Recurring concern

Failure to provide prompt life-saving response to hanging casualties

First to latest report 21 Apr 2016 — 19 Feb 2024

Reports that mention this concern: 3
Times this concern has been raised: 5
Stated actions linked to this concern: 8

What this concern includes

Includes failures in dedicated responses to people found hanging, including recognition, immediate release or cutting down, airway and breathing assessment, first aid or resuscitation, emergency activation, responder competence, equipment and escalation arrangements.

What is not included

Excludes generic first-aid or emergency-response deficiencies where no hanging casualty is involved.
Excludes suicide or self-harm risk assessment, prevention and observation failures occurring before a hanging is discovered.
Excludes failures in treatment, transport or investigation after an appropriate immediate response to the hanging casualty has been provided.
Excludes unrelated ligature hazards or hanging risks where no deficient response to an actual or suspected hanging casualty is asserted.

Trends

Reports over time

Reports mentioning this concern, 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.

College of Policing1

Greater Manchester Police1

Ministry of Justice1

NHS England1

Stoke Heath Prison1

Reports and published responses 3 reports

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

19 Feb2024
Manchester South
Concerns raised2
1. Inadequate training of attending officers to preserve the life of a hanging casualty
2. Failure to provide timely First Aid refresher training on Basic Life Support for hanging casualties
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses

College of Policing
Greater Manchester Police
Stated actions 8
1. College of Policing
  Complete a national review of the First Aid Learning Programme, incorporating police clinical expertise and relevant external recommendations.
2. College of Policing
  Publish the revised First Aid Learning Programme focused on casualty care, preserving life and first-responder skills.
3. College of Policing
  Increase recommended annual refresher training from four to six hours and initial training from nine to twelve hours for public-facing officers.
1. Greater Manchester Police
  Present Dealing with Death learning at the monthly Tutor Constable Forum and quality-assure delivery through periodic classroom observations.
2. Greater Manchester Police
  Raise inquest learning at the Tactical Organisational Learning Board to share learning and reinforce preservation-of-life messages.
3. Greater Manchester Police
  Disseminate Dealing with Death learning across the force through intranet, bulletins, organisational-learning meetings and local learning leads.
4. Greater Manchester Police
  Include ligature-removal training in Module 1 and 2 initial and refresher first-aid courses.
5. Greater Manchester Police
  Strengthen first-aid training governance through monitoring, regular attendance-data sharing, monthly governance oversight and compliance accountability.
AI-generated summary

Samuel Curless (Sam) · 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

Samuel Curless died in hospital on 24 October 2022 after being found suspended from a ligature and receiving delayed life-support intervention. The concerns included failures to call an ambulance promptly, delays in checking vital signs and removing the ligature, and possible inadequacies in police training and refresher training for responding to hanging casualties.

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 training of attending officers to preserve the life of a hanging casualty
Wider context from the report
“2. That the training delivered to the first two attending officers did not adequately prepare them for responding to a scene where someone is found hanging in a way which is consistent with their priority to preserve life of a hanging casualty. ”
Source location
Samuel Curless (Sam) · 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
Failure to provide timely First Aid refresher training on Basic Life Support for hanging casualties
Wider context from the report
“4. There was evidence given to me by Detective Superintendent ████████ that there is an unknown number of GMP officers who are not meeting the expectation of receiving First Aid refreser training within 12 months, which since May 2022 has included training on how to resuscitate a hanging casualty. I am therefore concerned that there remains a cohort of officers who have not had the post May 2022 training that includes how to provide Basic Life Support to this kind of casualty until the arrival of an ambulance. ”
Source location
Samuel Curless (Sam) · 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
Complete a national review of the First Aid Learning Programme, incorporating police clinical expertise and relevant external recommendations.

Verbatim wording from the response
“In 2020, the College of Policing commenced a national working group to review the First Aid Learning Programme (FALP). The review engaged and consulted with police clinical subject matter experts and input from clinical governance leads in forces, in addition to recommendations made by Coroners, the Independent Office for Police Conduct and the Manchester Arena Inquiry. The FALP has now been published with a focus on casualty care, preserving life and providing police officers and staff with the first aid skills required as first responders.”

