Recurring concern

Failure to reliably recognise and assess unconsciousness

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First reported 17 Dec 2013•Latest report 7 Oct 2025

Definition

What this concern includes

Includes failures of controls specifically dedicated to recognising or assessing suspected unconsciousness, including emergency questioning, staff training and induction, clinical assessment, distinction from sleep or cardiac arrest, and treatment decisions that rely on establishing consciousness.

Not included

Excludes generic emergency response, first-aid, resuscitation or clinical-deterioration deficiencies unless they specifically concern recognition or assessment of unconsciousness.
Excludes failures limited to treatment or monitoring after unconsciousness has been reliably recognised, unless the treatment or monitoring failure arises from an inadequate consciousness assessment.
Excludes failures concerning general mental state, reduced consciousness or altered behaviour where unconsciousness is not the material safety concern.
Excludes generic staffing, communication, policy or documentation deficiencies that are not dedicated to recognising or assessing unconsciousness.

Reports: 5
Individual concerns: 6
Date range: 2013–2025
Stated actions: 17

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.

HM Prison and Probation Service2

Care UK1

Caring Limited1

College of Policing1

London Ambulance Service NHS Trust1

London Central & West Unscheduled Care Collaborative Limited1

National Police Chiefs’ Council1

Pentonville Prison1

Springbank Care Home Limited1

Wandsworth Prison1

West Yorkshire Police1

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.

7 Oct2025
West Yorkshire (Western)
Concerns raised1
1. Lack of clear training on assessing whether a person is responsive or unresponsive
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 9
1. Action
  Embed casualty assessment, primary survey, breathing checks and acute alcohol intoxication recognition in initial and annual refresher first-aid training.
  Stated by College of PolicingStated completed
2. Action
  Review Regulation 28 reports and relevant inquest findings as standing agenda items of the NPCC First Aid Forum.
  Stated by College of PolicingStated in progress
3. Action
  Produce and circulate national learning summaries and practice notes to all police forces.
  Stated by College of PolicingStated in progress
1. Action
  Engage force training leads and clinical governance advisers to support local implementation of national learning.
  Stated by College of PolicingStated in progress
2. Action
  Implement revised First Aid Learning Programme content mandating assessment of breathing and responsiveness in Learning Outcome 1.3.
  Stated by National Police Chiefs’ CouncilStated completed
3. Action
  Teach officers that failure to obtain a suitable AVPU response means the casualty is unresponsive and requires an ambulance call.
  Stated by West Yorkshire PoliceStated completed
4. Action
  Invite officers to discuss what constitutes a suitable response during first aid training.
  Stated by West Yorkshire PoliceStated completed
5. Action
  Use an unresponsive-sleeper scenario to develop officers’ decision-making about calling an ambulance.
  Stated by West Yorkshire PoliceStated planned
6. Action
  Teach officers to distinguish involuntary limb, head or facial movements from a suitable response and call an ambulance.
  Stated by West Yorkshire PoliceStated completed
Respondent positions 2
1. Position
  Individual forces are responsible for delivering FALP training in accordance with their local clinical governance arrangements.
  Stated by College of PolicingRedirects responsibility
1. Position
  Nationally standardised teaching methods are not mandated; each force’s clinical governance group determines them with consultant-level medical input.
  Stated by National Police Chiefs’ CouncilRedirects responsibility
AI-generated summary

Ann Sabrina LASKOWSKY · 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

Ann Sabrina Laskowsky was found unresponsive at home on 5 October 2024 after police attended when an inactivity alarm was triggered. She was taken to hospital later that day and died on 6 October 2024 from naturally occurring disease contributed to by self-neglect and exacerbated by longstanding alcohol dependence. The principal concerns were the adequacy and clarity of police first-aid training, including recognising abnormal breathing and unresponsiveness, and officers’ knowledge, use and training regarding the Partner Triage Line.

