Recurring concern

Unreliable emergency response to patient collapse

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First reported 16 Dec 2013•Latest report 26 May 2026

Definition

What this concern includes

Includes failures in the dedicated emergency-response process for a collapsed patient, including response guidance and policies, staff training and familiarity with emergency systems, recognition and escalation, emergency equipment use, attendance, positioning and resuscitation actions.

Not included

Excludes generic emergency-response or resuscitation deficiencies where patient collapse is not the identified operational context.
Excludes failures limited to later hospital treatment, admission or post-resuscitation care after the immediate collapse response was adequate.
Excludes generic staffing, communication or documentation deficiencies unless they directly impair the emergency response to patient collapse.
Excludes condition-specific emergency systems, such as Code Blue or agonal-breathing recognition, when that named system provides the more specific supported parent boundary.
Excludes the occurrence or outcome of a collapse where no deficiency in the dedicated response process is identified.

Reports: 33
Individual concerns: 47
Date range: 2013–2026
Stated actions: 77

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.

East London NHS Foundation Trust3

Ministry of Justice3

NHS England3

Central and North West London NHS Foundation Trust2

Department of Health and Social Care2

Essex Partnership University NHS Foundation Trust2

HM Prison and Probation Service2

Metropolitan Police Service2

Aspray House1

Barts Health NHS Trust1

Broadmoor Hospital1

Bupa Care Homes (GL) Limited1

Caremark (Chiltern & Three Rivers)1

Care Quality Commission1

Greater Manchester Mental Health NHS Foundation Trust1

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.

26 May2026
West Sussex, Brighton and Hove
Concerns raised1
1. Failure to coordinate cardiac-arrest responses
This report raised 6 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 3
1. Action
  Deliver regular unannounced emergency simulation training to strengthen staff confidence and response to cardiac arrest and opioid overdose.
  Stated by SPFTStated completed
2. Action
  Update the Resus policy to require monthly clinical and non-clinical emergency simulations across inpatient hospitals.
  Stated by SPFTStated completed
3. Action
  Develop a structured ward-level improvement plan to clarify responsibilities, improve documentation and track actions through to completion.
  Stated by SPFTStated in progress
Respondent positions 1
1. Position
  Existing Trust actions embedded in policy, training, governance and ward-level processes are considered sufficient; no further new actions are needed.
  Stated by SPFTExisting arrangements considered sufficient
AI-generated summary

Kristian Edward Allen · 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

Kristian Edward Allen, who had complex mental health issues and a history of drug and alcohol abuse, died at Millview Hospital on 16 February 2025 after taking heroin, cocaine and alcohol. The report identifies concerns about inappropriate authorisation of leave, inadequate searches and observations, poor communication, and a delayed and ineffective response to his cardiac arrest. The concerns also include staff being insufficiently trained to manage cardiac arrests and drug overdoses in acute mental health wards.

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 coordinate cardiac-arrest responses
Wider context from the report
“I am also concerned that staff are not properly able to deal with cardiac arrests in acute mental health wards. In Kristian’s inquest, evidence was heard that the response to Kristian’s arrest was chaotic and disorganised. Nobody appeared to be in charge, staff were unable to do CPR properly, the 999 call was of a poor standard, there were considerable delays in contacting 999 and the on call doctor and the staff did not have Naloxone training. I had the same issues in an Inquest I did nine months ago in the exact same ward, indeed in the neighbouring room. The fact that the same set of facts have repeated themselves in Kristian’s case leads me to a very real concern that future deaths will happen if action is not taken. ”
Source location
Kristian Edward Allen · 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
Deliver regular unannounced emergency simulation training to strengthen staff confidence and response to cardiac arrest and opioid overdose.

Verbatim wording from the response
“Response to cardiac arrest I appreciate your concern in relation to staff not being properly able to deal with cardiac arrests. You will have heard how this was recognised within the Trust's PSII and the need to strengthen preparedness and response to medical emergencies, including opioid overdose, resulted in recommended action. The identified action was the need to increase staff confidence in administering Immediate Life Support (ILS). I am informed that the Inquest heard of the impact upon staff of conducting ILS and how their confidence can be impacted by the rarity of having to conduct ILS. I confirm, as you heard, that as a direct action from the PSII into Kristian's death the Trust introduced regular simulation training ie: unannounced emergency simulations to which staff then have to respond.”

Source location
Response from Sussex Partnership Foundation Trust
Page 3 · response
Published 22 June 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
Update the Resus policy to require monthly clinical and non-clinical emergency simulations across inpatient hospitals.

Verbatim wording from the response
“As you also heard in evidence the Trust's Resus policy has been updated to formalise the inclusion of simulation as standard in both clinical and non-clinical areas to enhance and embed medical emergency and cardiac arrest training, thereby ensuring staff remain competent and confident with emergency processes and procedures. The policy stipulates that simulations will be completed monthly throughout SPFT in inpatient hospitals. As ████████ informed you, the most recent simulation on Kristian's ward took place on 20th May, involving 8 staff and simulated a scenario of an opioid overdose leading to cardiac arrest. I am informed that feedback from the ILS team was that the ward-team's response was well led.”

