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.

14 Jan2015
Inner South London
Concerns raised1
1. Failure to provide on-site medical assistance at unlicensed raves
This report raised 8 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

Max Carlton-Smith · 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

Max Carlton-Smith died after taking MDMA at an illegal rave and collapsing when emergency medical assistance was not summoned immediately. The rave had no on-site medical assistance, inadequate ventilation, and unregulated fire exits and procedures; the report also raised concerns about delays in calling an ambulance and the authorities’ ability to intervene at the squatted commercial premises.

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 on-site medical assistance at unlicensed raves
Wider context from the report
“The organizers of the unlicensed rave had not provided on-site medical assistance and had spent between 12 and 42 minutes before calling the ambulance service, when the deceased collapsed. There was inadequate ventilation for a very hot venue, and fire exits and procedure had not been regulated. The organizers had taken over an empty squatted commercial building and barricaded against those who attempted to enter, (including police, who attended and spoke earlier to a security man and then later following complaints of noise). I concluded that had the event been licensed and normal facilities and regulation in place, he would probably not have died when he did. ”
Source location
Max Carlton-Smith · Prevention of Future Deaths report
Page 1 · concerns
Open source report
5 Dec2014
Buckinghamshire
Concerns raised1
1. Insufficient availability of trained first aiders across the site, including at night
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 1
1. Action
  Increase trained first-aid staffing and establish 24-hour cover at Springhill.
  Stated by Governing Governor of HMP Grendon and SpringhillStated in progress
AI-generated summary

Peter Harry Mackie · 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

Peter Harry Mackie, a prisoner at HMP Springhill, was found hanging in the prison chapel on 28 December 2013 and was declared deceased. The inquest concluded that he took his own life while the balance of his mind was disturbed. Concerns included the availability and deployment of first aiders and healthcare staff across the prison sites, and a lack of clarity about when CPR should be commenced and what action untrained staff should take.

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 availability of trained first aiders across the site, including at night
Wider context from the report
“(1) Despite improvements during 2014 concerns remain as to the overall numbers of first aiders available on the Springhill site at any time including at night. A first aider on the Grendon site is unlikely to be able to respond in time due necessary security moving from a closed estate to an open prison. This applies in respect of those trained to “First aid at work (FAW) and Emergency First aid at work (EFAW). Operational needs may deplete numbers with FAW and/or EFAW by transferring them to the closed part of the overall site. ”
Source location
Peter Harry Mackie · 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
Increase trained first-aid staffing and establish 24-hour cover at Springhill.

Verbatim wording from the response
“HMP Grendon and Springhill are currently working on increasing the number of trained first aid staff at both establishments to First Aid at Work (FAW) and Emergency First Aid at Work (EFAW) level. A number of staff were trained to these levels during 2014 but it is recognised that more are needed at the Springhill site to provide cover, especially at night when healthcare staff are located at Grendon. A new risk assessment is being completed to ensure appropriate levels of staff are identified to provide 24 hour cover. This system will be fully operational within 12 months.”

Source location
2014-0528-Response-by-NOMS
Page 1 · response
Published 5 December 2014
Open published response
25 Feb2014
Inner South London
Concerns raised1
1. Failure to use available urgent medical services and communications
This report raised 4 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
  Review the information and training provided to trek leaders about passenger travel insurance and medical-care decisions.
  Stated by Intrepid Travel Group UK LimitedStated completed
2. Action
  Put guidelines in place requiring consultation with nearby medical posts for illness, inability to continue, or suspected altitude-related illness.
  Stated by Intrepid Travel Group UK LimitedStated completed
3. Action
  Remove the overseas leader manual's guidance on finding cost-effective solutions from circulation.
  Stated by Intrepid Travel Group UK LimitedStated completed
AI-generated summary

Rachel Ann Burke · 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

Rachel Ann Burke died in Dole, Nepal, after developing high altitude cerebral oedema and high altitude pulmonary oedema during a Himalayan trek. Concerns included an excessive rate of ascent, failure to use a nearby health post or satellite phone for urgent care, failure to recognise the severity of her illness, and sending her to descend under her own steam with a guide who had inadequate or no training in acute mountain sickness.

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 use available urgent medical services and communications
Wider context from the report
“(2) The HE trek leader was concerned about the costs of accessing services from the Health Centre and of making satellite phone calls, possibly mindful of the TAC manual for overseas group leaders, which states under “emergency” on page 20, that priority must be given to finding a cost effective solution. Despite having a satellite phone at Macheremo and 12 minutes from a health post, neither was used, when the trekker needed urgent medical care. ”
Source location
Rachel Ann Burke · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Review the information and training provided to trek leaders about passenger travel insurance and medical-care decisions.

Verbatim wording from the response
“With regard to the knowledge of our trek leaders in respect of the travel insurance that passengers have we have reviewed the information and training that is provided to our trek leaders. This has always formed part of the training for our leaders and is incorporated into not only the initial training provided but also our ongoing refresher training. It is made clear to leaders that passengers take out travel insurance that will cover them for necessary medical expenses whilst on treks. It is further emphasised that the primary concern is always for the safety and wellbeing of the trekkers. Any decisions in this regard are to be made to provide the most suitable and effective remedy and not based on relative cost.”

Source location
2014-0074-Response-by-The-Family-Adventure-Company
Page 2 · response
Published 25 February 2014
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
Put guidelines in place requiring consultation with nearby medical posts for illness, inability to continue, or suspected altitude-related illness.

Verbatim wording from the response
“Further guidelines on always consulting any nearby medical posts, such as the one at Macchermo, in cases of illness, inability to continue with a trip or suspected AMS have also been put in place.”

Source location
2014-0074-Response-by-The-Family-Adventure-Company
Page 2 · response
Published 25 February 2014
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
Remove the overseas leader manual's guidance on finding cost-effective solutions from circulation.

Verbatim wording from the response
“The general TAC overseas leader manual that did refer to finding cost effective solutions to more general situations has been removed from circulation to avoid any possibility of confusion in this regard.”

Source location
2014-0074-Response-by-The-Family-Adventure-Company
Page 2 · response
Published 25 February 2014
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to provide on-site medical assistance at unlicensed raves

Concerns raised1

Insufficient availability of trained first aiders across the site, including at night

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.1

Concerns raised1

Failure to use available urgent medical services and communications

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

Actions described in response 1

Actions described in response 3