Recurring concern

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

First to latest report 25 Feb 2014 — 20 Feb 2026

Reports that mention this concern
33
Times this concern has been raised
40
Stated actions linked to this concern
35

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.

What is 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 and published responses 33 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Inner South London

    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

  2. Buckinghamshire

    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

  3. Inner South London

    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

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026