Source location
Response from Sussex Partnership Foundation Trust
Page 3 · response
Published 22 June 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
Develop a structured ward-level improvement plan to clarify responsibilities, improve documentation and track actions through to completion.

Verbatim wording from the response
“Additionally, Mill View Hospital, as a whole, have been subject to external review by recognised specialist consultants in organisational performance and service improvement. Their work has focused on strengthening ward-level processes and operational consistency, including clarifying roles and responsibilities, improving documentation standards, and ensuring that actions agreed in MDTs and reviews are clearly recorded, owned and followed through. This has supported the development of a structured ward-level improvement plan, enabling learning, including from PSIIs, to be translated into consistent day-to-day practice and more reliable delivery of care processes.”

Source location
Response from Sussex Partnership Foundation Trust
Page 4 · response
Published 22 June 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
Existing Trust actions embedded in policy, training, governance and ward-level processes are considered sufficient; no further new actions are needed.

Verbatim wording from the response
“In summary, given the comprehensive range of actions already taken by the Trust there are no further new actions that I consider the Trust needs to take. That said, as I recognised above, all improvement requires sustained, committed focus. So, whilst I can already say that the actions described above are now embedded within policy, training, governance and ward-level quality improvement processes, which are subject to ongoing monitoring to ensure improvements continue, I would like to assure you that the oversight and focus on”

Source location
Response from Sussex Partnership Foundation Trust
Page 4 · response
Published 22 June 2026
Open published response
24 Mar2026
Milton Keynes
Concerns raised1
1. Failure to recognise suspected synthetic cannabinoid intoxication promptly during collapse response
This report raised 15 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 3
1. Action
  Provide structured assessment tools, escalation expectations and clinical leadership to improve recognition and response to synthetic-cannabinoid deterioration.
  Stated by Central and North West London NHS Foundation TrustStated completed
2. Action
  Train clinical staff to recognise deterioration using NEWS2 and reinforce escalation pathways across services.
  Stated by Central and North West London NHS Foundation TrustStated completed
3. Action
  Participate in joint simulation exercises and prison-led first-aid and emergency-response training.
  Stated by Central and North West London NHS Foundation TrustStated in progress
AI-generated summary

Ronald William MEIKLE · 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

Ronald William Meikle was found unresponsive in his single-occupancy cell at HMP Woodhill on 30 April 2024 and was pronounced dead at 09:43. The report identified concerns about illicit substances, inconsistent responses to suspected intoxication, fragmented information-sharing, inadequate welfare observations, management of self-isolation and vulnerability, absence of ACCT proceedings, mental-health input, emergency response, staffing, and recurring systemic problems at the prison.

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 recognise suspected synthetic cannabinoid intoxication promptly during collapse response
Wider context from the report
“Concern 9: Emergency response to suspected synthetic cannabinoid collapse The evidence raised concern about whether staff responding to collapse were adequately trained and equipped to consider synthetic cannabinoid intoxication promptly as a possible cause. Synthetic cannabinoid use can cause rapid deterioration and death. If staff do not recognise that possibility, there is a risk of delay in appropriate emergency action, clinical escalation and treatment. ”
Source location
Ronald William MEIKLE · 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
Provide structured assessment tools, escalation expectations and clinical leadership to improve recognition and response to synthetic-cannabinoid deterioration.

Verbatim wording from the response
“Concern 9: Emergency response to suspected synthetic cannabinoid collapse We have improved staff capability to recognise deterioration linked to synthetic cannabinoid use by providing structured assessment tools, clear escalation expectations, and more visible clinical leadership. All CNWL clinical staff receive training in recognising deterioration using the NEWS2 protocol, and we have reinforced clear escalation pathways across our services, ensuring every clinician understands how and when to escalate concerns. We actively participate in joint simulation exercises and contribute to prison-led first aid and emergency response”

Source location
Response from Central & North West London NHS Foundation Trust
Page 2 · response
Published 26 March 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
Train clinical staff to recognise deterioration using NEWS2 and reinforce escalation pathways across services.

Verbatim wording from the response
“Concern 9: Emergency response to suspected synthetic cannabinoid collapse We have improved staff capability to recognise deterioration linked to synthetic cannabinoid use by providing structured assessment tools, clear escalation expectations, and more visible clinical leadership. All CNWL clinical staff receive training in recognising deterioration using the NEWS2 protocol, and we have reinforced clear escalation pathways across our services, ensuring every clinician understands how and when to escalate concerns. We actively participate in joint simulation exercises and contribute to prison-led first aid and emergency response”

Source location
Response from Central & North West London NHS Foundation Trust
Page 2 · response
Published 26 March 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
Participate in joint simulation exercises and prison-led first-aid and emergency-response training.

