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

    Catherine Mary GIBBON · 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

    Catherine Mary Gibbon suffered a seizure while swimming at a gym on 1 June 2018 and remained face down in the water for around ten minutes. She sustained a hypoxic-ischaemic brain injury following non-fatal drowning and died. Concerns included inadequate pool monitoring and CCTV arrangements, a broken camera, insufficient staff training and emergency equipment, and gaps in first-aid certification systems.

    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 prevent first aid certificate lapses through a failsafe renewal system

    Wider context from the report

    “9. Fitness First had made the decision that all first aid certificates would be renewed after one year rather than the usual three, but then the certificates were allowed to lapse because one person made an error and there was no failsafe system. ”

    Source location

    Catherine Mary GIBBON · 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

    Absence of immediate poolside telephone access for summoning medical assistance

    Wider context from the report

    “7. There was no landline at poolside that could be used to call an ambulance in case of emergency, to enable medical assistance to be summoned immediately by someone who actually had sight of the casualty. ”

    Source location

    Catherine Mary GIBBON · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  2. Inner North London

    AI-generated summary

    Kamal Yahyia AL-HIRSI · 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

    Kamal Yahyia AL-HIRSI, a cleaner at a London health club, suffered a cardiac arrhythmia and slipped beneath the water while cleaning the swimming pool on 10 October 2017. Resuscitation attempts were too late to change the outcome. Concerns included dangerous pool-cleaning practices, inadequate water-safety and defibrillator training, ineffective emergency alarms and communication, limited CCTV coverage, and procedures that remained substantially unchanged ten months after his death.

    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 the alarm-response process to provide trained responders with the nature of the emergency

    Wider context from the report

    “5. The panic button alarm was audible by a beeping sound in reception and a light was illuminated on a control panel there, but this relied solely on the reactions of one individual who was not necessarily first aid trained and, if the receptionist did call 999, s/he would not necessarily know the nature of the emergency. In this instance, the receptionist who called an ambulance did not know that Mr Al-Hirsi had suffered a cardiac arrest. ”

    Source location

    Kamal Yahyia AL-HIRSI · 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

    Upskill designated first aiders to obtain pool responder qualifications.

    Verbatim wording from the response

    “It is also the Company’s intention to upskill its designated first aiders to have a pool responder qualification. We will endeavour to complete this by 31 December 2018.”

    Source location

    2018-0265-Response-by-Bannatyne-Fitness-Limited
    Page 1 · response
    Published 11 October 2018

    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 emergency action procedures and conduct regular documented drills covering multiple emergencies.

    Verbatim wording from the response

    “As noted above, the Company requires all of its new and existing employees to undertake a documented Workplace Induction Checklist, where they will be given a guided tour of their site to ensure that they are aware of the location and use of the building’s emergency and life saving apparatus. The Company will also review its Emergency Action Procedures (“EAP”) and ensure that its employees participate in regular documented drills. The Company’s new Health & Safety Compliance Manager will audit these centrally on a quarterly basis from 1 October 2018.”

    Source location

    2018-0265-Response-by-Bannatyne-Fitness-Limited
    Page 2 · response
    Published 11 October 2018

    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

    Amend emergency procedures and notification processes, and retrain receptionists on alarm recognition and immediate response.

    Verbatim wording from the response

    “The Company has reviewed and amended its EAP, procedures and notification process for emergencies at the Maida Vale Club. Receptionists have been re-trained in recognising an alarm and the immediate next steps to be taken. The panic buttons when pressed will activate an automated message, which will be audible from all member areas of the Club and will notify all staff, including the Duty Manager(s), to muster at the Club’s Reception. The Duty Manager will dispatch employees to the emergency together with the Defibrillator and the other emergency equipment. The Company’s contractors will complete the installation work by 10 October 2018. It is the Company’s intention to pilot this revised emergency response system at its Maida Vale and Durham health clubs. Following a review of these systems, the Company intends to roll it out across its estate.”

    Source location

    2018-0265-Response-by-Bannatyne-Fitness-Limited
    Page 3 · response
    Published 11 October 2018

    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

    Install an automated panic-button message audible throughout member areas and notifying staff to muster at reception.