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 clear training on assessing whether a person is responsive or unresponsive
Wider context from the report
“1. The adequacy of First Aid Training provided by West Yorkshire Police The body worn camera footage which was played during the course of the inquest, clearly shows that when the Officers arrived, they found Ann lying slumped on the sofa, appearing pale with an increased respiratory rate. Ann was profoundly unwell and required urgent medical attention. The attending Officers did not recognise the severity of Ann's condition and instead considered that Ann was asleep but could not be woken. This of itself, raises significant concerns in respect of the nature and adequacy of the training that had been provided to the officers at the time. Expert evidence received during the course of the Inquest concluded that even if the Officers had sought medical attention when they attended, given the severity of her condition, such treatment would not have prevented her death. During the course of the Inquest, evidence was received from a variety of sources, in respect of nature and quality of the First Aid Training provided to Officers, in both their initial training and their annual refresher training. This evidence demonstrated an overwhelming lack of clarity in terms of the way in which officers are trained to assess whether an individual is alive, breathing and conscious, something which it is expected that Officers can assess, in line with their authorised professional practice. The very nature of this evidence was such as to raise significant concerns as to the impact of this training upon the preservation of life. There were two main areas in which the lack of clarity and consequent inadequacy of training were of particular concern:- a. The assessment of whether a person is breathing normally and how this is to be assessed; and b. Whether an individual is responsive or unresponsive, particularly in cases where there may be some involuntary movements from the individuals concerned. ”
Source location
Ann Sabrina LASKOWSKY · 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
Embed casualty assessment, primary survey, breathing checks and acute alcohol intoxication recognition in initial and annual refresher first-aid training.

Verbatim wording from the response
“In 2023, the College undertook a comprehensive review of the FALP, which was subsequently endorsed by the NPCC. This review expanded both the learning content and the associated training time. The programme now includes high-level learning outcomes covering casualty assessment, primary survey techniques including responsiveness and breathing checks, and recognition of acute alcohol intoxication. These outcomes are embedded in both initial and annual refresher training for all public-facing officers. While the College sets the learning outcomes, individual forces retain discretion over delivery methods, in line with their local clinical governance arrangements.”

Source location
Response from College of Policing
Page 1 · 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
Review Regulation 28 reports and relevant inquest findings as standing agenda items of the NPCC First Aid Forum.

Verbatim wording from the response
“The operational deployment of local clinical support tools, such as the Partner Triage Line, is determined by individual forces in collaboration with local healthcare providers and falls outside the scope of the FALP licensing framework. Nonetheless, the College recognises the critical importance of ensuring that learning from incidents involving first aid provision is captured and shared across the policing community.”

Source location
Response from College of Policing
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
Produce and circulate national learning summaries and practice notes to all police forces.

Verbatim wording from the response
“To ensure that national learning identified through the Forum is effectively disseminated and embedded, the College works closely with NPCC strategic and clinical leads to:”

Source location
Response from College of Policing
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
Engage force training leads and clinical governance advisers to support local implementation of national learning.

Verbatim wording from the response
“To ensure that national learning identified through the Forum is effectively disseminated and embedded, the College works closely with NPCC strategic and clinical leads to:”

Source location
Response from College of Policing
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
Implement revised First Aid Learning Programme content mandating assessment of breathing and responsiveness in Learning Outcome 1.3.

Verbatim wording from the response
“Whilst the College of Policing are responsible for the Police First Aid Learning Programme, and the quality assurance of the same through their licensing regime, the National Police Chiefs' Council (NPCC) Health, Safety and Welfare portfolio work closely with the College to ensure that the content of the FALP is fit for purpose. A full review of the content was conducted by a panel of doctors and paramedics in 2023 which has been implemented this year, and I can confirm that an assessment of whether a person is breathing and responsiveness levels are mandated in Learning Outcome 1.3. Exactly how this is taught is not mandated nationally to allow for local variations in practice which is determined by each forces' Clinical Governance group with the input of a consultant-level doctor meeting criteria laid down in NPCC guidelines.”