Verbatim wording from the response
“Concern 9: Emergency response to suspected synthetic cannabinoid collapse We have improved staff capability to recognise deterioration linked to synthetic cannabinoid use by providing structured assessment tools, clear escalation expectations, and more visible clinical leadership. All CNWL clinical staff receive training in recognising deterioration using the NEWS2 protocol, and we have reinforced clear escalation pathways across our services, ensuring every clinician understands how and when to escalate concerns. We actively participate in joint simulation exercises and contribute to prison-led first aid and emergency response”

Source location
Response from Central & North West London NHS Foundation Trust
Page 2 · response
Published 26 March 2026
Open published response
20 Feb2026
Inner North London
Concerns raised1
1. Delays in opening a detainee cell and administering emergency first aid
This report raised 11 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 4
1. Action
  Revise relevant prisoner welfare, vehicle escort, death-in-custody and associated procedures, and align corresponding training materials.
  Stated by Serco Group plcStated completed
2. Action
  Create and require staff to complete a separate online medical-emergency vehicle course covering emergency response, basic life support and related vehicle incidents, with an 80% pass threshold.
  Stated by Serco Group plcStated completed
3. Action
  Develop and display laminated emergency-response flowcharts in escort vehicles to clarify required actions and support consistent responses.
  Stated by Serco Group plcStated completed
1. Action
  Develop and display an OCC emergency flowchart with structured prompt questions at controller desks to standardise alarm-activation responses.
  Stated by Serco Group plcStated completed
AI-generated summary

Sean Perry WILLIAMS · 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

Sean Williams died in the back of a Serco van outside Thames Magistrates’ Court after suffering a fit during transport and then a cardiac arrest. Concerns included gaps in his custody healthcare assessment and treatment, inadequate Serco first-aid training and competence assessment, failure to provide timely first aid, unclear emergency procedures, and insufficient emphasis on preserving life.

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
Delays in opening a detainee cell and administering emergency first aid
Wider context from the report
“For the MPS The MPS had already recognised before inquest that, following Mr Williams’ detention, he was not seen by a custody nurse for 23 hours. However, there was another sub optimal element of his care that did not appear to have been identified. The custody nurse who reviewed Mr Williams on two separate occasions in the twelve hours immediately before he attended court, did not on the second occasion take any observations of Mr Williams’ vital signs before (or after) prescribing dihydrocodeine, and did not record any part of Mr Williams’ clinical picture. Despite having prescribed dihydrocodeine for drug withdrawal, when giving evidence in court the nurse was unable to describe the signs and symptoms of withdrawal. For Serco By 18.11 hours, the Serco van that was transporting Mr Williams had returned to the court car park entrance and the driver had got out of the cab and into the back of the van. At that point, neither the escort nor the driver opened the door to Mr Williams’ cell to administer first aid - at the very least to relieve his slumped, squashed position to try to deal with any potential airway obstruction. At 18.15 hours when he stopped showing any signs of life, they still did not open his door. They only opened his door at 18.23 hours, removing him from the cell at 18.24 hours, and administering chest compressions at 18.25 hours. The driver did not press the emergency button in the cab to alert the operations control centre of the situation. The Serco crew did call the London Ambulance Service from the van, but were unable to give the postcode of their location. I put it to the Serco driver that the focus of the two Serco crew members seemed to be on talking to the three other prisoners in their cells, on phone calls, in fact on anything except getting Mr Williams out of his cell to see if the crew could help him. The driver agreed. The Serco driver eventually administered chest compressions but could not face giving rescue breaths. He seemed to have forgotten that he had a face guard hanging from his belt. Despite evidence from Serco that they were satisfied with the first aid training that was given to the two officers, the jury found that: - the Serco first aid training was inadequate; - it did not include a video of a seizure; - it did not sufficiently emphasise the urgency of potentially life saving measures such as use of the recovery position; - the Serco assessment of the first aid knowledge and competence of its staff was inadequate; - Serco failed to provide clear guidance on the emergency button procedures; - Serco’s policy appeared to conflict with its training slides about whether staff should or are even permitted to drive a casualty direct to hospital; - Serco gave insufficient emphasis on urgency and the paramount importance of preserving life. ”
Source location
Sean Perry WILLIAMS · 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
Revise relevant prisoner welfare, vehicle escort, death-in-custody and associated procedures, and align corresponding training materials.

Verbatim wording from the response
“Since the death of Mr Williams we have revised Standard Operating Procedure (SOP) 038 Prisoner Welfare on a Vehicle, SOP 009 Duties of a Vehicle Escort Officer and SOP 047 Death or attempted suicide of a prisoner in custody, to improve the clarity of the steps to be taken where a medical emergency is suspected and I understand copies of the updated SOPs have been provided to you. The changes have also been reflected in other SOPs and training documents to ensure consistency.”

Source location
Response from Serco
Page 1 · response
Published 24 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
Create and require staff to complete a separate online medical-emergency vehicle course covering emergency response, basic life support and related vehicle incidents, with an 80% pass threshold.

Verbatim wording from the response
“In addition, in order to remind staff of the required process and aid their retention of the information provided during the training, in March 2025 we created a new online course on Serco’s LMS. This is a mandatory course for all staff members and includes what to do in an emergency medical incident, basic life support, self-harm incidents, vehicle breakdown, fire and anything deemed a vehicle emergency. The content provides a refresher of the training covered in the ITC course, to reinforce learning and gives additional prominence by being a separate module and links together the concepts that staff have learned during their Highfield First Aid training.”

Source location
Response from Serco
Page 3 · response
Published 24 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
Develop and display laminated emergency-response flowcharts in escort vehicles to clarify required actions and support consistent responses.

