Recurring concern

Inadequate prison staff training for responding to medical emergencies

First to latest report 7 Nov 2014 — 21 May 2026

Reports that mention this concern
19
Times this concern has been raised
23
Stated actions linked to this concern
35

What this concern includes

Includes failures to provide, maintain, refresh or verify prison staff training and familiarisation specifically for responding to medical emergencies, including training for on-duty Governors and staff expected to use emergency-response procedures or systems such as ERIC.

What is not included
  • Excludes general prison staffing, communication, leadership or emergency-procedure deficiencies where inadequate staff training for medical-emergency response is not identified.
  • Excludes clinical training for healthcare professionals unless the assertion specifically concerns prison staff training for responding to medical emergencies.
  • Excludes first-aid or CPR training concerns where the report does not connect them to the broader prison staff medical-emergency response training process.
  • Excludes failures in the conduct of a particular medical emergency after staff training was adequate.

Reports and published responses 19 reports

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

  1. Dorset

    AI-generated summary

    George Edward James Haldenby · 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

    George Edward James Haldenby was a serving prisoner with severe heart failure who collapsed at HMP The Verne on 29 January 2022 and died that day at Dorset County Hospital. The report identifies delays in receiving an increased dose of Furosemide, and a delay in recognising the collapse and starting CPR, as substantive concerns. It also raises concerns about the absence of regular refresher training in first aid and CPR and the lack of a clear process for handling hospital prescriptions issued outside prison healthcare hours.

    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 refresher training in first aid and CPR for prison staff

    Wider context from the report

    “After prison officers and prison staff carry out their induction training which covers basic first aid training including the delivery of cardio pulmonary resuscitation (CPR), there is no further mandatory refresher training on first aid or CPR. During the evidence, a Custodial Manager at HMP the Verne stated that the last time he had first aid or CPR training was in 1991, 35 years ago, when he started as a prison officer. Whilst there is a requirement to have a duty first aider on site 24 hours a day, without all staff being suitably and regularly trained in signs of collapse and administering CPR, there could be a delay in delivering effective CPR as it may take time for the duty first aider to get to the prisoner, and a future death could occur. ”

    Source location

    George Edward James Haldenby · 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

    Provide ongoing refresher first-aid resources and learning materials, including bespoke first-on-scene emergency-response videos for prison and frontline staff.

    Verbatim wording from the response

    “You will be aware that all new prison officers receive mandatory Emergency First Aid and CPR training as part of their foundation programme. This training remains valid for three years and is subject to requalification. In addition, the HMPPS First Aid Policy Framework (re-issued in August 2023) requires Governors to maintain sufficient first aid provision based on a local First Aid Needs Assessment. To support staff capability, HMPPS provides ongoing refresher resources and learning materials to maintain and enhance first aid knowledge and skills. For example, HMPPS has worked with St John Ambulance to develop bespoke “first-on-scene” video resources for prison officers and frontline staff, offering practical guidance on responding to a range of emergency situations prior to the arrival of healthcare professionals.”

    Source location

    2026-0312 - Response from HM Prison and Probation Service
    Page 2 · response
    Published 14 August 2026

    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

    Undertake a comprehensive Training Needs Analysis to inform a structured First Aid training plan at HMP The Verne.

    Verbatim wording from the response

    “HMP The Verne is undertaking a comprehensive Training Needs Analysis to inform the development of a structured First Aid training plan. From July 2026, the prison intends to deliver monthly three-day First Aid at Work training programmes. These sessions will be jointly led by the Head of Business Assurance and supported by the Health and Safety Manager. The programme is designed to increase the number of staff trained to a recognised First Aid at Work standard and strengthen the prison’s emergency response capability. Increasing the number of staff trained in First Aid at Work will enable the implementation of a 24-hour, seven-day nominated staff rota, to ensure a coordinated and timely response to emergencies. The initial rollout of training will prioritise key staff groups, including Custodial Managers, Supervising Officers, Care and Separation Unit staff, and Induction Wing staff.”

    Source location

    2026-0312 - Response from HM Prison and Probation Service
    Page 2 · response
    Published 14 August 2026

    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

    Deliver monthly three-day First Aid at Work programmes from July 2026, supported by a forward-planned schedule of initial and refresher training.

