practice’ guidance which states that ‘You must offer help if emergencies arise in clinical settings or in the community, taking account of your own safety, your competence and the availability of other options for care’.”

Source location
2019-0416 - Response from Secretary of State for Defence and Capita
Page 17 · response
Published 30 December 2019
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
Maintain generic exertional-collapse clinical policy and review it annually for coherence with Sickle Cell Trait guidance.

Verbatim wording from the response
“There is joint clinical policy in place for exertional collapse including Joint Service Publication 950 Leaflet 2-4-4: Exertional Heat Illness: Acute Treatment (v1.3 February 2022).”

Source location
2019-0416 - Response from Secretary of State for Defence and Capita
Page 18 · response
Published 30 December 2019
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
Incorporate exertional-collapse scenarios into Defence Medic training to support early differential diagnosis and appropriate intervention.

Verbatim wording from the response
“Work is under way with the Defence Medical Academy to ensure Defence Medic training (our most likely first responders) incorporates exertional collapse scenarios to ensure early differential diagnosis, particularly where this requires any specific interventions (for example, cooling with heat illness).”

Source location
2019-0416 - Response from Secretary of State for Defence and Capita
Page 18 · response
Published 30 December 2019
Open published response
25 Aug2022
Black Country
Concerns raised1
1. Unavailability of a registered first aider on the premises
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Provide formal first-aider training to four employees.
  Stated by Hibiscus Housing Association LimitedStated planned
2. Action
  Introduce a formal first-aid duty rota after the four employees complete first-aider training.
  Stated by Hibiscus Housing Association LimitedStated planned
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
Unavailability of a registered first aider on the premises
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
Provide formal first-aider training to four employees.

Verbatim wording from the response
“On 17 October 2022 all employees of Hibiscus undertook First Aid Workplace Awareness training provided by High Speed Training. Additionally, four employees of Hibiscus will undertake First Aider Training via St John’s Ambulance which is scheduled for the end of October.”

Source location
Response from Hibiscus House
Page 2 · 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
Introduce a formal first-aid duty rota after the four employees complete first-aider training.

Verbatim wording from the response
“There is no formal first aid duty rota in place, however with all staff being trained and the overlap of shifts which cover the week, there will always be at least one person who has first aid awareness on site. After the four employees have undertaken First Aider Training with St John’s Ambulance, a formal rota will be put in place.”

Source location
Response from Hibiscus House
Page 2 · response
Published 4 November 2022
Open published response
28 Jul2022
South Yorkshire (Western)
Concerns raised1
1. Unavailability of an advanced first aider on site during emergencies
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Brian Parry · 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

Brian Parry died at Brunswick Retirement Village on 3 November 2021 after choking on food. The report identified delays in calling emergency services, an emergency cord system that did not alert nearby staff, limited confidence in first-aid training, and no advanced first aider available on site.

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 an advanced first aider on site during emergencies
Wider context from the report
“I am concerned that there is not an advanced first aider on site available to be called upon in an emergency ”
Source location
Brian Parry · Prevention of Future Deaths report
Page 2 · concerns
Open source report
16 Jun2022
West Sussex
Concerns raised3
1. Lack of a written procedure for making a 999 emergency call
2. Lack of a written procedure for obtaining first aid help quickly
3. Unavailability of an external phone line for emergencies
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

James Joseph MANNING · 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

James Joseph Manning, aged two, choked on a piece of sausage at Butlins, Bognor Regis, on 6 June 2018, suffered a cardiac arrest and hypoxic ischaemic brain injury, and died in hospital on 20 June 2018. The concerns included delays and weaknesses in healthcare referral, follow-up and information-sharing systems, and shortcomings in the management of health and safety, incident reporting, first-aid provision and emergency procedures at Bourne Leisure sites.

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 written procedure for making a 999 emergency call
Wider context from the report
“e) Witnesses confirmed that there was no written standard operating procedure setting out how staff can get first aid help quickly as well as when and how to make a 999-emergency call especially if a trained first aider is not immediately available. ”
Source location
James Joseph MANNING · 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
Lack of a written procedure for obtaining first aid help quickly
Wider context from the report
“e) Witnesses confirmed that there was no written standard operating procedure setting out how staff can get first aid help quickly as well as when and how to make a 999-emergency call especially if a trained first aider is not immediately available. ”
Source location
James Joseph MANNING · 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 an external phone line for emergencies
Wider context from the report
“d) I was concerned to hear evidence that many months after this tragic incident during Tots Week, installation of an external phone line and sufficient AEDs in key areas such as restaurants and swimming pool areas had not been completed. ”
Source location
James Joseph MANNING · Prevention of Future Deaths report
Page 3 · concerns
Open source report
10 Jun2021
Manchester South
Concerns raised1
1. Failure to provide first-aid-trained staff and a first-aid kit
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Emiel Ariel Malinski · 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

Emiel Ariel Malinski attended a miniature rifle range on 2 November 2020, where he fired a rifle in the direction of his right temple and later died in hospital. The report recorded that he died as a consequence of suicide and raised concerns about the limited regulation of miniature rifle ranges, including the absence of requirements for supervision, secure weapons, ammunition control and first-aid provision.