Source location
Response from National Police Chief's Council
Page 1 · 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
Teach officers that failure to obtain a suitable AVPU response means the casualty is unresponsive and requires an ambulance call.

Verbatim wording from the response
“The First Aid Trainers now teach Officers that when they are looking for a response using AVPU (Alert, Voice, Pain, Unresponsive) that if they are unable to obtain a ‘suitable response’ from the casualty using Voice or to Pain then the casualty is unresponsive, and they should call for an ambulance.”

Source location
Response from West Yorkshire Police
Page 1 · 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
Invite officers to discuss what constitutes a suitable response during first aid training.

Verbatim wording from the response
“Trainers now invite Officers to question and discuss “what is a suitable response”. A scenario based on a person who appears to be asleep who the Officers are unable to wake up will be used to invite discussion between the Trainer and the Officers to support effective decision making. Officers will now be taught that if someone is asleep and they are unable to wake them using painful stimuli and they do not respond to their voice then this is not normal, and an ambulance should be called.”

Source location
Response from West Yorkshire Police
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
Use an unresponsive-sleeper scenario to develop officers’ decision-making about calling an ambulance.

Verbatim wording from the response
“Trainers now invite Officers to question and discuss “what is a suitable response”. A scenario based on a person who appears to be asleep who the Officers are unable to wake up will be used to invite discussion between the Trainer and the Officers to support effective decision making. Officers will now be taught that if someone is asleep and they are unable to wake them using painful stimuli and they do not respond to their voice then this is not normal, and an ambulance should be called.”

Source location
Response from West Yorkshire Police
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
Teach officers to distinguish involuntary limb, head or facial movements from a suitable response and call an ambulance.

Verbatim wording from the response
“Trainers now teach Officers to be aware of involuntary movements of limbs, head or face and that these are not to be mistaken for a suitable response. The Trainer now emphasises the need to call for an ambulance.”

Source location
Response from West Yorkshire Police
Page 2 · response
Published 14 October 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
Individual forces are responsible for delivering FALP training in accordance with their local clinical governance arrangements.

Verbatim wording from the response
“In 2023, the College undertook a comprehensive review of the FALP, which was subsequently endorsed by the NPCC. This review expanded both the learning content and the associated training time. The programme now includes high-level learning outcomes covering casualty assessment, primary survey techniques including responsiveness and breathing checks, and recognition of acute alcohol intoxication. These outcomes are embedded in both initial and annual refresher training for all public-facing officers. While the College sets the learning outcomes, individual forces retain discretion over delivery methods, in line with their local clinical governance arrangements.”

Source location
Response from College of Policing
Page 1 · response
Published 14 October 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
Nationally standardised teaching methods are not mandated; each force’s clinical governance group determines them with consultant-level medical input.

Verbatim wording from the response
“Whilst the College of Policing are responsible for the Police First Aid Learning Programme, and the quality assurance of the same through their licensing regime, the National Police Chiefs' Council (NPCC) Health, Safety and Welfare portfolio work closely with the College to ensure that the content of the FALP is fit for purpose. A full review of the content was conducted by a panel of doctors and paramedics in 2023 which has been implemented this year, and I can confirm that an assessment of whether a person is breathing and responsiveness levels are mandated in Learning Outcome 1.3. Exactly how this is taught is not mandated nationally to allow for local variations in practice which is determined by each forces' Clinical Governance group with the input of a consultant-level doctor meeting criteria laid down in NPCC guidelines.”