    Verbatim wording from the response

    “HMP The Verne is undertaking a comprehensive Training Needs Analysis to inform the development of a structured First Aid training plan. From July 2026, the prison intends to deliver monthly three-day First Aid at Work training programmes. These sessions will be jointly led by the Head of Business Assurance and supported by the Health and Safety Manager. The programme is designed to increase the number of staff trained to a recognised First Aid at Work standard and strengthen the prison’s emergency response capability. Increasing the number of staff trained in First Aid at Work will enable the implementation of a 24-hour, seven-day nominated staff rota, to ensure a coordinated and timely response to emergencies. The initial rollout of training will prioritise key staff groups, including Custodial Managers, Supervising Officers, Care and Separation Unit staff, and Induction Wing staff.”

    Source location

    2026-0312 - Response from HM Prison and Probation Service
    Page 2 · response
    Published 14 August 2026

    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 prison officers’ refresher training lies with HM Prison and Probation Service, with the prisons minister best placed to respond.

    Verbatim wording from the response

    “The issue of training for prison officers is the responsibility of HM Prison and Probation Service, so NHS England is unable to answer this concern. We note that the Coroner has also addressed the Report to the Minister for Prisons, Probation and Reducing Reoffending, who will be best placed to answer this.”

    Source location

    2026-0312 - Response from NHS England
    Page 1 · response
    Published 14 August 2026

    Open published response

  2. Kent and Medway

    AI-generated summary

    Josh Yemi TARRANT · 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

    Josh Yemi Tarrant died at HMP Elmley on 1 November 2023 after cocaine intoxication and exertion during a lengthy and challenging restraint. The principal concern was that acute behavioural disturbance was not recognised by healthcare staff, who lacked relevant training, and that an ambulance was not called at the earliest appropriate opportunity.

    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 ABD training for prison healthcare staff

    Wider context from the report

    “I am concerned that: (a) No training is provided to prison healthcare staff in relation to ABD (despite the clear advice of PSO 1600). (b) If prison nurses remain unaware of ABD and the need to treat it as a medical emergency, then further deaths are likely in future. Accordingly, this situation should be reviewed and consideration given as to whether any steps should be taken to reduce the risk of death by from ABD. In particular, training of prison clinicians should be carefully reviewed at a national level. ”

    Source location

    Josh Yemi TARRANT · Prevention of Future Deaths report
    Page 6 · 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

    Ensure establishments include clear ABD red-flag criteria and emergency escalation pathways in healthcare training and operational briefings, with governance review of incidents.

    Verbatim wording from the response

    “We will be sharing the details of this report with all prison and Immigration Removal Centre healthcare providers with an action to ensure all establishments have a clear red flag criteria and emergency escalation pathway within existing healthcare training structures and operation briefings. This should include a focus on early recognition of deterioration, prompt ambulance activation where indicated, minimising restraint duration and maintaining continuous observation until handover, with routine governance review of such incidents.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 10 February 2026

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    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

    Prison healthcare staff cannot reasonably be expected to diagnose ABD reliably; safety depends on recognising severe agitation, physiological red flags and emergency escalation.

    Verbatim wording from the response

    “Given the rarity and complexity of ABD and the operational realities of prisons, it is not reasonable to expect prison healthcare staff to diagnose ABD reliably. The critical safety issue is recognition of severe agitation accompanied by physiological red flags and escalation as a medical emergency.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 10 February 2026

    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 available reviews do not identify ABD or excited delirium, suggesting the presentation was related to cocaine use and an undiagnosed heart condition.

    Verbatim wording from the response

    “South East Regional Colleagues have shared reports around the Trust’s PSII and PPOs independent review. South East Regional Colleagues have advised that both sets of reports identify that clinical staff should receive training in managing violence, aggression and mental health crises, as well as the fact some actions taken by staff, particularly around restraint, were not with current guidance and policy. Neither report shared mentions ABD or ‘Excited Delirium’, suggesting that Mr Tarrant’s presentation”

    Source location

    Response from NHS England
    Page 2 · response
    Published 10 February 2026

    Open published response

  3. Kent and Medway

    AI-generated summary

    Josh Yemi TARRANT · 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

    Josh Yemi Tarrant died at HMP Elmley on 1 November 2023 after cocaine toxicity following a lengthy and challenging restraint while experiencing an acute behavioural disturbance. The principal concerns were that the disturbance was not recognised by healthcare staff, that an ambulance was not called at the earliest appropriate opportunity, and that prison and healthcare staff lacked training in acute behavioural disturbance. The inquest jury found that the failure to provide sufficient medical treatment probably significantly contributed to his death and that his death was contributed to by neglect.