Source location
Response from College of Policing
Page 2 · response
Published 22 February 2024
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
Publish the revised First Aid Learning Programme focused on casualty care, preserving life and first-responder skills.

Verbatim wording from the response
“In 2020, the College of Policing commenced a national working group to review the First Aid Learning Programme (FALP). The review engaged and consulted with police clinical subject matter experts and input from clinical governance leads in forces, in addition to recommendations made by Coroners, the Independent Office for Police Conduct and the Manchester Arena Inquiry. The FALP has now been published with a focus on casualty care, preserving life and providing police officers and staff with the first aid skills required as first responders.”

Source location
Response from College of Policing
Page 2 · response
Published 22 February 2024
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
Increase recommended annual refresher training from four to six hours and initial training from nine to twelve hours for public-facing officers.

Verbatim wording from the response
“Annual refresher training is a core requirement of the FALP licence, and as a result of the above mentioned review, the recommended training time for both refresher and initial training has been increased for all public facing officers.”

Source location
Response from College of Policing
Page 2 · response
Published 22 February 2024
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
Present Dealing with Death learning at the monthly Tutor Constable Forum and quality-assure delivery through periodic classroom observations.

Verbatim wording from the response
“To support the implementation of this learning, dealing with death has been presented at GMP’s monthly Tutor Constable Forum to support those who tutor students on District whilst responding to incidents. Finally, our training Sergeants undertake periodical in-class observations to quality assure both the training content and that the delivery is in line with best practice.”

Source location
Response from Greater Manchester Police
Page 2 · response
Published 22 February 2024
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
Raise inquest learning at the Tactical Organisational Learning Board to share learning and reinforce preservation-of-life messages.

Verbatim wording from the response
“This case has also been raised at the Tactical Organisational Learning Board (TOLB). The TOLB is attended by representatives from across GMP with a view to sharing the learning and reinforcing the key messages around preservation of life.”

Source location
Response from Greater Manchester Police
Page 4 · response
Published 22 February 2024
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
Disseminate Dealing with Death learning across the force through intranet, bulletins, organisational-learning meetings and local learning leads.

Verbatim wording from the response
“To further reinforce police officer and staff understanding of the Dealing with Death Policy and the expected actions of those at the scene I have tasked the Organisational Learning Hub to disseminate learning across the Force, using a variety of established communications channels, which will include the following:”

Source location
Response from Greater Manchester Police
Page 4 · response
Published 22 February 2024
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
Include ligature-removal training in Module 1 and 2 initial and refresher first-aid courses.

Verbatim wording from the response
“GMP uses the FALP as the core syllabus for its first aid training but in addition to the core syllabus supplementary elements or scenarios are incorporated into the training based upon operational risks and/or learning derived from incidents that have occurred in Greater Manchester or nationally. From April 2022 one of the supplementary elements GMP introduced into the Module 1 and 2 initial and refresher training courses was ligature removal. This training will continue in place moving forward.”

Source location
Response from Greater Manchester Police
Page 5 · response
Published 22 February 2024
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
Strengthen first-aid training governance through monitoring, regular attendance-data sharing, monthly governance oversight and compliance accountability.

Verbatim wording from the response
“GMP has also improved the governance around first aid training to ensure that officers remain up to date with their training requirements. The numbers are monitored by People & Development Branch Learning Services Team and reported to the Clinical Governance Panel. Attendance data is shared with GMP Districts and Branches on a regular basis, including individual officer details and course booking dates. In addition, First Aid Training is a standing item at GMP’s monthly Major Incident Response Governance Board (MIRGB) meeting which is chaired by the Deputy Chief Constable (DCC). At the monthly meeting the DCC holds Districts and Branches to account in respect of their compliance with the first aid training requirements. First Aid training will remain a focus of the MIRGB moving forward.”