Source location
Response from National Police Chief's Council
Page 1 · response
Published 14 October 2025
Open published response
11 Jun2024
Inner West London
Concerns raised1
1. Failure to implement induction training on responding to suspected prisoner unconsciousness
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.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Yuri Hatton · 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

Yuri Hatton, who was detained at HMP Wandsworth, died in hospital on 9 November 2018 after being found unresponsive following a suspected opiate overdose and later showing features of brain stem death. The jury identified four failures that cumulatively possibly contributed to his death, including failures involving emergency response, clinical observations and communications. The report also raised concerns about limited OSG training, the frequency and monitoring of first aid training, and the lack of prison-specific training on recognising unconsciousness.

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 implement induction training on responding to suspected prisoner unconsciousness
Wider context from the report
“(3) Recognising unconsciousness. The First Aid training offered, whilst addressing unconsciousness, is not prison specific. A new induction package was said to be rolled out imminently which will include instructions about what a member of prison staff should do if they believe that a prisoner could be unconscious and will reiterate the instruction to call a code blue in such circumstances. This training has not yet been implemented. ”
Source location
Yuri Hatton · Prevention of Future Deaths report
Page 2 · concerns
Open source report
6 Dec2016
Inner North London
Concerns raised1
1. Failure to distinguish cardiorespiratory arrest from unconsciousness during emergency assessment
This report raised 14 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 2
1. Action
  Check that all Care UK clinical staff receive mandatory intermediate life-support training.
  Stated by Care UKStated completed
2. Action
  Develop and circulate a standard operating procedure for emergency response.
  Stated by Care UKStated in progress
AI-generated summary

Tedros Habtom KAHSSAY · 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

Tedros Kahssay killed himself by hanging in HM Prison Pentonville about a month after being admitted on a charge of murdering his pregnant partner. Concerns included incomplete transfer and recording of information, shortcomings in reception screening, and significantly deficient and chaotic resuscitation procedures. The report states that he was already dead when resuscitation commenced, while expressing concern for other prisoners requiring first aid.

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 distinguish cardiorespiratory arrest from unconsciousness during emergency assessment
Wider context from the report
“7. The resuscitation led by the two nurses occupying the positions of primary (Hotel 7) and secondary (Hotel 12) leads for emergency healthcare in the prison that night, was significantly lacking in the following ways. • The nurse with primary responsibility for emergency care in the prison did not have a proper understanding of the nature of a code red and a code blue prison medical emergency. (I have raised this issue in the past.) • One minute and twelve seconds elapsed after nurse arrival before any substantive care was given. The action during that one minute and twelve seconds did not appear to progress the resuscitation attempt. • There seemed no clear demarcation of roles and responsibilities during the resuscitation. Of course these may change as those giving resuscitation tire, but the changes seemed haphazard. • There was no checking for breath or airway manoeuvre at the outset or at any time during the resuscitation. • There was no checking for pulse at the outset, before commencing chest compressions, or at any time during the resuscitation. The lead nurse attempted to justify this by saying that she had not wanted to waste time. This was despite the first action upon finding the casualty being to apply a blood pressure cuff, on the basis that this was part of the nurse assessment. • When giving evidence, the lead nurse appeared to conflate the casualty who is in cardiorespiratory arrest with the casualty who is merely unconscious. She repeatedly talked about the need to give cardiopulmonary resuscitation (CPR) to an unconscious casualty. She said that, at the time she started chest compressions, she did not know whether Mr Kahssay was breathing or not breathing. • When CPR was given, chest compressions were ineffective, being too quick and too shallow. • There was only one brief attempt to use an ambubag, the majority of the resuscitation taking place without airway assistance or with a non rebreathe oxygen mask. • It appeared that one oxygen cylinder was empty, as it had to be changed for another. The nurse leading the resuscitation described it as chaotic. That is indeed how it appeared to me from her description and from viewing the bodycam footage. I was and remain very gravely concerned, not in this respect for Mr Kahssay who was in fact already dead when resuscitation commenced, but for anyone else in the prison in need of first aid. ”
Source location
Tedros Habtom KAHSSAY · 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
Check that all Care UK clinical staff receive mandatory intermediate life-support training.

