Recurring concern

Failure to ensure mandatory safety training is completed before safety-critical work

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First reported 25 Feb 2014•Latest report 17 Nov 2025

Definition

What this concern includes

Includes failures of mandatory safety-training compliance controls, including timely completion, current-status monitoring, verification, escalation and preventing non-compliant personnel from undertaking safety-critical duties.

Not included

  • Excludes voluntary, developmental or general training where completion is not mandatory for the relevant safety-critical role or duty.
  • Excludes deficiencies in the content or quality of training where the training-compliance process itself is not deficient.
  • Excludes generic staffing, competence, supervision or workforce-capacity concerns that do not involve mandatory training compliance.
  • Excludes training failures confined to a separately named safety system or hazard where that named system provides the more specific supported parent boundary.
Reports
10

Distinct published reports

Individual concerns
10

A report can raise multiple concerns

Date range
2014–2025

First to latest report issue date

Stated actions
15

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.

Department of Health and Social Care2
Home Office2
NHS England2
ABTA Ltd1
AITO - The Specialist Travel Association Ltd1
British Medical Association1
Department for Transport1
Essex Partnership University NHS Foundation Trust1
General Practitioners Committee UK1
Himalayan Encounters Pvt. Ltd.1
Intrepid Travel Group UK Limited1
Metropolitan Police Service1
Ministry of Culture, Tourism and Civil Aviation (Nepal)1
National Police Chiefs’ Council1
NHS Lancashire and South Cumbria Integrated Care Board1

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. Essex

    AI-generated summary

    Paolino AMICO · 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

    Paolino Amico, who had metastatic bladder cancer and advanced clinical frailty, was admitted with severe bilateral pneumonia and died in hospital on 12 June 2024. He received multiple overdoses of slow-release morphine following a prescription error, with concerns also raised about medication administration, delayed emergency escalation, oxygen provision after discharge, and the management of morphine reversal and pain relief.

    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

    Non-mandatory medicines-administration refresher training for nurses

    Wider context from the report

    “(8) Medicines administration refresher training for nurses is not mandatory and the Trust in reviewing this case has not followed a local recommendation from senior nurses for this to be included. ”

    Source location

    Paolino AMICO · Prevention of Future Deaths report
    Page 4 · 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 training framework, including whether management training should become mandatory and whether refresher training should be tracked and monitored.

    Verbatim wording from the response

    “courses are not systematically required or monitored. Senior nursing staff previously recommended refresher training to be included as part of ongoing competency assurance; however, this recommendation has not yet been implemented.”

    Source location

    Response from Princess Alexandra Hospital
    Page 9 · response
    Published 19 November 2025

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Education and training alone would not sufficiently mitigate recurrence; systems improvements and mechanisms are also required.

    Verbatim wording from the response

    “The NICE medicines optimisation guidance NG 5 (2015) referenced above recommends that organisations support healthcare professionals through training and education to ensure safe prescribing, dispensing and administration. In this specific case, education and training alone would not prevent these types of safety system issues and would not be sufficient to mitigate the risk of reoccurrence. Systems improvements and mechanisms will need to be implemented to ensure lessons are learnt and that the current organisational and systems factors and processes highlighted in this case are addressed, to ensure the safe and effective checking and administration of medications. This has been substantiated by safety research and incident analysis.”

    Source location

    Response from NHS England
    Page 4 · response
    Published 19 November 2025

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    The hospital trust is responsible for providing the response and addressing the reported concerns through its governance arrangements and actions.

    Verbatim wording from the response

    “The Princess Alexandra Hospital NHS Trust will be providing their own response to this Report, however, the Hertfordshire & West Essex ICB have advised NHS England of the Trust’s governance arrangements and actions being taken to address the concerns raised. It is understood that the Trust’s Patient Safety Group (PSG) has active oversight of several of the areas highlighted in the Report, particularly medicines safety, recognition of deterioration, and incident learning.”