    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 prison officer training in acute behavioural disturbance (ABD)

    Wider context from the report

    “HMPPS acknowledged that, despite this clear guidance, the Prison Service stopped teaching officers about ABD (aka ‘Excited Delirium’) in 2015 and have not taught it since then. None of the officers who gave evidence in this inquest said that they had never been given any training in relation to ABD. Dr ████████ explained that ABD is a well-recognised condition. Indeed, SEAmb witnesses provided evidence in this inquest that, if their call handlers are told that a person is displaying signs of ABD whilst under restraint, the response would be upgraded to aa Category 1 response and the immediate despatch of a Critical Care Paramedic (“CCP”). Dr ████████ also stated that: (1) Mr Tarrant was displaying ‘textbook’ signs of ABD which would have been apparent to a properly trained person within a matter of minutes; (2) It was clearly a medical emergency that required the attendance of a CCP who would have provided sedation and other treatments; (3) Had treatment been initiated at any time before 1 am Mr Tarrant probably would have survived. I am concerned that: (a) No training is provided to prison officers in relation to ABD (despite the clear advice of PSO 1600). (b) If officers who are required to restrain prisoners remain unaware of ABD and the need to treat it as a medical emergency, then further deaths are likely in future. ”

    Source location

    Josh Yemi TARRANT · Prevention of Future Deaths report
    Page 6 · 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

    Consult clinical expertise to inform written guidance on recognising and escalating potential Acute Behavioural Disturbance emergencies.

    Verbatim wording from the response

    “In the period following the inquest, HMPPS has taken active steps to ensure staff are better supported in recognising and responding to behavioural and physiological indicators associated with ABD. We are currently consulting with ████████, whose clinical expertise is informing written guidance that will be issued to staff. This guidance is designed to equip officers with a clearer understanding of what signs may indicate ABD, while emphasising that the diagnosis and response to ABD rests solely with healthcare professionals. The intention is to ensure officers recognise potential medical emergencies quickly and escalate concerns appropriately.”

    Source location

    Response from HMP Elmley
    Page 1 · response
    Published 10 February 2026

    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 staff guidance explaining signs of Acute Behavioural Disturbance and appropriate escalation to healthcare professionals.

    Verbatim wording from the response

    “In the period following the inquest, HMPPS has taken active steps to ensure staff are better supported in recognising and responding to behavioural and physiological indicators associated with ABD. We are currently consulting with ████████, whose clinical expertise is informing written guidance that will be issued to staff. This guidance is designed to equip officers with a clearer understanding of what signs may indicate ABD, while emphasising that the diagnosis and response to ABD rests solely with healthcare professionals. The intention is to ensure officers recognise potential medical emergencies quickly and escalate concerns appropriately.”

    Source location

    Response from HMP Elmley
    Page 1 · response
    Published 10 February 2026

    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

    Diagnosis and response to Acute Behavioural Disturbance rest solely with healthcare professionals, while officers recognise indicators and escalate concerns.

    Verbatim wording from the response

    “In the period following the inquest, HMPPS has taken active steps to ensure staff are better supported in recognising and responding to behavioural and physiological indicators associated with ABD. We are currently consulting with ████████, whose clinical expertise is informing written guidance that will be issued to staff. This guidance is designed to equip officers with a clearer understanding of what signs may indicate ABD, while emphasising that the diagnosis and response to ABD rests solely with healthcare professionals. The intention is to ensure officers recognise potential medical emergencies quickly and escalate concerns appropriately.”

    Source location

    Response from HMP Elmley
    Page 1 · response
    Published 10 February 2026

    Open published response

  4. Kent and Medway

    AI-generated summary

    Josh Yemi TARRANT · 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

    Josh Yemi Tarrant died at HMP Elmley on 1 November 2023 after cocaine intoxication and a lengthy, challenging restraint while he was experiencing acute behavioural disturbance. The report raises concerns that acute behavioural disturbance was not recognised, that sufficient medical treatment was not provided at the earliest appropriate opportunity, and that prison staff lacked training to identify and respond to it.