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 provide first-aid-trained staff and a first-aid kit
Wider context from the report
“It is a matter of concern that the continued existence and operation of s11 (4) Firearms Act 1968 enables miniature rifle ranges to operate with no minimal regulation, with attendees able to fire miniature rifles and ammunition not exceeding .23 calibre and air weapons in a largely unregulated environment. In addition, it is a matter of particular concern that the following specific requirements do not currently apply to miniature rifle ranges: 1) Requirement for the user to sign a prohibited person (Section 21) declaration on each and every visit; 2) Requirement for the weapon to be securely tethered so that any projectile discharged from it can only be ‘down range’; 3) Requirement for a competent Range Conducting Officer (“RCO”) to be present on the range at all times to enable effective supervision of the shooter; 4) Requirement for the weapon to be loaded for the customer by the RCO or other member of staff so ammunition may be accounted for; 5) Requirement for the RCO or other member of staff present to be first aid trained with a first aid kit present; 6) Requirement for any weapon or ammunition used on the range to be kept secure, controlled and supervised by a member of staff at all times. ”
Source location
Emiel Ariel Malinski · Prevention of Future Deaths report
Page 2 · concerns
Open source report
2 Mar2020
North East Kent
Concerns raised1
1. Unclear guidance for obtaining anaesthetic help in paediatric emergencies
This report raised 19 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions 1
1. Position
  The Trust is responsible for setting out and implementing actions to address the identified maternity-service safety risks.
  Stated by Department of Health and Social CareRedirects 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
Unclear guidance for obtaining anaesthetic help in paediatric emergencies
Wider context from the report
“Concern 9 The resuscitation of Harry was eventually carried out by ████████, the anaesthetist looking after ████████. His evidence was that leaving his own patient to help the paediatric team was an unusual action to take in the UK although he had often performed such actions in Nepal. Doctors at QEQM indicated that there was an informal policy that if a middle grade paediatrician found themselves in an emergency, they could seek help from their anaesthetic colleagues. It was unclear whether the anaesthetists were aware of this informal policy. This informal policy should be clarified, and guidance given because there is a risk, that in an emergency, it will be overlooked. ”
Source location
HARRY RICHFORD · Prevention of Future Deaths report
Page 14 · 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
5 Nov2019
Manchester North
Concerns raised1
1. Inadequate emergency response arrangements for out-patient iron infusions
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Christopher Byron · Prevention of Future Deaths report

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

Report summary

Christopher Byron, who had multiple sclerosis and had become bedbound, developed infected pressure sores and was admitted to hospital. He received a second intravenous iron infusion on 9 January 2017 without adequate consideration of the risks and was not observed for 30 minutes afterwards; he suffered cardiac arrest within minutes and died. Concerns included inadequate continuity and documentation of nursing and pharmacy care, shortages of staff and dressings, unclear observation guidance for iron infusions, and inaccurate post-mortem reporting that failed initially to identify anaphylaxis.

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 emergency response arrangements for out-patient iron infusions
Wider context from the report
“5. In addition for out-patients who may receive an iron infusion the Court received evidence that they would be handed a buzzer. The Court would question how this would be of use should a patient suffer a cardiac arrest such occurred with Mr Byron. Points 4 and 5 link into the Regulation 28 to the Royal College of Nursing also. ”
Source location
Christopher Byron · Prevention of Future Deaths report
Page 2 · concerns
Open source report
14 Oct2019
Inner North London
Concerns raised2
1. Failure to ensure first aider knowledge of ambulance-summoning arrangements
2. Failure to ensure first aider identification of venue staff during emergencies
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

César Cuauhtémoc González Barrón · 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