    Source location

    Response from NHS England
    Page 4 · response
    Published 19 November 2025

    Open published response
  2. Manchester South

    AI-generated summary

    Derek Crowther · 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

    Derek Crowther died on 16 December 2024 on the Saffron Unit, The Meadows, Stockport, as a consequence of complications arising from cerebral amyloid angiopathy. The concerns identified were that a registered nurse was not up to date with mandatory Intermediate Life Support training and that observations were not being recorded contemporaneously through a digital system, creating potential risks in monitoring and recording deteriorating patients.

    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 that clinical staff are up to date with required Life Support training before undertaking shifts

    Wider context from the report

    “1. The Court heard evidence that a registered nurse working on the Unit at the time of Mr Crowther’s death was not up to date with Intermediate Life Support (‘ILS’) training, despite this being termed ‘mandatory’. Having heard evidence from the Trust’s Clinical Excellence Lead for Older Peoples’ Services, I am concerned that instances continue to arise across the Trust whereby clinical staff are undertaking shifts despite not being up to date with the required level of Life Support training. ”

    Source location

    Derek Crowther · 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 the Trust-wide ILS compliance target to 85% and monitor compliance through mandatory-training dashboards and governance reporting.

    Verbatim wording from the response

    “compliance and availability of training, which is overseen within our Resuscitation Committee but also reported as part of our management structures and governance meetings.”

    Source location

    Response from Pennine Care NHS Foundation Trust
    Page 2 · response
    Published 14 October 2025

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Provide additional ILS training sessions and adjust timetables to increase capacity, improve ward-staff access and reduce booking delays.

    Verbatim wording from the response

    “Increased training capacity has been created by ensuring additional ILS training sessions have been made available. This has increased capacity and reduced waiting times for staff who need to book onto available training. Timetabling of training has been adjusted to improve access for ward-based staff. The Trust is also addressing non-attendance on ILS training, which is recognised to impact on compliance rates. Non-attendance on a booked course is escalated to Ward Managers and Network Quality Leads to support awareness but also understanding of the underlying causes or reasons why staff could not attend as planned.”

    Source location

    Response from Pennine Care NHS Foundation Trust
    Page 2 · response
    Published 14 October 2025

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Escalate non-attendance at booked ILS courses to Ward Managers and Network Quality Leads to address attendance barriers and improve compliance.

    Verbatim wording from the response

    “Increased training capacity has been created by ensuring additional ILS training sessions have been made available. This has increased capacity and reduced waiting times for staff who need to book onto available training. Timetabling of training has been adjusted to improve access for ward-based staff. The Trust is also addressing non-attendance on ILS training, which is recognised to impact on compliance rates. Non-attendance on a booked course is escalated to Ward Managers and Network Quality Leads to support awareness but also understanding of the underlying causes or reasons why staff could not attend as planned.”

    Source location

    Response from Pennine Care NHS Foundation Trust
    Page 2 · response
    Published 14 October 2025

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Incorporate ILS compliance into ward rota planning to release staff for refresher training while maintaining appropriate staffing.

    Verbatim wording from the response

    “ILS compliance is being incorporated into ward rota planning to ensure wards are appropriately staffed whilst simultaneously releasing those staff who require refresher training, which will in turn lead to an increase in compliance. The Trust is extending ILS training to additional clinical staff groups such as Bank staff and trainee doctors to increase resilience and the number of ILS trained staff present on the ward on a shift.”

    Source location

    Response from Pennine Care NHS Foundation Trust
    Page 2 · response
    Published 14 October 2025

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Extend ILS training to Bank staff and trainee doctors to increase the number of trained staff available on ward shifts.

    Verbatim wording from the response

    “ILS compliance is being incorporated into ward rota planning to ensure wards are appropriately staffed whilst simultaneously releasing those staff who require refresher training, which will in turn lead to an increase in compliance. The Trust is extending ILS training to additional clinical staff groups such as Bank staff and trainee doctors to increase resilience and the number of ILS trained staff present on the ward on a shift.”

    Source location

    Response from Pennine Care NHS Foundation Trust
    Page 2 · response
    Published 14 October 2025

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Require and daily-monitor at least one ILS-trained nursing staff member on every inpatient ward shift, escalating staffing gaps.

    Verbatim wording from the response

    “Each ward is required to have at least one ILS trained member of nursing staff on every shift, including nights and weekends. Compliance with this requirement is monitored daily through Safer Staffing meetings, with escalation where gaps arise to ensure an ILS trained staff member is available for all shifts on every inpatient ward across the Trust.”