    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 training for prison officers in relation to ABD

    Wider context from the report

    “HMPPS acknowledged that, despite this clear guidance, the Prison Service stopped teaching officers about ABD (aka ‘Excited Delirium’) in 2015 and have not taught it since then. None of the officers who gave evidence in this inquest said that they had never been given any training in relation to ABD. Dr████████ explained that ABD is a well-recognised condition. Indeed, SEAmb witnesses provided evidence in this inquest that, if their call handlers are told that a person is displaying signs of ABD whilst under restraint, the response would be upgraded to aa Category 1 response and the immediate despatch of a Critical Care Paramedic (“CCP”). Dr████████ also stated that: (1) Mr Tarrant was displaying ‘textbook’ signs of ABD which would have been apparent to a properly trained person within a matter of minutes; (2) It was clearly a medical emergency that required the attendance of a CCP who would have provided sedation and other treatments; (3) Had treatment been initiated at any time before 1 am Mr Tarrant probably would have survived. I am concerned that: (a) No training is provided to prison officers in relation to ABD (despite the clear advice of PSO 1600). (b) If officers who are required to restrain prisoners remain unaware of ABD and the need to treat it as a medical emergency, then further deaths are likely in future. Accordingly, this situation should be reviewed and consideration given as to whether any steps should be taken to reduce the risk of death by from ABD. In particular, training should be reviewed and assessed by the Prison Service with assistance from appropriately qualified clinicians. ”

    Source location

    Josh Yemi TARRANT · Prevention of Future Deaths report
    Page 6 · concerns

    Open source report

  5. Inner North London

    AI-generated summary

    Gareth Chumber-Kelly · 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

    Gareth Chumber-Kelly died after hanging himself while in custody at HMP Pentonville on 17 July 2023. The report identified concerns about lost or incomplete transfer documentation, inadequate recognition and management of suicide and self-harm risks, insufficient staff training, failures to provide basic life support, and inadequate staffing and support during crucial periods.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to provide regular mandatory basic life support training to prison officers

    Wider context from the report

    “(3) The court heard evidence that the first two officers on the scene failed to provide any form of basic life support despite having received training on how to do so. Both officers described how they panicked and did not know what to do. The court heard evidence from a consultant paramedic from the London Ambulance service with extensive experience in resuscitation who explained that for every minute without CPR there is a 10-22% drop in survival rates. It is critically important that the first person on the scene in such emergency situations (who will almost always be the prison officers) are properly and regularly trained in basic life support so that they are able to render such aid immediately on arrival. The Governor of the prison told the court that no refresher CPR training had been provided to prison staff since 2023 notwithstanding the 5 deaths of prisoners by ligature suspension that have occurred since. This is deeply concerning given that this very same issue was raised in a Prevention of Future Deaths Report by Mary Hassell, HM Senior Coroner of Inner North London on 18th September 2023 relating to the death of Amarjit Singh and yet in the 2 years since that PFD was issued there is still no mandatory basic life support training for prison officers. The failure of the prison to provide regular, mandatory basic life support to all prison officer creates a risk of future deaths. ”

    Source location

    Gareth Chumber-Kelly · Prevention of Future Deaths report
    Page 3 · 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

    Develop and provide first-aid instructional materials through staff e-learning platforms.

    Verbatim wording from the response

    “More widely, HMPPS develops staff capability through refresher courses and communication packages. Materials, including instructional videos, have been developed and are available to staff through E-learning platforms to update and maintain their first aid knowledge and skills. These provide practical guidance on what to do in several potential scenarios that staff may encounter in the course of their duties.”

    Source location

    Response from HMPPS
    Page 3 · response
    Published 12 February 2026

    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

    Deliver basic life-saving and CPR refresher sessions to staff through qualified Physical Education Instructors.

    Verbatim wording from the response

    “The Pentonville Speed School will support this work by utilising Physical Education Instructors, who are qualified first aid trainers, to deliver basic life-saving skills to staff, including training in CPR. These short, practical sessions will ensure that staff receive essential refresher training and thereby increasing their confidence when responding to medical emergencies. In addition, HMP Pentonville is promoting the first aid at work course and encouraging wider staff participation to ensure that key areas of the establishment maintain sufficient qualified first aiders.”

    Source location

    Response from HMPPS
    Page 3 · response
    Published 12 February 2026

    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

    Promote the first-aid-at-work course and encourage wider staff participation to maintain sufficient qualified first aiders.