Source location
Response from Greater Manchester Police
Page 6 · response
Published 22 February 2024
Open published response
30 Sep2019
Liverpool and Wirral
Concerns raised2
1. First aid training lacking hanging-specific response content
2. Failure to cut down a person found hanging
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response

NHS England
Respondent positions 2
1. NHS England
  The NHS does not determine the content of public first aid courses.
  Outside remit
1. NHS England
  Responsibility for considering changes to public first aid course content rests with the British Red Cross.
  Redirects responsibility
AI-generated summary

Ceara Marie Thacker · 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

Ceara Marie Thacker, a 19-year-old University of Liverpool student with a history of self-harm and contact with mental health services, was found deceased hanging on 11 May 2018. Concerns included the lack of discussion about involving her family in care planning and the absence of attempts to cut her down after she was found hanging; the first-aid training received by the person who found her did not cover hangings.

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
First aid training lacking hanging-specific response content
Wider context from the report
“2. Concern was raised that once Ceara was found hanging, no attempts were made to cut her down. The pathologist gave evidence to the effect it would be difficult to say how quick the death would have occurred, however, there was a very small window after the hanging where a person could survive, be it with brain damage. He stated it was rare that an individual was not cut down. The Residential Adviser who found Ceara had received first aid training but this did not include anything in relation to hangings. ”
Source location
Ceara Marie Thacker · 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
Failure to cut down a person found hanging
Wider context from the report
“2. Concern was raised that once Ceara was found hanging, no attempts were made to cut her down. The pathologist gave evidence to the effect it would be difficult to say how quick the death would have occurred, however, there was a very small window after the hanging where a person could survive, be it with brain damage. He stated it was rare that an individual was not cut down. The Residential Adviser who found Ceara had received first aid training but this did not include anything in relation to hangings. ”
Source location
Ceara Marie Thacker · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
The NHS does not determine the content of public first aid courses.

Verbatim wording from the response
“One of the actions to prevent future deaths that you directed to NHS Improvement was related to the content of first aid courses for members of the public. The NHS does not determine the content of public first aid courses. We understand the appropriate body to consider action would be the British Red Cross who are a direct provider of first aid training and whose curriculum is the basis for most first training provided by a range of independent training organisations in workplaces, etc. They can be contacted at contactus@redcross.org.uk”

Source location
Response from NHS England
Page 2 · response
Published 4 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
Responsibility for considering changes to public first aid course content rests with the British Red Cross.

Verbatim wording from the response
“One of the actions to prevent future deaths that you directed to NHS Improvement was related to the content of first aid courses for members of the public. The NHS does not determine the content of public first aid courses. We understand the appropriate body to consider action would be the British Red Cross who are a direct provider of first aid training and whose curriculum is the basis for most first training provided by a range of independent training organisations in workplaces, etc. They can be contacted at contactus@redcross.org.uk”

Source location
Response from NHS England
Page 2 · response
Published 4 June 2025
Open published response
21 Apr2016
Shropshire, Telford and Wrekin
Concerns raised1
1. Insufficient first-aid training among first-attending prison officers
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Derrick Edward ROSE-FOWLER · 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

Derrick Edward ROSE-FOWLER was found hanging by his neck from his prison cell window on 5 June 2015 and was pronounced dead after being transferred to hospital. The concerns included the first attending prison officer not being first-aid trained, the handling of alleged bullying, and the failure to raise concerns about the deceased at a MASH meeting despite several relevant factors.

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 first-aid training among first-attending prison officers
Wider context from the report
“(1) Although on the facts of this case it made no difference to the outcome, the first prison officer on the scene was not first aid trained. The evidence at the inquest was that there was no national requirement for all prison officers to be first aid trained provided a certain proportion were. (2) In hanging cases time is of the essence for CPR and if there is any significant delay by reason of the first attending prison officer not being first aid trained there is the risk of future deaths occurring. ”
Source location
Derrick Edward ROSE-FOWLER · Prevention of Future Deaths report
Page 1 · concerns
Open source report