    Source location

    Response from Pennine Care NHS Foundation Trust
    Page 2 · response
    Published 14 October 2025

    Open published response
  3. Essex

    AI-generated summary

    Carol Taylor · 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

    Carol Taylor, aged 75, was a detained psychiatric patient found unresponsive in her bed on a ward for elderly patients, and resuscitation efforts were attempted. The report raised concerns that staff who were not compliant with mandatory training, including basic life support training, could work on in-patient wards, particularly wards treating elderly patients.

    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 staff non-compliant with mandatory training from working on inpatient wards

    Wider context from the report

    “(1) There is no system that prevents staff that are non- compliant with mandatory training, including basic life support training, from being able to work on EPUT in- patient wards. (2) This is a particular concern generally, but especially in hospitals such as St Margaret’s where at least some of the wards specialise in treating elderly patients who are likely to be at greater risk of medical collapse than the general population. ”

    Source location

    Carol Taylor · 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

    Manage mandatory-training compliance using ward training trackers, monthly reviews, expiry alerts, booking support and escalation of non-compliant temporary staff.

    Verbatim wording from the response

    “Response: Ward managers are able to access and review the skills of staff on the ward, which includes bank worker training compliance, via a training tracker. If there is a staff shortage then requests may be made for bank and agency staff, identifying the skill set required to ensure those booked onto shift hold the necessary skills / training to deliver the required care competently.”

    Source location

    Response from Essex Partnership University NHS Trust
    Page 1 · response
    Published 19 June 2025

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    A complete bar on staff lacking mandatory training is not implemented because it risks insufficient staffing levels on wards.

    Verbatim wording from the response

    “A ‘bar’ on temporary staff / substantive working on the ward unless they are compliant with all mandatory training, including basic life support training brings the significant risk in relation to having the necessary number of staff on shift however compliance with mandatory training is vital. To address this Ward Managers actively manage compliance with mandatory training.”

    Source location

    Response from Essex Partnership University NHS Trust
    Page 1 · response
    Published 19 June 2025

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Operational concerns are assigned to HMPPS, whose Interim Director General of Operations has responsibility for responding to them.

    Verbatim wording from the response

    “The concerns you have raised within your report are operational issues and it is therefore appropriate that ████████ who is the Interim Director General of Operations, HM Prison and Probation Service (HMPPS), has responded to them. I have seen the response from ████████ and I endorse the content of it, which sets out the action being taken by HMPPS to address your concerns.”

    Source location

    Response from Ministry of Justice
    Page 1 · response
    Published 19 June 2025

    Open published response
  4. Lancashire and Blackburn with Darwen

    AI-generated summary

    Ida Jean Lock · 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

    Ida Jean Lock died on 16 November 2019 after suffering a lack of oxygen during delivery on 9 November 2019, resulting in severe hypoxic-ischaemic brain damage. The report describes missed opportunities for enhanced care and obstetric input, delays in responding to fetal distress, and initially ineffective neonatal resuscitation. The principal concerns include the Trust’s alleged lack of candour and transparency, deficient clinical and maternity governance, inadequate investigations, gaps in mandatory and remedial training, and inappropriate grading of the harm suffered.

    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 midwives complete current mandatory training

    Wider context from the report

    “11. The Band 5 midwife supporting ████████ in Labour had not undertaken her required mandatory training and this fact had not been provided and was only revealed at the inquest as part of the evidence of the Head of Midwifery in March 2025. I was also concerned to learn that in 2025 non-completion of mandatory training was still an issue as ████████ had not completed her mandatory training. 12. It concerns me that the Trust do not have robust systems in place to ensure that any midwife who has not completed her mandatory training is subject to immediate action to ensure that all mandatory training is completed and is in date. ”

    Source location

    Ida Jean Lock · Prevention of Future Deaths report
    Page 8 · 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

    Map critical clinical training requirements across the Trust and ensure staff compliance.