Verbatim wording from the response
“All clinical staff that are employed by Care UK have ILS as a mandatory training requirement. A check has been undertaken to ensure that all Care UK clinical staff are receiving the ILS training. This has been confirmed to be the case.”

Source location
2016-0437-Response-by-Care-UK.pdf
Page 3 · response
Published 6 December 2016
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
Develop and circulate a standard operating procedure for emergency response.

Verbatim wording from the response
“In addition to this, the healthcare team plan to discuss issues relating to resuscitation and use of emergency bags regularly in their Friday afternoon training sessions. A SOP for emergency response is in development by the national team and is due for circulation shortly.”

Source location
2016-0437-Response-by-Care-UK.pdf
Page 3 · response
Published 6 December 2016
Open published response
27 May2015
Inner North London
Concerns raised1
1. Failure to use a clear method for establishing whether a patient is conscious or unconscious
This report raised 2 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

Yusuf ABDISMAD · 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

Yusuf died from meningococcal septicaemia after his mother called 999 and was advised to call 111; by the time the London Ambulance Service arrived, he was in cardiac arrest. The principal concern was that the emergency medical dispatcher used a potentially confusing method to assess whether Yusuf was conscious, alongside difficulties recognising possible signs of meningitis.

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 a clear method for establishing whether a patient is conscious or unconscious
Wider context from the report
“In attempting to gain an answer to the question, “Is the patient awake (conscious)?”, the emergency medical dispatcher first asked “Is Yusuf awake?” When Yusuf’s mother replied “no”, the EMD went on to ask “Is he conscious?” This seems a confusing way of approaching this very important question. If a person is asleep, then one cannot know if they are conscious without waking them. If the answer to the question “Is he awake?” is “no”, then the most obvious follow up to that would appear to be, “Can you wake him?” Yusuf’s mother was by now panicking and erroneously replied “yes” to the question of whether Yusuf was conscious, though she had not tried to wake him. The EMD assumed that Yusuf was asleep but rousable, which in fact is unlikely to have been the case. There were other difficulties with the call, such as the EMD’s failure to recognise that a description of scratches all over might actually refer to a rash, missing the description of pupils no longer visible, and not thinking about the possibility of meningitis. These have, I was told at inquest, been addressed by training, but I remain concerned that such a method of attempting to elicit whether the patient is conscious or unconscious might be used by other EMDs. ”
Source location
Yusuf ABDISMAD · Prevention of Future Deaths report
Page 2 · concerns
Open source report
17 Dec2013
Cardiff & the Vale of Glamorgan
Concerns raised2
1. Risk of unnecessary death or injury to residents treated without appropriate assessment of unconsciousness
2. Failure to seek medical opinion for prolonged unconsciousness
This report raised 1 other concern. 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 6
1. Action
  Provide all staff with first-aid and life-support training focused on the immediate care of unconscious residents.
  Stated by Springbank Care Home LimitedStated planned
2. Action
  Assess nurses’ competency in recognising consciousness levels, providing and documenting life support, conducting neurological observations, and following relevant guidance.
  Stated by Springbank Care Home LimitedStated planned
3. Action
  Instruct staff to summon emergency services promptly for unconscious residents, follow valid DNNAR instructions, and use a protocol available to all staff.
  Stated by Springbank Care Home LimitedStated completed
1. Action
  Update residents’ risk assessments and care plans with specific information about causes of unconsciousness, including detailed epilepsy seizure types and recovery periods.
  Stated by Springbank Care Home LimitedStated planned
2. Action
  Provide the unconscious-person management protocol to occasional staff through agency induction materials.
  Stated by Springbank Care Home LimitedStated completed
3. Action
  Inform nurse agencies and provide their head offices with the unconscious-person management protocol.
  Stated by Springbank Care Home LimitedStated planned
AI-generated summary

Sandra Wordingham · 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

Sandra Wordingham, a resident of Springbank nursing home, was found unconscious after a suspected epileptic fit on 22 July 2013 and remained unconscious overnight before being taken to hospital. She died in hospital on 26 July 2013; the medical cause of death was recorded as intracerebral haemorrhage. The principal concern was that no medical opinion was sought despite her remaining unconscious for longer than expected after an epileptic fit, creating a risk to similarly treated residents.