César Cuauhtémoc González Barrón died while performing as a Mexican wrestler at a Lucha Libre event. After he lost consciousness and suffered cardiac arrest, there were delays in recognising the emergency, summoning assistance, starting CPR and providing effective resuscitation. The report also identified inadequate event briefing, unclear emergency roles and procedures, communication difficulties, delayed ambulance access, and a confused handover to ambulance 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 ensure first aider knowledge of ambulance-summoning arrangements
Wider context from the report
“2. The first aider covering the Lucha Libre event had never worked at the Roundhouse before that day, but she did not seek and was not offered any sort of briefing by the Roundhouse staff either before she began her shift or at any time during it. She did not appreciate that there would be non native English (mostly Spanish) speakers working on the event, which might raise language barriers in an emergency. She did not know who the staff were, how to identify them or where they would be positioned. She did not know the procedure for summoning assistance. She did not know the protocol for ringing an ambulance. She did not know who should do this or how she could ensure that it was done. She did not know that the ambulance should be directed to the rear of the building. ”
Source location
César Cuauhtémoc González Barrón · 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
Failure to ensure first aider identification of venue staff during emergencies
Wider context from the report
“6. When Mr González Barrón collapsed, the scene was chaotic. No person took charge. There were lots of people in the ring, but the first aider was unable to identify which, if any, were staff, so that she could ask them for assistance, for example, in retrieving her equipment. She was distracted by the noise and comment of those around. ”
Source location
César Cuauhtémoc González Barrón · Prevention of Future Deaths report
Page 2 · concerns
Open source report
26 Jul2019
Milton Keynes
Concerns raised1
1. Failure to include a fully qualified paramedic in the first response to prison emergencies
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 4
1. Action
  Establish a Resuscitation Review Group to share best practice, standardise emergency equipment and response, and review staff training needs.
  Stated by Central and North West London NHS Foundation TrustStated completed
2. Action
  Commission an independent external review of emergency-response practice in Offender Care to inform recommendations for policy, practice and training.
  Stated by Central and North West London NHS Foundation TrustStated completed
3. Action
  Maintain a specification requiring paramedic backup for immediately life-threatening incidents, including cardiac or respiratory arrest.
  Stated by South Central Ambulance Service NHS Foundation TrustStated completed
1. Action
  Complete a prison call-triage process requiring callers to provide accurate information about the patient’s condition.
  Stated by South Central Ambulance Service NHS Foundation TrustStated in progress
Respondent positions 1
1. Position
  Paramedic shortages make it infeasible to guarantee that every ambulance crew includes a paramedic.
  Stated by South Central Ambulance Service NHS Foundation TrustUnable to act
AI-generated summary

William VICKERS · 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

William Vickers was found collapsed in his cell at HMP Woodhill on 19 July 2018, was resuscitated and taken to hospital after suffering hypoxic brain damage, and died there on 26 July 2018. The report raised concern about delays in prison staff gaining access and, in particular, the 11-minute delay escorting the ambulance through five sets of gates to reach him.

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 include a fully qualified paramedic in the first response to prison emergencies
Wider context from the report
“Secondly I am concerned that the first response did not include a “paramedic”. I believe that consideration should be given to a review to ensure that the first responder to an emergency at the prison should always include a fully qualified paramedic. ”
Source location
William VICKERS · 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
Establish a Resuscitation Review Group to share best practice, standardise emergency equipment and response, and review staff training needs.

Verbatim wording from the response
“In December 2018, the Offender Care Directorate established a Resuscitation Review Group with the purpose of sharing best practice, standardising emergency equipment and response and to review the training needs of staff. The review group is led by the Lead Nurse for Offender Care and includes senior clinicians from services and the Trust Resuscitation Lead.”

Source location
2019-0255-Response-by-CNWL-NHS-Trust
Page 3 · response
Published 9 September 2019
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
Commission an independent external review of emergency-response practice in Offender Care to inform recommendations for policy, practice and training.

Verbatim wording from the response
“An external independent review has been commissioned to review the practice of emergency response within Offender Care and make recommendations for policy, practice and training. The findings will form the basis of a detailed action plan to ensure staff are equipped by the training provided and equipment available to respond to a medical emergency according to their role and expertise. These actions are expected to improve patient safety and outcomes.”

Source location
2019-0255-Response-by-CNWL-NHS-Trust
Page 3 · response
Published 9 September 2019
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
Maintain a specification requiring paramedic backup for immediately life-threatening incidents, including cardiac or respiratory arrest.

Verbatim wording from the response
“To offer you assurance that a Paramedic will always be dispatched to attend immediately life-threatening incidents, within our standard operating procedures, there is already a specification for a paramedic crew to be sent to all patients who are in cardiac or respiratory arrest (see below).”

Source location
2019-0255-South-Central-Ambulance-Service-NHS-Trust
Page 2 · response
Published 9 September 2019
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
Complete a prison call-triage process requiring callers to provide accurate information about the patient’s condition.

Verbatim wording from the response
“As part of the review we are undertaking with our local prisons, we are facilitating a fixed process regarding call triaging, access to the prison and retention of our personnel’s operational radios and mobile telephones. I will detail each point separately below.”