    Verbatim wording from the response

    “What we are going to do next:”

    Source location

    Response from University Hospitals of Morecambe Bay NHS Foundation Trust
    Page 9 · response
    Published 26 March 2025

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Seek monthly assurance on mandatory maternity-training compliance, including reasons for non-compliance and actions taken to protect patient safety.

    Verbatim wording from the response

    “It is acknowledged that whilst the LMNS has oversight and assurance of training in line with Training Needs Analysis (Maternity Incentive scheme safety action 8), this does not include mandatory training. The Director of Midwifery at UHMBT has provided reassurance to the LMNS that further actions are underway to ensure there is monthly reporting on mandatory maternity training with deep dives to understand those staff not compliant and immediate action taken to remedy this position. As an LMNS we will seek assurance through the monthly reporting process that all staff are compliant and where this is not the case the rationale and actions being taken to ensure patient safety.”

    Source location

    Response from NHS Lancashire and South Cumbria Integrated Care Board
    Page 6 · response
    Published 26 March 2025

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    University Hospitals Morecambe Bay NHS Foundation Trust and Lancashire and South Cumbria ICB will address specific changes arising from the report.

    Verbatim wording from the response

    “My response therefore focuses on concern D and E. I note that you have also addressed this report to University Hospitals Morecambe Bay NHS Foundation Trust (UHMBT) and NHS Lancashire and South Cumbria Integrated Care Board (LSC ICB). These organisations will address specifics as to the changes being implemented as a result of the Report. NHS England’s response to you is also made on behalf of the Department of Health and Social Care (DHSC), and I understand that they will not therefore be issuing a separate response to the Coroner. With DHSC input, I have also addressed in this response some of your concerns regarding A and B.”

    Source location

    Joint response from DHSC and NHSE
    Page 2 · response
    Published 26 March 2025

    Open published response
  5. Norfolk

    AI-generated summary

    Peggy COPEMAN · 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

    Mrs Peggy Copeman became unresponsive and was declared dead at the scene while being transported by ambulance on the M11. Concerns included delayed recognition of her deterioration, delay in calling emergency services, ineffective CPR because of her position, and inadequate CPR training among the transporting 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 transport staffing complies with the CPR training requirement

    Wider context from the report

    “1. PRAS Response Policy provides that staff escorting patients “are to be fully trained in Basic Life Support (BLS) and are deemed to be competent to apply the techniques when needed. Staff can notice any changes or deteriorating patients and act appropriately in line with BLS training. Starting with Primary assessments followed by secondary assessment then commencing CardioPulmonary Resuscitation (CPR) while waiting for ambulance to arrive ... “ 2. The evidence so far is that during transit, Peggy did not respond when being called or when moving her head and on being noted as being unresponsive, emergency services were not called immediately but calls were initially made to Cygnet and then PRAS. CPR was started on being told to do so by emergency services 3. On attendance by Paramedics it was noted that due to the position of the patient in the back of the van, CPR was ineffective 4. A report has been obtained from a Consultant Cardiologist and General Physician as an expert witness who is of the firm view that the staff transporting Mrs Copeman did not recognise she was in respiratory distress and/or cardiac arrest and that she had effectively died whilst sat between them 5. Only one member of staff out of three had training in CPR 6. An internal investigation (undated) carried out shortly after the incident did not raise concern about these matters 7. A statement provided by the Compliance Manager, PRAS, dated 7 May 2021 concludes that “the ambulance was adequately staffed to enable the journey to be safely carried out”, despite only one member of staff being trained in CPR contrary to PRAS’s own Conveyance Policy ”

    Source location

    Peggy COPEMAN · 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

    Provide basic life-support and CPR training to all patient-conveying staff, including drivers, completing internal training as external certificates expire.

    Verbatim wording from the response

    “1. In response to the concerns raised by the Coroner, Premier Rescue Ambulance Services Ltd., have made a decision that ALL members of staff, including drivers, are to have training in relation to CPR. As a consequence of this decision, ████████ has attended the following courses:”

    Source location

    2021-0182-Response-from-Premier-Rescue-Ambulance-Service-Ltd_Published
    Page 1 · response
    Published 2 June 2021

    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

    Establish an authorised internal training capacity by qualifying a staff member to train others within the company.