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
Risk of unnecessary death or injury to residents treated without appropriate assessment of unconsciousness
Wider context from the report
“(3) Residents in an unconscious state who are treated in future in the same way as Sandra Wordingham may be at risk of unnecessary death or injury. ”
Source location
Sandra Wordingham · 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 seek medical opinion for prolonged unconsciousness
Wider context from the report
“(1) Sandra Wordingham, was put to bed in the nursing home in an unconscious state after a suspected epileptic fit. In fact she had suffered a sudden primary intracerebral haemorrhage. No medical opinion was sought even though Sandra Wordingham remained unconscious throughout the night for a longer period than would be expected after an epileptic fit. ”
Source location
Sandra Wordingham · 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 all staff with first-aid and life-support training focused on the immediate care of unconscious residents.

Verbatim wording from the response
“Improved First Aid & Life Support Training All staff to attend training with specific training element for the immediate care of the unconscious person Persons Responsible: ████████ Operations Manager Springbank & ████████ Manager Date By: Planned for March 2014.”

Source location
2013-0373-Response-by-Springbank-Nursing-Home
Page 3 · response
Published 17 December 2013
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
Assess nurses’ competency in recognising consciousness levels, providing and documenting life support, conducting neurological observations, and following relevant guidance.

Verbatim wording from the response
“Ensuring Nursing Staff Competency Following training and instruction nurses will have an assessment of their competency to:”

Source location
2013-0373-Response-by-Springbank-Nursing-Home
Page 3 · response
Published 17 December 2013
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
Instruct staff to summon emergency services promptly for unconscious residents, follow valid DNNAR instructions, and use a protocol available to all staff.

Verbatim wording from the response
“Summoning Emergency Assistance”

Source location
2013-0373-Response-by-Springbank-Nursing-Home
Page 4 · response
Published 17 December 2013
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
Update residents’ risk assessments and care plans with specific information about causes of unconsciousness, including detailed epilepsy seizure types and recovery periods.

Verbatim wording from the response
“Knowledge of probable reasons and causes for residents who may become unconscious due to epilepsy (and other illnesses)”

Source location
2013-0373-Response-by-Springbank-Nursing-Home
Page 4 · response
Published 17 December 2013
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 the unconscious-person management protocol to occasional staff through agency induction materials.

Verbatim wording from the response
“Providing & Sharing Information about the management of unconscious people with Bank and Agency Nurses working occasional shifts”

Source location
2013-0373-Response-by-Springbank-Nursing-Home
Page 4 · response
Published 17 December 2013
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
Inform nurse agencies and provide their head offices with the unconscious-person management protocol.

Verbatim wording from the response
“Providing & Sharing Information about the management of unconscious people with Bank and Agency Nurses working occasional shifts”

Source location
2013-0373-Response-by-Springbank-Nursing-Home
Page 4 · response
Published 17 December 2013
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Lack of clear training on assessing whether a person is responsive or unresponsive

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.9

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Concerns raised1

Failure to implement induction training on responding to suspected prisoner unconsciousness

Concerns raised1

Failure to distinguish cardiorespiratory arrest from unconsciousness during emergency assessment

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.2

Concerns raised1

Failure to use a clear method for establishing whether a patient is conscious or unconscious

Concerns raised2

Risk of unnecessary death or injury to residents treated without appropriate assessment of unconsciousness

Failure to seek medical opinion for prolonged unconsciousness

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.6

Actions described in response 9

Respondent positions 2

Actions described in response 2

Actions described in response 6