    Verbatim wording from the response

    “The Pentonville Speed School will support this work by utilising Physical Education Instructors, who are qualified first aid trainers, to deliver basic life-saving skills to staff, including training in CPR. These short, practical sessions will ensure that staff receive essential refresher training and thereby increasing their confidence when responding to medical emergencies. In addition, HMP Pentonville is promoting the first aid at work course and encouraging wider staff participation to ensure that key areas of the establishment maintain sufficient qualified first aiders.”

    Source location

    Response from HMPPS
    Page 3 · response
    Published 12 February 2026

    Open published response

  6. Dorset

    AI-generated summary

    Colin David Lovett · 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 29 October 2022, Colin David Lovett was found collapsed and unresponsive in his room at HMP The Verne. The report raised concerns about prison staff’s lack of awareness and training regarding diabetes, limited out-of-hours healthcare access, and the support available to prisoners with insulin-dependent diabetes. It also identified concerns about telephone-call monitoring, access to medication, and the adequacy of risk management and support at HMP The Verne.

    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 diabetes training and awareness among Prison Service staff

    Wider context from the report

    “(1) Evidence was provided by Prison Service staff during the Inquest that they have never received training about diabetes and there is a lack of understanding, and national guidance for Prison Service staff relating to the symptoms of a hypo glycaemic or hyper glycaemic attack, which can be fatal. (2) The healthcare department at HMP The Verne is only operated between 7.30am and 6pm daily and is not therefore available 24 hours a day. Outside of these operational times, access to healthcare would be via 111 or 999 which could cause delay in action being taken to resolve a hypo glycaemic or hyper glycaemic attack. This will be the position in other prisons nationally. (3) Whilst insulin dependent diabetics are likely to be experts in their own care, some prisoners may have poorly managed diabetes and require support which could be at any time. (4) It is acknowledged that there is a balance to be stuck with training non-medical individuals in diagnosing medical symptoms, which could lead to miss diagnosis, and ensuring care is provided without delay, however the Head of Healthcare at HMP The Verne stated that there would be benefit in providing an awareness to Prison Service staff of the impact on prisoners of long term conditions such as diabetes. (5) Several members of Prison Service staff gave evidence at the Inquest and only one, who had personal experience through a family member, had an understanding of diabetes and the impact it can have upon an individual, including the symptoms of a hypo glycaemic or hyper glycaemic attack. (6) Prisoners are dependent upon support provided by Prison Staff. I am concerned that the lack of awareness of the needs of prisoners with insulin dependent diabetes amongst Prison Service staff who provide care to prisoners at times when healthcare staff are not on site, could lead to future deaths. ”

    Source location

    Colin David Lovett · 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

    Discussed local diabetes awareness needs with the healthcare provider at HMP The Verne.

    Verbatim wording from the response

    “This is precisely what has now happened at The Verne where following discussion with the Governor, the healthcare provider has provided a diabetes awareness and guidance document which has been disseminated to all staff.”

    Source location

    Response from HMPPS
    Page 2 · response
    Published 10 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

    Requiring all operational prison staff to undertake diabetes-specific training is unnecessary because training time is prioritised for higher-priority or broadly applicable topics.

    Verbatim wording from the response

    “I understand your concern to ensure that prisoners with diabetes receive high quality care. However, I do not believe that it is necessary or appropriate to require all operational prison staff to undertake specific training or awareness sessions relating to diabetes. Training time is limited and there are many other topics that are of higher priority and/or have more general application. Instead, where a healthcare provider identifies a need for prison officers to have increased awareness of diabetes (or any other particular medical condition) locally, they are able to raise this with the Governor and consideration can then be given to developing local awareness sessions, which can be delivered by healthcare staff as deemed necessary.”

    Source location

    Response from HMPPS
    Page 2 · response
    Published 10 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

    Training, guidance and diabetes awareness for prison staff are to be addressed by His Majesty’s Prison and Probation Service.

    Verbatim wording from the response

    “In preparing this response, my officials have made enquiries with NHS England to ensure we adequately address your concerns related to healthcare services at the prison. Your other concerns regarding issues related to training, guidance and raising awareness of diabetes for prison staff are for the Director General Chief Executive of His Majesty’s Prison and Probation Service to address in their response to you.”