Verbatim wording from the response
“As outlined by Serco’s Head of Professional Standards and Security in his evidence, and to support staff on scene in following the correct process, Serco has developed a flowchart for escort officers following the death of Mr Williams. A copy appears in the Inquest bundle. This has since been incorporated into training, and laminated copies are now displayed within all escort vehicles in a position visible from the escort seat. The intention is that this readily accessible guide will reinforce existing training, clarify the required steps, and support escort officers in responding with confidence and consistency during suspected medical emergencies.”

Source location
Response from Serco
Page 4 · response
Published 24 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
Develop and display an OCC emergency flowchart with structured prompt questions at controller desks to standardise alarm-activation responses.

Verbatim wording from the response
“Serco has also developed a corresponding flowchart for the OCC to reflect that provided to PCOs, together with structured prompt questions to assist OCC controllers in identifying the nature of an emergency and providing appropriate support and direction to PCOs when an incident occurs. A copy of the OCC flowchart has also been provided.”

Source location
Response from Serco
Page 4 · response
Published 24 February 2026
Open published response
8 Feb2026
Essex
Concerns raised2
1. Delay in bringing the emergency grab bag
2. Delay in obtaining and attaching the defibrillator
This report raised 29 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 3
1. Action
  Implement deteriorating-patient, non-touch-observation and emergency-call guidance tools and disseminate their learning to staff.
  Stated by Essex Partnership University NHS Foundation TrustStated completed
2. Action
  Introduce Resus Link Practitioners across inpatient wards to support simulations, equipment readiness, life-support training, audit and dissemination of updates.
  Stated by Essex Partnership University NHS Foundation TrustStated completed
3. Action
  Undertake medical-emergency simulations every three months in inpatient settings and record them using the approved report.
  Stated by Essex Partnership University NHS Foundation TrustStated completed
AI-generated summary

Elise Kay Louise Sebastian · 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

Elise Kay Louise Sebastian tied a fatal ligature in her room on Longview Ward on 17 April 2021 and died two days later in hospital. The principal concerns included inadequate and falsified observations, insufficiently trained and staffed ward personnel, poor communication about ligaturing and self-harm, medication-recording errors, failures involving Oxevision, and other care and record-keeping deficiencies.

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
Delay in bringing the emergency grab bag
Wider context from the report
“10. Whilst this did not directly cause Elise’s death, there were plenty of staff who responded quickly to the emergency when Elise was found unresponsive but there was a delay: a. bringing the grab bag to this emergency b. obtaining and attaching the defibrillator. c. In notifying the duty doctor who was not contacted for over 40 minutes. d. The expert witness was of the opinion once the defibrillator was attached, it was being switched on and off in the first few minutes. When looking at the machine analysis there appeared to be 3 analysis checks on the machine within the first few minutes when the machine is set to conduct analysis at set intervals which is inconsistent with this. ”
Source location
Elise Kay Louise Sebastian · Prevention of Future Deaths report
Page 5 · 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
Delay in obtaining and attaching the defibrillator
Wider context from the report
“10. Whilst this did not directly cause Elise’s death, there were plenty of staff who responded quickly to the emergency when Elise was found unresponsive but there was a delay: a. bringing the grab bag to this emergency b. obtaining and attaching the defibrillator. c. In notifying the duty doctor who was not contacted for over 40 minutes. d. The expert witness was of the opinion once the defibrillator was attached, it was being switched on and off in the first few minutes. When looking at the machine analysis there appeared to be 3 analysis checks on the machine within the first few minutes when the machine is set to conduct analysis at set intervals which is inconsistent with this. ”
Source location
Elise Kay Louise Sebastian · Prevention of Future Deaths report
Page 5 · 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
Implement deteriorating-patient, non-touch-observation and emergency-call guidance tools and disseminate their learning to staff.

Verbatim wording from the response
“The ‘Assessing a Critically Unwell Patient’ Aide memoir document has been implemented within EPUT. The aim of the document is to help identify the deteriorating patient, treat and stabilise in order to prevent cardiac arrest and the resus bag will be taken to every unwell patient if an alarm is raised. The tool acts as an aide memoir to support the team carrying out the physical health assessment of the unwell patient. The aide-memoire must be located within the resus bags on the wards, so staff have easy access to the guidance during a medical emergency.”

Source location
2026-0078 - Response from Essex University Partnership Trust
Page 12 · response
Published 13 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
Introduce Resus Link Practitioners across inpatient wards to support simulations, equipment readiness, life-support training, audit and dissemination of updates.

Verbatim wording from the response
“The Trust has also introduced the role of Resus Link Practitioners (RLP) to all inpatient ward settings. These volunteers will play a key role in strengthening the response to medical emergency situations within the wards. The role is open to all nurses and HCAs/support workers and the RLP will act as a link between the Resuscitation and Deteriorating Patient Group and their ward, promoting best practice and raising awareness. The RLP will:”

Source location
2026-0078 - Response from Essex University Partnership Trust
Page 13 · response
Published 13 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
Undertake medical-emergency simulations every three months in inpatient settings and record them using the approved report.