    Verbatim wording from the response

    “The Company has reviewed and amended its EAP, procedures and notification process for emergencies at the Maida Vale Club. Receptionists have been re-trained in recognising an alarm and the immediate next steps to be taken. The panic buttons when pressed will activate an automated message, which will be audible from all member areas of the Club and will notify all staff, including the Duty Manager(s), to muster at the Club’s Reception. The Duty Manager will dispatch employees to the emergency together with the Defibrillator and the other emergency equipment. The Company’s contractors will complete the installation work by 10 October 2018. It is the Company’s intention to pilot this revised emergency response system at its Maida Vale and Durham health clubs. Following a review of these systems, the Company intends to roll it out across its estate.”

    Source location

    2018-0265-Response-by-Bannatyne-Fitness-Limited
    Page 3 · response
    Published 11 October 2018

    Open published response

  3. Manchester South

    AI-generated summary

    William Joseph WILSON · 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 Joseph WILSON choked on a piece of steak, suffered hypoxic brain damage and remained in a coma before receiving end-of-life care and dying in hospital on 2 February 2017. Concerns included that the designated first aider was not called, there was no clear system for alerting the first aider, and staff attending Mr Wilson were unfamiliar with all life-saving first-aid techniques.

    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 system for alerting the first aider to problems

    Wider context from the report

    “[BRIEF SUMMARY OF MATTERS OF CONCERN] (1) I was informed in evidence by the manager of the Church Inn that the designated first aider was the Chef who was not called to the scene. (2)The Manager of the Church Inn was unable to inform me of the system for alerting the first aider to any problem to ensure he attended the scene. (3)The manager and his colleague who attended upon the deceased were unfamiliar with all of the first aid life saving techniques when dealing with Mr Wilson. ”

    Source location

    William Joseph WILSON · Prevention of Future Deaths report
    Page 1 · 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 call the designated first aider to the scene

    Wider context from the report

    “[BRIEF SUMMARY OF MATTERS OF CONCERN] (1) I was informed in evidence by the manager of the Church Inn that the designated first aider was the Chef who was not called to the scene. (2)The Manager of the Church Inn was unable to inform me of the system for alerting the first aider to any problem to ensure he attended the scene. (3)The manager and his colleague who attended upon the deceased were unfamiliar with all of the first aid life saving techniques when dealing with Mr Wilson. ”

    Source location

    William Joseph WILSON · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  4. West Yorkshire Eastern

    AI-generated summary

    Paul David Whitehead · Prevention of Future Deaths report

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

    Report summary

    Paul David Whitehead sustained severe crush injuries after becoming trapped between the moving conveyors of a packing machine at work and subsequently died in hospital. Concerns were raised that the workplace emergency response, including first aid provision and contacting and directing emergency services, was not sufficiently efficient or effective.

    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 immediately available First Aid provision

    Wider context from the report

    “(1) When Mr Whitehead was released from the machine and fell on to the floor, a witness said that there was no one in the vicinity able to give First Aid to the casualty. (2) The designated First Aider from the Security Office, when informed of the incident, rang the Health and Safety Manager before calling for an Ambulance. The statement giving this evidence was challenged, however, by the evidence taken at the Inquest from the Health and Safety Manager. (3) The First Aider who attended the casualty was herself in shock and unable to carry out mouth to mouth resuscitation. (4) The Paramedic who initially attended in response to the 999 call said in a statement that on arriving at the large site of W E Rawson Ltd the Ambulance stopped in a small car park but could not see anyone around and had to drive back on to the main road before eventually finding someone stood by a fire exit door. The Paramedic’s statement said that from arriving at the site to arriving with the patient took approximately five minutes. These factors in combination suggest that the emergency response procedures at W E Rawson Ltd were not sufficiently efficient or effective. Whilst it is unlikely that these factors contributed to Mr Whitehead’s eventual death, they do give rise to the concern that if another emergency were to arise involving a time critical situation, an avoidable death might occur. Evidence was taken at the Inquest to the effect that the Disaster Recovery Plan at W E Rawson Ltd was reviewed after Mr Whitehead’s death but the conclusion reached that no significant changes were required. I consider that a further review of the standard of First Aid provision is merited along with the actions to be taken in the immediate aftermath of an unexpected occurrence to ensure that the Emergency Services are contacted immediately and steps taken to expedite their arrival with any casualty. ”

    Source location

    Paul David Whitehead · Prevention of Future Deaths report
    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

    Introduce appointed persons across factory departments and train production charge hands in basic first aid and initial emergency response.