    Source location

    Response from Department of Health and Social Care
    Page 1 · response
    Published 10 June 2025

    Open published response

  7. Inner West London

    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 of first aid training to be prison specific for recognising 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

  8. Derby and Derbyshire

    AI-generated summary

    Paul Edward DAY · 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

    Paul Edward Day was found collapsed and unresponsive in a prison toilet cubicle on 22 March 2017 after exposure to cold running water from a broken pipe. Prison officers did not attempt CPR because they believed he was in rigor mortis; CPR was started about 15 minutes later, but he subsequently died in hospital in the early hours of 23 March. The principal concern was that national prison CPR guidance included rigor mortis as an exclusion, despite prison officers not being trained to recognise it, creating a risk that CPR could be withheld in prisons without 24-hour healthcare staffing.

    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 train prison officers to assess and recognise rigor mortis for CPR decisions

    Wider context from the report

    “1. I understand that the prison guidance re CPR which I have referenced, is in effect guidance provided nationally to all prisons. The inclusion of rigor mortis in the exclusions for CPR is something of an outlier as compared to the other reasons which would clearly and obviously evidence that death had occurred, even to someone without first aid training. In those prisons without 24-hour healthcare staffing prison officer staff are operating under guidance that they are not trained to be able to follow (re rigor mortis). In prisons with 24-hour healthcare staffing it is likely that healthcare staff would attend a resuscitation incident. 2. Given the current guidance, in those prisons without 24-hour healthcare staffing, and where prison officer staff attend a prisoner in a state of collapse who is not breathing and is pulseless, there is the clear potential to mistakenly assess the person to be in a state of rigor mortis, and thus miss the opportunity to undertake CPR and potentially prevent death, because quite clearly they have not been trained to assess for and recognise rigor mortis. This was very clearly illustrated in Mr Day’s inquest. 3. The current CPR guidance does not appear to be appropriate for those prisons without 24-hour healthcare staffing, and in my view presents the real risk that future deaths could occur unless action is taken. ”

    Source location

    Paul Edward DAY · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  9. Inner North London

    AI-generated summary

    Amarjit SINGH · 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

    Amarjit Singh, aged 41, was found dead in his cell at HMP Pentonville on the morning of 21 November 2021 after his cellmate reported that he had suffered a fit, but medical attention was not sought and the cell door remained locked. The inquest jury determined that he died from natural causes, contributed to by neglect. Outstanding concerns included a careless cell-sharing risk assessment and gaps in prison staff and prisoner guidance and first-aid understanding, including failures to recognise the need for CPR or distinguish unconsciousness from death.

    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 seizure-response training for prison staff

    Wider context from the report

    “2. Though I was told that training for prison staff in how to deal with fits is to be given at HMP Pentonville in October 2023, I heard that there is only a hope that prisoners will also receive some guidance in what to do if their cellmate suffers a fit. Apparently, this has already been implemented in HMP Brixton. ”

    Source location

    Amarjit SINGH · Prevention of Future Deaths report
    Page 2 · 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

    Lack of ongoing first aid training for prison officers

    Wider context from the report

    “3. Whilst the fact that not all prison officers receive ongoing first aid training is a national resourcing issue, the level of first aid understanding of some prison officers at HMP Pentonville seemed surprisingly low. One officer told me that it did not cross his mind to start CPR in the three minutes it took nurses to arrive after Mr Singh was found not breathing. (Mr Singh had been assessed by a custodial manager as having died, but the other officer did not know this at the time.) A different officer told me he did not know that there is a difference between a person who is unconscious and a person who is dead. ”

    Source location

    Amarjit SINGH · 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

    Schedule training for prison staff at HMP Pentonville on responding to fits.

    Verbatim wording from the response

    “Training for prison staff in how to deal with fits is scheduled to be given at HMP Pentonville in October, and prisoners are given instructions at their induction on how to report concerns regarding a cellmate and the need to ring the emergency cell bell in circumstances where their cellmate is unwell so that staff can ensure healthcare attend.”

    Source location

    Response from HM Prison and Probation Service
    Page 2 · response
    Published 22 September 2023

    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

    Prison authorities, rather than healthcare, are responsible for addressing staff training and prisoner guidance on managing seizures and first aid.

    Verbatim wording from the response

    “Only number 1 above relates to healthcare, and therefore PPG, so we do not propose to respond to points 2 and 3, which no doubt will be addressed by the Prison.”