Source location
2019-0255-South-Central-Ambulance-Service-NHS-Trust
Page 4 · response
Published 9 September 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
Paramedic shortages make it infeasible to guarantee that every ambulance crew includes a paramedic.

Verbatim wording from the response
“As you will be aware, there are a number of different operational job roles within the prehospital environment. These include Specialist Paramedics, Paramedics, Ambulance Technicians and Emergency Care Assistants. Nationally there is a shortage of Paramedics which means that it is not feasible for us to guarantee a Paramedic is part of a crew on every resource.”

Source location
2019-0255-South-Central-Ambulance-Service-NHS-Trust
Page 2 · response
Published 9 September 2019
Open published response
11 Mar2019
Brighton and Hove
Concerns raised1
1. Unavailability of first-aid or designated emergency personnel on site
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

David Alexander MOBSBY · 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

David Alexander MOBSBY fell while working at Blatchington Mill School on 3 August 2018 and was found unconscious after working alone. The report raises concerns about inadequate health and safety arrangements for work at height, lack of training, supervision and risk assessment, and delays in providing CPR, including the absence of a first aider or designated person on site.

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 first-aid or designated emergency personnel on site
Wider context from the report
“(1) Brighton and Hove City Council were “advising” Blatchington Mill School (BMS) on health and safety. They were apparently using a template which made no mention of work at height when considering the health and safety of the facilities (caretaking/cleaning) department at BMS. This is dangerous and may have led to the fact that neither of their audits of 2014 or 2018 made any mention of the risks associated with and training requirements regarding working at height. (2) Although Mr MOBSBY was employed either by Brighton and Hove City Council or BMS or a combination of the two, he was not monitored or instructed in his work. He was allowed to choose how, when and where he worked. Even though anyone who knew his job description or knew Mr MOBSBY was aware that he was using ladders and step ladders he was untrained with regard to working at height. • On the 3rd August 2018 he was unchallenged when he announced his work programme for the day. • His line manager’s did not instruct him with regard to the jobs he did, even though those jobs were considered to be unnecessary by the managers. • No methodology was explored when he announced his job for the day, there was no discussion about the equipment that he was going to use. • There was no risk assessment undertaken in respect of any of the jobs that he did. • He was allowed to work alone and unsupervised. He lay alone and unconscious for 9-10 minutes before he was spotted. It was over 20 minutes before CPR was started. There was no first aider or designated person on the school site that day. • His working environment on the 3rd August 2018 meant that he was working with ambient temperatures of around 26 degrees centigrade. • He was not wearing a hat and he worked in the heat initially and then in direct sunlight latterly, from 0848 hrs until his fall at 1255 hrs having taken one forty minute break at 1100 hrs. • It seems clear that working at BMS formed a huge part of Mr MOBSBY’s life. He had been there for many years and was probably set in his ways and not amenable to being managed. • Those managing him were all relatively new to their managerial posts and yet none of them had received any management training. It was clear they had no idea how to deal with him. • They were not assisted by the fact that it was supposed to be the case that every employee was appraised annually. • There was no evidence at all to suggest that Mr MOBSBY had ever been appraised. I am concerned that this situation which was demonstrated to be in existence at BMS could well be replicated, not only throughout Brighton and Hove, but throughout England and Wales and this is the reason why this Report has been sent to the Department of Education and I think the matters raised in it should have wider discussion throughout the Country. ”
Source location
David Alexander MOBSBY · Prevention of Future Deaths report
Page 2 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised2

Lack of a mechanism to broadcast a medical emergency by tannoy at the base

Lack of a system for obtaining urgent medical attention at the Lichfield base

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3

Concerns raised1

Unavailability of a registered first aider on the premises

Actions described in response 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

Unavailability of an advanced first aider on site during emergencies

Concerns raised3

Lack of a written procedure for making a 999 emergency call

Lack of a written procedure for obtaining first aid help quickly

Unavailability of an external phone line for emergencies

Concerns raised1

Failure to provide first-aid-trained staff and a first-aid kit

Concerns raised1

Unclear guidance for obtaining anaesthetic help in paediatric emergencies

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

Concerns raised1

Inadequate emergency response arrangements for out-patient iron infusions

Concerns raised2

Failure to ensure first aider knowledge of ambulance-summoning arrangements

Failure to ensure first aider identification of venue staff during emergencies

Concerns raised1

Failure to include a fully qualified paramedic in the first response to prison emergencies

Actions described in response 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.1

Actions described in response 3

Actions described in response 2

Respondent positions 1

Actions described in response 4

Respondent positions 1