    Verbatim wording from the response

    “1. In response to the concerns raised by the Coroner, Premier Rescue Ambulance Services Ltd., have made a decision that ALL members of staff, including drivers, are to have training in relation to CPR. As a consequence of this decision, ████████ has attended the following courses:”

    Source location

    2021-0182-Response-from-Premier-Rescue-Ambulance-Service-Ltd_Published
    Page 1 · response
    Published 2 June 2021

    Open published response
  6. Surrey

    AI-generated summary

    Christine Ann Lee and Lucy Daisy Lee · 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

    Christine Ann Lee and Lucy Daisy Lee, mother and daughter, died after being shot with a shotgun at Keepers Cottage Stud on 23 February 2014. The report identified failures by Surrey Police firearms licensing staff to sufficiently investigate and consider relevant information, apply the correct standard of proof, and ensure appropriate senior oversight before returning the perpetrator’s shotgun certificate and shotguns. It also raised concerns about insufficient mandatory training for firearms enquiry officers and an unreliable system for assessing applicants’ medical fitness to hold shotgun certificates.

    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

    Absence of mandatory comprehensive training for Firearms Enquiry Officers

    Wider context from the report

    “It was apparent from the evidence that, at the time of the deaths, there was no national training course for staff working in police firearms licensing departments as Firearms Enquiry Officers (“FEOs”). I was told that work is now being undertaken by the College of Policing to produce an accreditation process for FEOs, but that this work is not yet complete. Currently, what is known as “the South Yorkshire Training Course” is available. This is a five day, residential course which appears to be comprehensive. I was told that all Surrey Police’s current FEOs have completed the South Yorkshire Training Course, but that it is not mandatory for them to do so. I am concerned that, pending the introduction of a full accreditation scheme, the absence of a mandatory requirement for all new FEOs (whether in Surrey or elsewhere) to undertake comprehensive training for the role, in the form of the South Yorkshire Training Course or equivalent, will result in the risk of insufficient training, incorrect decision making concerning certification and, consequently, future deaths. ”

    Source location

    Christine Ann Lee and Lucy Daisy Lee · Prevention of Future Deaths report
    Page 5 · concerns

    Open source report
  7. East London

    AI-generated summary

    Edir Frederico Araujo DA COSTA · 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

    Edir Frederico Araujo DA COSTA died after his airway became obstructed by a plastic bag containing drugs while he was being restrained by police. The report identified concerns about emergency life-support training, supervision and safety-officer roles during restraint, risks associated with plastic bags and CS spray, recognition of agonal breathing, and communication with the ambulance service.

    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 systems for supervisors to monitor mandatory training attendance

    Wider context from the report

    “(1) The evidence at the Inquest revealed that not all police officers are up to date with mandatory Emergency Life Support training. In addition, the current system in place makes it difficult for supervisors to check whether members of their team have received mandatory training. I request that the working group, driven by Met training, review the attendance of officers at mandatory ELS training and review the systems in place for supervisors to monitor attendance. I request that in doing so they consider the concerns raised by Inspector BC in his evidence at the Inquest. ”

    Source location

    Edir Frederico Araujo DA COSTA · 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

    Progress an external-system change to produce and circulate monthly training-compliance reports to senior managers.

    Verbatim wording from the response

    “Recognising that the current electronic training system ‘PSOP’ has some limitations on the data being provided to supervisors, a request for a change with our external partner is being progressed to allow a monthly compliance package to be produced and circulated to senior managers. In the interim, the MPS is re-introducing a paper ‘Form 250C’ training card to be carried by all officers which will be stamped with the date of their last attendance at an approved Officer Safety Training/Emergency Life Support training session. This will make the information more accessible for officers and supervisors to check compliance. As a shorter term measure I have also issued local data packs to enable police commanders to readily understand which of their officers are in need of up-to-date training.”

    Source location

    2019-0211-Response-by-Metropolitan-Police
    Page 2 · response
    Published 23 August 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

    Reintroduce paper training cards recording officers’ latest approved Officer Safety or Emergency Life Support training attendance.