Verbatim wording from the response
“The Essex Partnership NHS Foundation Trust’s CPR procedure document (CLPG14A) states the Ward Manager, Matron or Service Manager/Clinical lead for each inpatient setting, will be responsible for ensuring that medical emergency simulations are undertaken every three months in the clinical environment. Each inpatient setting must record when a medical emergency simulation is facilitated, using the approved ‘Medical Emergency Simulation Practice Report’”

Source location
2026-0078 - Response from Essex University Partnership Trust
Page 12 · response
Published 13 February 2026
Open published response
17 Nov2025
Essex
Concerns raised1
1. Failure to make an emergency call for an unresponsive patient
This report raised 18 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 1
1. Action
  Include the emergency department escalation process in area-specific orientation for nurses redeployed from their base wards.
  Stated by the Princess Alexandra Hospital NHS TrustStated planned
Respondent positions 2
1. Position
  The hospital trust is responsible for providing the response and addressing the reported concerns through its governance arrangements and actions.
  Stated by NHS EnglandRedirects responsibility
1. Position
  The records do not corroborate that the patient was unresponsive from 3:00 am, and no concerns were raised then.
  Stated by the Princess Alexandra Hospital NHS TrustDisputes the concern
AI-generated summary

Paolino AMICO · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

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

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to make an emergency call for an unresponsive patient
Wider context from the report
“(3) Mr Amico’s NEWS score increased, and an emergency call was not put out on 11 June when it was established that Mr Amico was unresponsive even to pain from 03:00 hours . ”
Source location
Paolino AMICO · 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
Include the emergency department escalation process in area-specific orientation for nurses redeployed from their base wards.

Verbatim wording from the response
“A Multi-Disciplinary After-Action Review meeting was held, including staff involved in the incident. This identified learnings and actions to be taken. It established that the ED nurses looking after Mr Amico had been redeployed from another ward so were not fully aware of the ED escalation process that occurs in the emergency department.”

Source location
Response from Princess Alexandra Hospital
Page 4 · response
Published 19 November 2025
Open published response
Source evidence

How this respondent position was interpreted

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

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

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

Source location
Response from NHS England
Page 4 · response
Published 19 November 2025
Open published response
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 records do not corroborate that the patient was unresponsive from 3:00 am, and no concerns were raised then.

Verbatim wording from the response
“It is noted that the documentation from the doctor who reviewed Mr Amico suggests that Mr Amico had been unresponsive since 3 am however the Trust is unable to ascertain where this information came from as the observation and medication records do not corroborate that finding.”

Source location
Response from Princess Alexandra Hospital
Page 6 · response
Published 19 November 2025
Open published response
26 Aug2025
Inner North London
Concerns raised1
1. Failure to recognise breathing difficulty and place an unresponsive person in the recovery position
This report raised 7 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

Gabriella Omolabake Torisheju JAYIESIMI · 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

Gabriella Omolabake Torisheju Jayiesimi suffered seizures and a cardiac arrest at a Tesco supermarket on 24 January 2025 and died a month later from the hypoxic brain injury sustained during the arrest. The concerns included the absence of effective first aid and CPR, failure to recognise that she had stopped breathing, failure to check her pulse or use a defibrillator, and inadequate first-aid training and preparedness among relevant Tesco and security staff.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to recognise breathing difficulty and place an unresponsive person in the recovery position
Wider context from the report
“When Ms Jaiyesimi was on the floor having suffered several fits, no person put her in the recovery position. They were apparently unaware that her present position could be causing an airway obstruction preventing her breathing. Then when Ms Jaiyesimi stopped breathing, nobody recognised this, though they were looking at her and made one inadequate attempt to feel for breathing (by placing a single finger somewhere near her nose). No person ever attempted to check Ms Jaiyesimi’s pulse to see if her heart was still beating. Even if they had identified her cardiac arrest, there was nobody present who would have started CPR. Nobody thought of fetching one of the store defibrillators. Lack of CPR notwithstanding, the failure to understand the situation properly meant that nobody relayed the crucial information of the arrest to the ambulance service. ”
Source location
Gabriella Omolabake Torisheju JAYIESIMI · Prevention of Future Deaths report
Page 2 · concerns
Open source report
21 Jul2025
East London
Concerns raised1
1. Failure to make 999 calls immediately on discovering an unresponsive person
This report raised 7 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 1
1. Action
  Deliver lessons-learned, anti-choking, first-aid and competency training to permanent, agency, care and non-care staff, including refresher training.
  Stated by Aspray HouseStated completed
AI-generated summary

Madeline Reding · 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

Madeline Reding, a 79-year-old nursing-home resident with advanced vascular dementia, became unwell after lunch on 17 May 2024, regurgitated food, developed an upper-airway obstruction and respiratory arrest, and died that afternoon. The inquest identified delayed and disorganised staff responses, including a failure to sound the emergency alarm or make an immediate 999 call, delayed CPR, and ineffective 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 make 999 calls immediately on discovering an unresponsive person
Wider context from the report
“3. A 999 call was not made immediately on discovering Mrs Reding was unresponsive. ”
Source location
Madeline Reding · 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
Deliver lessons-learned, anti-choking, first-aid and competency training to permanent, agency, care and non-care staff, including refresher training.

Verbatim wording from the response
“Immediately following the incident, an urgent flash Lessons Learnt training session was held with all nursing staff (including the management nurses present at the incident) on 23 May 2025 to reinforce the existing Swallowing Difficulties policy and Basic Life support, Resuscitation and DNARCPR policies and the procedures to be followed in the event of a choking incident. Both policies were subsequently reviewed on 31 July 2024 and noted to be compliant with Resuscitation Council, Royal College of Nursing and CQC guidance.”