    Verbatim wording from the response

    “It is proposed to introduce a number of ‘Appointed Persons’ within the factory departments. Production Charge Hands across the manufacturing facility will be trained in basic first aid skills and will be able to provide initial and first response aid to a person in the event of an accident or injury in the immediate vicinity. The existing first aiders (First Aid at Work qualification) would then take over once arriving at the scene of an incident. We would expect this to enable a more immediate response in the event of a future incident. We are targeting this to be implemented and training provided as suggested above by 31 March 2016.”

    Source location

    Paul-Whitehead-Response
    Page 1 · response
    Published 14 December 2015

    Open published response

  5. Inner North London

    AI-generated summary

    Codrut IEDERAN · 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

    Codrut Iederan died after pushing an unstable wall at a construction site, which collapsed on him. The report raised concerns that the site’s first aider was absent, the remaining workers were not first-aid trained, and some workers did not know how to summon an ambulance.

    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 trained first aider on site

    Wider context from the report

    “I heard at inquest that the site manager for the Anchor and Hope Public House construction was the site first aider, but he was off site at the time of the fatal accident. The remaining four workers were all Romanian non native English speakers, and none was first aid trained. Mr Iederan had the best English of the four, but of course after the accident he was not in a position to help himself. When one of his colleagues tried to call an ambulance, he realised that he did not know the number. He asked a passer by and so no time was lost in this case. However, when I asked him in court if he now knew the number, some eleven months after Mr Iederan’s death, he did not, despite still being employed by Zelltec. I am conscious that many construction sites in London are heavily supported by foreign workers. It seems to me that it would be of great assistance if employers and site managers were to ensure that all members of their workforce were able to summon help in an emergency. In addition to signs (perhaps in languages other than English) with the 999 number displayed clearly, this could be covered in toolbox talks – of course how it is done is of course a matter for you. ”

    Source location

    Codrut IEDERAN · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  6. County Durham and Darlington

    AI-generated summary

    Kevin Anthony Forster · 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

    Kevin Anthony Forster died in his prison cell at HMP Durham on 14 September 2014 after taking drugs he had hidden within his body. Staff identified that he was under the influence of an unknown substance, but no thorough or clinical assessment was undertaken. The principal concerns included inadequate policies, training, assessment, observation, treatment planning, communication and emergency response to prisoners who may have overdosed.

    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 request emergency attendance by the on-duty nurse

    Wider context from the report

    “7. Discipline staff summoned healthcare staff and perhaps not appreciating the significance of the apparent health of the deceased, did not call for the on-duty nurse to attend as an emergency, but just asked for the nurse to attend. Such an oversight could lead to a delay which in certain circumstances might be very significant. ”

    Source location

    Kevin Anthony Forster · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  7. Suffolk

    AI-generated summary

    ANTHONY STEPHEN CLEVELAND · 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

    Anthony Stephen Cleveland collapsed after exercising unsupervised at a gym on 11 June 2013 and died some days later in intensive care following a cardiac arrest and hypoxic injury associated with severe coronary artery stenosis. Concerns included inadequate supervision and resuscitation, inadequate risk assessment, a lack of qualified first aiders, and the absence of formalised national guidance for risk assessment in fitness centres and gyms.

    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 qualified first aiders

    Wider context from the report

    “It is possible and entirely foreseeable that significant medical problems may arise in an environment where people are exercising and may have underlying medical problems that could predispose them to collapse. Given the severity of the underlying coronary artery disease and subsequent cardiac arrest here it is not possible to say in this particular situation whether this tragic outcome could have been avoided with an earlier and more effective response, but the evidence here was that there was not a level of supervision that enabled the problem to be recognised immediately, and neither was there an adequate attempt to resuscitate once it had been established that a person had collapsed. There was also evidence of absence of adequate risk assessment in respect of gym users, a lack of qualified first aiders, and an absence of formalised national guidance on risk assessment in fitness centres and gyms. There was evidence that there was HSE guidance on swimming pool operations, but there is not for other facilities and it was felt that this would help the industry, particularly given the proliferation of such gymnasia in recent years, if there was formalised national guidance on risk assessment in fitness centres and gyms. ”

    Source location

    ANTHONY STEPHEN CLEVELAND · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  8. London (East)