    Verbatim wording from the response

    “Recognising that the current electronic training system ‘PSOP’ has some limitations on the data being provided to supervisors, a request for a change with our external partner is being progressed to allow a monthly compliance package to be produced and circulated to senior managers. In the interim, the MPS is re-introducing a paper ‘Form 250C’ training card to be carried by all officers which will be stamped with the date of their last attendance at an approved Officer Safety Training/Emergency Life Support training session. This will make the information more accessible for officers and supervisors to check compliance. As a shorter term measure I have also issued local data packs to enable police commanders to readily understand which of their officers are in need of up-to-date training.”

    Source location

    2019-0211-Response-by-Metropolitan-Police
    Page 2 · response
    Published 23 August 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

    Issue local training data packs enabling commanders to identify officers requiring up-to-date training.

    Verbatim wording from the response

    “Recognising that the current electronic training system ‘PSOP’ has some limitations on the data being provided to supervisors, a request for a change with our external partner is being progressed to allow a monthly compliance package to be produced and circulated to senior managers. In the interim, the MPS is re-introducing a paper ‘Form 250C’ training card to be carried by all officers which will be stamped with the date of their last attendance at an approved Officer Safety Training/Emergency Life Support training session. This will make the information more accessible for officers and supervisors to check compliance. As a shorter term measure I have also issued local data packs to enable police commanders to readily understand which of their officers are in need of up-to-date training.”

    Source location

    2019-0211-Response-by-Metropolitan-Police
    Page 2 · response
    Published 23 August 2019

    Open published response
  8. North Yorkshire (East)

    AI-generated summary

    Ajvir Singh Sandhu and Cameron James 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

    On 30 April 2016, Flying Officers Ajvir Singh Sandhu and Cameron James Forster were flying a Slingsby T67 Firefly during aerobatics near Castle Howard when the aircraft entered a spin and crashed, killing both occupants. Concerns included that neither occupant was wearing a parachute, parachutes were not supplied, and that regulations might be needed regarding parachute provision and spin recovery training for light aircraft. Evidence also raised concern that Mr Sandhu’s spin recovery training had taken place on different aircraft rather than the Slingsby Firefly.

    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 mandatory spin recovery training before flying specific types of light aircraft and carrying out aerobatics

    Wider context from the report

    “2 That there should be a review taking place of whether regulations should be introduced to make spin recovery training mandatory on specific types of light aircraft before a person can fly that light aircraft and carry out aerobatics. ”

    Source location

    Ajvir Singh Sandhu and Cameron James Forster · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
  9. North West Wales

    AI-generated summary

    Mr Hywel Llewelyn Hughes · 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

    Mr Hywel Llewelyn Hughes was forcibly removed from a nightclub, restrained face down by door staff, and later declared deceased in hospital on 3 May 2003. The inquest concluded that the medical cause of death was traumatic asphyxia and that police actions were inappropriate and more probably than not contributed more than minimally to his death. Concerns included training and monitoring of detainees during restraint and transport, and shortcomings in the licensing, training, auditing and review of door supervisors.

    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

    Uncertainty about completion of physical intervention training by licensed door supervisors

    Wider context from the report

    “(10) It is not clear that all persons presently working as door supervisors have yet undertaken physical intervention training (it appears that those who already have a licence will only be required to undertake ‘top training’ when they seek renewal of a licence). ”

    Source location

    Mr Hywel Llewelyn Hughes · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  10. 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 ensure and verify guide training in acute mountain sickness

    Wider context from the report

    “(3) The severity of her illness was not appreciated by the trek leader. The expert said that it was very well known in the trekking community that people were loathe to admit they were as ill as they were and that a good mountain guide was as capable of picking up the subtle signs of mountain sickness as most doctors. Nevertheless, this severely sick trekker with ataxia and cyanosis, signs of HACE and HAPE, was asked by the trek leader to descend under her own steam with a Himalayan Encounters guide who had inadequate or no training in acute mountain sickness. This should not happen, the expert said, since exercise worsens HAPE. Ideally she should descend passively or be treated at the health centre. The information about the training of each leader and guide was not passed to TAC, who assured themselves of the adequacy of training by statements of general compliance from HE. Whilst the companies report that action has been taken to address this, there may remain a similar risk for other trek organizers. ”

    Source location

    Rachel Ann Burke · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026