Source location
2025-0368 Response from Aspray House Nursing Home
Page 2 · response
Published 23 July 2025
Open published response
11 Mar2025
West Yorkshire Eastern
Concerns raised4
1. Failure to coordinate detention and medical staff roles during a medical emergency
2. Failure to appreciate the importance of early CPR
3. Delays in commencing CPR during a medical emergency in a cell
1. Failure of communication between detention and medical staff to facilitate prompt CPR commencement
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
  Review custody contracts, policies and procedures with Leeds Community Healthcare to clarify emergency roles for Detention Officers and Healthcare Professionals.
  Stated by West Yorkshire PoliceStated planned
2. Action
  Expand life-support training with custody-suite simulations and joint scenarios to improve coordination between healthcare professionals and detention officers.
  Stated by Leeds Community Healthcare NHS TrustStated planned
3. Action
  Review the Death in Custody procedure through a clinical working group and strengthen joint reflection with colleagues involved in incidents.
  Stated by Leeds Community Healthcare NHS TrustStated in progress
1. Action
  Include coordination of response in investigations of life-threatening incidents and deaths in custody.
  Stated by Leeds Community Healthcare NHS TrustStated planned
2. Action
  Agree the reviewed procedure with police to define robust coordination of responses in life-threatening situations.
  Stated by Leeds Community Healthcare NHS TrustStated planned
3. Action
  Incorporate recommendations from reflective discussions with incident staff into CPR training.
  Stated by Leeds Community Healthcare NHS TrustStated completed
Respondent positions 1
1. Position
  Existing training and emergency procedures appropriately require Detention Officers to provide Basic Life Support and follow Healthcare Professional direction.
  Stated by West Yorkshire PoliceExisting arrangements considered sufficient
AI-generated summary

NICHOLAS OLIVER JAMES GEDGE · 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

Nicholas Oliver James Gedge was found unresponsive in a police station cell on 14 November 2022 and was pronounced deceased at hospital later that day. The principal concerns were the delay in commencing CPR, the lack of a shared understanding and coordinated roles among detention and medical staff, and uncertainty about protocols for responding to medical emergencies in cells.

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 coordinate detention and medical staff roles during a medical emergency
Wider context from the report
“(1) From the point when the Detention Officer first entered Nicholas' cell to when CPR was commenced, 8 minutes and 12 seconds elapsed without CPR being given. Within that timeframe, two Detention Officers and a nurse were present in the cell after 75 seconds had passed. (2) On the evidence, there did not appear to be any shared understanding between the three people in the cell with Nicholas of the urgency of starting CPR on an unresponsive person. There did not appear to be a co-ordinated approach to assisting Nicholas, with the Detention Officers and the nurse not appearing to have defined roles which they understood and undertook. (3) It was not clear whether there were any protocols in place to define the respective roles of detention staff and medical staff attending a medical emergency in a cell. The passage of time before CPR was commenced gives rise to a concern either that the importance of early CPR was not appreciated, or that the communication between detention and medical staff did not facilitate its prompt commencement. ”
Source location
NICHOLAS OLIVER JAMES GEDGE · 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
Failure to appreciate the importance of early CPR
Wider context from the report
“(1) From the point when the Detention Officer first entered Nicholas' cell to when CPR was commenced, 8 minutes and 12 seconds elapsed without CPR being given. Within that timeframe, two Detention Officers and a nurse were present in the cell after 75 seconds had passed. (2) On the evidence, there did not appear to be any shared understanding between the three people in the cell with Nicholas of the urgency of starting CPR on an unresponsive person. There did not appear to be a co-ordinated approach to assisting Nicholas, with the Detention Officers and the nurse not appearing to have defined roles which they understood and undertook. (3) It was not clear whether there were any protocols in place to define the respective roles of detention staff and medical staff attending a medical emergency in a cell. The passage of time before CPR was commenced gives rise to a concern either that the importance of early CPR was not appreciated, or that the communication between detention and medical staff did not facilitate its prompt commencement. ”
Source location
NICHOLAS OLIVER JAMES GEDGE · 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
Delays in commencing CPR during a medical emergency in a cell
Wider context from the report
“(1) From the point when the Detention Officer first entered Nicholas' cell to when CPR was commenced, 8 minutes and 12 seconds elapsed without CPR being given. Within that timeframe, two Detention Officers and a nurse were present in the cell after 75 seconds had passed. (2) On the evidence, there did not appear to be any shared understanding between the three people in the cell with Nicholas of the urgency of starting CPR on an unresponsive person. There did not appear to be a co-ordinated approach to assisting Nicholas, with the Detention Officers and the nurse not appearing to have defined roles which they understood and undertook. (3) It was not clear whether there were any protocols in place to define the respective roles of detention staff and medical staff attending a medical emergency in a cell. The passage of time before CPR was commenced gives rise to a concern either that the importance of early CPR was not appreciated, or that the communication between detention and medical staff did not facilitate its prompt commencement. ”
Source location
NICHOLAS OLIVER JAMES GEDGE · 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
Failure of communication between detention and medical staff to facilitate prompt CPR commencement
Wider context from the report
“(1) From the point when the Detention Officer first entered Nicholas' cell to when CPR was commenced, 8 minutes and 12 seconds elapsed without CPR being given. Within that timeframe, two Detention Officers and a nurse were present in the cell after 75 seconds had passed. (2) On the evidence, there did not appear to be any shared understanding between the three people in the cell with Nicholas of the urgency of starting CPR on an unresponsive person. There did not appear to be a co-ordinated approach to assisting Nicholas, with the Detention Officers and the nurse not appearing to have defined roles which they understood and undertook. (3) It was not clear whether there were any protocols in place to define the respective roles of detention staff and medical staff attending a medical emergency in a cell. The passage of time before CPR was commenced gives rise to a concern either that the importance of early CPR was not appreciated, or that the communication between detention and medical staff did not facilitate its prompt commencement. ”
Source location
NICHOLAS OLIVER JAMES GEDGE · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Review custody contracts, policies and procedures with Leeds Community Healthcare to clarify emergency roles for Detention Officers and Healthcare Professionals.