    Source location

    Response from Practice Plus Group
    Page 2 · response
    Published 22 September 2023

    Open published response

  10. Inner South London

    AI-generated summary

    Mr Nathan Forrester · 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 Nathan Forrester died in a shared prison cell after consuming illicit drugs, and the jury concluded that he died of a drug-related death. Concerns included delays and insufficient training in removing an unresponsive prisoner from a top bunk for CPR, and gaps in nurses’ CPR, airway-management and handover training in detention settings.

    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 prison officer training for assessment, removal and immediate CPR of prisoners on top bunks

    Wider context from the report

    “1. Deaths on top bunks (HMPPS) The first prison officer to arrive and find Mr Forrester unresponsive to voice, blue and cold, decided she was too small to be able to get him off his top bunk, even with a colleague, and left the cell. A second officer, having confirmed no pulse or response to pain, stated that there was no specific training on how to manage an arrest and CPR of a person on a top bunk. He tried unsuccessfully to bring him down. A third officer attending did not attempt to do so. After some delay, nurses brought him down to floor level when they arrived. The Head of Safer Custody has asked the local health service provider to advise how prison officers should be trained to manage assessment, removal and immediate CPR of a prisoner on a top bunk. The concern is that this training gap may exist in other establishments. ”

    Source location

    Mr Nathan Forrester · 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

    Provide initial first-aid training covering movement of unresponsive prisoners to a hard, flat surface before CPR.

    Verbatim wording from the response

    “I can confirm that all new prison officers receive first aid training as part of their initial prison officer training. The training covers the requirement to move individuals to a hard, flat surface before commencing CPR, and as such staff are aware that anyone found unresponsive on a top bunk bed would need to be brought to the floor prior to commencing CPR. The Learning and Development team, responsible for the management and delivery of training for HMPPS staff, also provide training in manual handling and movement of prisoners to ensure that our staff are well equipped with the skills to move a prisoner in order to enable CPR and emergency first aid to commence.”

    Source location

    Response from HM Prison and Probation Service
    Page 1 · response
    Published 31 January 2023

    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 manual-handling and prisoner-movement training to equip staff to move prisoners for CPR and emergency first aid.

    Verbatim wording from the response

    “I can confirm that all new prison officers receive first aid training as part of their initial prison officer training. The training covers the requirement to move individuals to a hard, flat surface before commencing CPR, and as such staff are aware that anyone found unresponsive on a top bunk bed would need to be brought to the floor prior to commencing CPR. The Learning and Development team, responsible for the management and delivery of training for HMPPS staff, also provide training in manual handling and movement of prisoners to ensure that our staff are well equipped with the skills to move a prisoner in order to enable CPR and emergency first aid to commence.”

    Source location

    Response from HM Prison and Probation Service
    Page 1 · response
    Published 31 January 2023

    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

    Make manual-handling training available digitally through initial induction and an e-learning platform accessible to all staff.

    Verbatim wording from the response

    “Manual handling training has recently been updated to a digital format and all new prison officers complete this during their initial training induction. In addition, there is e-learning available to all staff on MyLearning which is the digital learning platform used by HMPPS.”

    Source location

    Response from HM Prison and Probation Service
    Page 1 · response
    Published 31 January 2023

    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

    Existing first aid and manual handling training is considered sufficient for officers to move prisoners and commence CPR.

    Verbatim wording from the response

    “I can confirm that all new prison officers receive first aid training as part of their initial prison officer training. The training covers the requirement to move individuals to a hard, flat surface before commencing CPR, and as such staff are aware that anyone found unresponsive on a top bunk bed would need to be brought to the floor prior to commencing CPR. The Learning and Development team, responsible for the management and delivery of training for HMPPS staff, also provide training in manual handling and movement of prisoners to ensure that our staff are well equipped with the skills to move a prisoner in order to enable CPR and emergency first aid to commence.”

    Source location

    Response from HM Prison and Probation Service
    Page 1 · response
    Published 31 January 2023

    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

    HMPPS is responsible for training prison officers to manage prisoners on top bunks and will respond directly.

    Verbatim wording from the response

    “1. Deaths on top bunks (HMPPS)”

    Source location

    Response from NHS England
    Page 1 · response
    Published 31 January 2023

    Open published response

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

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Data last updated 7 September 2026