    AI-generated summary

    David Efemena · 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 Efemena became unresponsive while sleeping outdoors during an Air Training Corps fieldcraft exercise on 23 March 2014 and was pronounced deceased in hospital at 09:09 after resuscitation attempts. The report raised concerns about the absence of an AED and AED-trained first aider, inadequate communication checks, the distance between cadets and adult staff, lack of overnight supervision, and insufficient staffing.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Lack of an AED-trained first aider at fieldcraft training activities

    Wider context from the report

    “1. The first aid equipment available at the training site did not include a defibrillator (AED). The location of David at the time of his collapse was in the woodland area of the training estate. The paramedics took 10 minutes to travel from the ambulance station to the Bramley Training Estate. Upon arrival at the Training Estate it took them 8 minutes to reach David. This type of fieldcraft activity is likely to involve some level of physical activity and some inherent risk, as a result of the terrain. Access by emergency services is likely to be challenging, as was experienced in this case. The consultant cardiologist who gave evidence at the Inquest, ████████ confirmed that in general terms the sooner an AED is used in resuscitation is the better prospect of a successful outcome. I note that the heart start training includes an optional session on AED but that this is not offered to squadrons within London. I would ask that this decision is reconsidered. The lack of an AED and AED trained first aider at this type of cadet activity, poses a risk to future cadets. 2. There were no communication checks between the adult staff and cadets when the two groups settled for sleep. There was radio contact after nightfall on the 22nd March 2014 but staff were located very near to the cadets at this time. There was no check to ensure that the communication was effective between the two groups in their final resting positions. We now know that the radios available to the cadets would not work at the distance where the staff were based. The new policy in place dealing with communication checks- Air Cadet Fieldcraft Training Instruction Number 7 -Improvised Camping in a Field Environment, remains unclear in relation to communication checks. Paragraph 12, dealing with emergency procedures, provides that “direct and reliable communications are to be established between cadets and supervising staff and this is to be tested before nightfall”. A footnote states that nightfall will vary according to the time of the year and prevailing weather conditions. The concern is that this particular direction was complied with in David Efemena’s case. There was radio contact before nightfall. There was however no effective communication between the cadets and the supervising staff during the night. Instructors therefore should be directed to ensure that effective communications exist between cadets and supervising staff before the 2 groups retire at night. It is suggested that this should be explicit within the instruction. ”

    Source location

    David Efemena · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  9. County Durham and Darlington

    AI-generated summary

    Sharon Louise Suki Butcher · 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 Louise Suki Butcher died of natural causes, with the inquest recording ischaemic heart disease, coronary artery atheroma, diabetes mellitus and cirrhosis of the liver. The report raised concerns about a 10-minute delay in calling an ambulance after an emergency medical code was broadcast, failure to follow the prison’s local protocol, and recurring lack of clarity in responding to medical emergencies.

    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 summoning ambulances after emergency medical codes are broadcast

    Wider context from the report

    “The PPO report highlights an issue relating to the delay in calling for an ambulance as soon as an emergency medical code was broadcast. There was a 10 minute delay and the prisons local protocol for summoning an ambulance was not followed. There have been a series of similar failings in dealing with medical emergencies of HMP Frankland and HMP Durham with either staff using wrong or inappropriate codes, or there being delays in the control room and this recurring issue of lack of clarity in response to a medical emergency could well lead to a fatality in the future. ”

    Source location

    Sharon Louise Suki Butcher · 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

    Revise local contingency plans and reissue emergency instructions requiring timely ambulance calls and defining medical emergency response codes.

    Verbatim wording from the response

    “HMP Frankland revised their local contingency plans and re-issued instructions following the death of Ms. Sharon Butcher to ensure that all staff understood, that they must not delay in calling an ambulance in all cases where there are serious concerns about the health of an offender.”

    Source location

    2015-0129-Response-by-NOMS
    Page 1 · response
    Published 31 March 2015

    Open published response

  10. West Yorkshire Eastern

    AI-generated summary

    Alison Dawn Evers · 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

    Alison Dawn Evers, who was dependent on care staff and had swallowing difficulties, suffered hypoxia and cardiac arrest after choking on a sweet given contrary to her dietary support plan. The principal concerns were the lack of a written no-treats policy, the absence of a policy ensuring first-aid-trained staff on every shift, and the level of first-aid training among healthcare support workers.

    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 policy ensuring first-aid-trained staff on duty for each shift

    Wider context from the report

    “(2) The lack of a policy ensuring a first aid trained member of staff is on duty for each shift. ”

    Source location

    Alison Dawn Evers · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026