Verbatim wording from the response
“3. Nevertheless, the Chief Constable intends to review the contracts, policies and procedures that are in place between Leeds Community Healthcare and the Force, in partnership with Leeds Community Healthcare, to ensure that the respective roles of the Detention Officers and Healthcare Professionals in custody in an emergency situation are sufficiently clear.”

Source location
Response from West Yorkshire Police
Page 2 · response
Published 26 March 2025
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Expand life-support training with custody-suite simulations and joint scenarios to improve coordination between healthcare professionals and detention officers.

Verbatim wording from the response
“• In addition to the organisational mandatory bespoke life support training, LCH will expand the scenario aspect of training to include simulation exercises in the custody suite environment with the aim of improving the co-ordination between LCH staff and detention officers in the event of emergency scenarios.”

Source location
Response from Leeds Community Healthcare NHS Trust
Page 2 · response
Published 26 March 2025
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Review the Death in Custody procedure through a clinical working group and strengthen joint reflection with colleagues involved in incidents.

Verbatim wording from the response
“• A working group consisting of LCH HCP’s, led by a clinical team manager, has commenced to review the Death in Custody (DIC) procedure.”

Source location
Response from Leeds Community Healthcare NHS Trust
Page 2 · response
Published 26 March 2025
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Include coordination of response in investigations of life-threatening incidents and deaths in custody.

Verbatim wording from the response
“• The service will ensure that they include ‘coordination of response’ in the investigation process of incidents where there has been a life-threatening response or a DIC.”

Source location
Response from Leeds Community Healthcare NHS Trust
Page 2 · response
Published 26 March 2025
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Agree the reviewed procedure with police to define robust coordination of responses in life-threatening situations.

Verbatim wording from the response
“• The procedure will be agreed with the police to ensure the coordination of response in life threatening situations is robust.”

Source location
Response from Leeds Community Healthcare NHS Trust
Page 3 · response
Published 26 March 2025
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Incorporate recommendations from reflective discussions with incident staff into CPR training.

Verbatim wording from the response
“• LCH has conducted a reflective conversation with the staff involved in the incident and has incorporated their recommendations and suggestions for improvements into the CPR training.”

Source location
Response from Leeds Community Healthcare NHS Trust
Page 3 · response
Published 26 March 2025
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Existing training and emergency procedures appropriately require Detention Officers to provide Basic Life Support and follow Healthcare Professional direction.

Verbatim wording from the response
“(i) Until the custody Healthcare Professional attends, they are to follow their training and provide Basic Life Support, including giving CPR to people who are not breathing.”

Source location
Response from West Yorkshire Police
Page 2 · response
Published 26 March 2025
Open published response
20 Jan2025
Inner North London
Concerns raised2
1. Failure to render basic assistance or first aid to an unresponsive student
2. Delays in escalating and responding to an apparent emergency
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.
Actions described in response 3
1. Action
  Change the Duty Manager rota geography to reduce each manager’s property coverage and improve responsiveness for room-entry requests.
  Stated by Unite StudentsStated completed
2. Action
  Review training, policies and procedures so staff promptly contact emergency services alongside requesting assistance for room entry during safety concerns or emergencies.
  Stated by Unite StudentsStated planned
3. Action
  Review Emergency Control Centre call-handling procedures to improve triage and ensure staff ask questions that establish the basis and potential seriousness of enquiries.
  Stated by Unite StudentsStated in progress
AI-generated summary

Student A · 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

Student A was found unresponsive in his student accommodation on 28 July 2024 and paramedics verified his death shortly thereafter; the medical cause was asphyxiation and the inquest conclusion was suicide. The principal concerns were delays in carrying out the welfare check and calling emergency services, limited assessment of Student A’s condition, failure to provide basic assistance or first aid, and possible inadequacy or ineffectiveness of staff training and procedures.

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 render basic assistance or first aid to an unresponsive student
Wider context from the report
“2. When attending Student A’s room at about 10:50 on 28 July 2024, the member of staff knocked repeatedly on the door and asked for Student A to come to the door. The staff member then used their staff pass to open the door, on account of getting no response. In their statement, the staff member sets out that they remained in the doorway and could see Student A’s legs (from the knees down) on the bed within the room. The statement continues, ‘I called out to the student and stated that it was reception and asked if they were okay. At this time I was scared so I closed the door and went to the stairwell.’ The staff member spoke to the ECC and explained the circumstances to them and the ECC advised the staff member to call an ambulance ‘and to also get someone from one of the other buildings that is run by the university.’ Following the call with the ECC, the staff member sent a text message to their ‘general manager’ explaining the situation and requesting that a receptionist from another building be sent to assist. The staff member’s statement then says, ‘At approximately 1134 I called my manager and whilst on the phone returned to the room and knocked on the door repeatedly. I shouted out and knocked twice. The student did not answer the door.’ The staff member then returned to reception and telephoned for a colleague in another building to come and assist. Assistance from a colleague arrived at approximately 12 noon. Both members of staff then made their way to Student A’s room where, upon entering they found Student A unresponsive on his bed in the manner already described at section 4 of this report. As a result, the staff left the room, returned to reception and ‘called our managers and emergency services and we waited for their arrival.’ The concerns here are numerous: • It was obvious to staff that Student A was, at the very least, unresponsive / difficult to rouse at about 10:50, which on any view would be regarded as a serious / emergency situation. However, it appears that no positive or definitive action was taken to assist for over an hour. • The ECC advised the staff member to call an ambulance at about 10:50, yet this was not done until approximately 12 noon. • The staff member who first checked on Student A at 10:50, went no further than threshold (seeing no more than his legs) and therefore did little, if anything, to satisfy themselves about the true welfare status of Student A. • The staff members who attended Student A’s room at approximately 12 noon, did not attempt to render basic assistance or first aid to Student A. • In the particular circumstances of Student A’s case, he was highly likely to have been deceased for hours prior to his death being verified by paramedics at 12:27. However, that fact was not known to staff at the material time and, therefore, they would have been expected to act in accordance with any protocols or policy in place at that time. Given these matters, I am concerned that there may be a lack of appropriate training in place for staff or, if there is such training in place, that it may not be effective. Nothing in the evidence available to me has suggested that the future risks posed by my concerns have been addressed. ”
Source location
Student A · 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
Delays in escalating and responding to an apparent emergency
Wider context from the report
“2. When attending Student A’s room at about 10:50 on 28 July 2024, the member of staff knocked repeatedly on the door and asked for Student A to come to the door. The staff member then used their staff pass to open the door, on account of getting no response. In their statement, the staff member sets out that they remained in the doorway and could see Student A’s legs (from the knees down) on the bed within the room. The statement continues, ‘I called out to the student and stated that it was reception and asked if they were okay. At this time I was scared so I closed the door and went to the stairwell.’ The staff member spoke to the ECC and explained the circumstances to them and the ECC advised the staff member to call an ambulance ‘and to also get someone from one of the other buildings that is run by the university.’ Following the call with the ECC, the staff member sent a text message to their ‘general manager’ explaining the situation and requesting that a receptionist from another building be sent to assist. The staff member’s statement then says, ‘At approximately 1134 I called my manager and whilst on the phone returned to the room and knocked on the door repeatedly. I shouted out and knocked twice. The student did not answer the door.’ The staff member then returned to reception and telephoned for a colleague in another building to come and assist. Assistance from a colleague arrived at approximately 12 noon. Both members of staff then made their way to Student A’s room where, upon entering they found Student A unresponsive on his bed in the manner already described at section 4 of this report. As a result, the staff left the room, returned to reception and ‘called our managers and emergency services and we waited for their arrival.’ The concerns here are numerous: • It was obvious to staff that Student A was, at the very least, unresponsive / difficult to rouse at about 10:50, which on any view would be regarded as a serious / emergency situation. However, it appears that no positive or definitive action was taken to assist for over an hour. • The ECC advised the staff member to call an ambulance at about 10:50, yet this was not done until approximately 12 noon. • The staff member who first checked on Student A at 10:50, went no further than threshold (seeing no more than his legs) and therefore did little, if anything, to satisfy themselves about the true welfare status of Student A. • The staff members who attended Student A’s room at approximately 12 noon, did not attempt to render basic assistance or first aid to Student A. • In the particular circumstances of Student A’s case, he was highly likely to have been deceased for hours prior to his death being verified by paramedics at 12:27. However, that fact was not known to staff at the material time and, therefore, they would have been expected to act in accordance with any protocols or policy in place at that time. Given these matters, I am concerned that there may be a lack of appropriate training in place for staff or, if there is such training in place, that it may not be effective. Nothing in the evidence available to me has suggested that the future risks posed by my concerns have been addressed. ”
Source location
Student A · 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
Change the Duty Manager rota geography to reduce each manager’s property coverage and improve responsiveness for room-entry requests.

Verbatim wording from the response
“We recognise that a second staff member could have attended sooner to facilitate a room entry after the call escalation at 11:00. The steps that we are taking to address this are twofold:”

Source location
Response from Unite Students
Page 2 · response
Published 28 January 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 training, policies and procedures so staff promptly contact emergency services alongside requesting assistance for room entry during safety concerns or emergencies.

Verbatim wording from the response
“We recognise that a second staff member could have attended sooner to facilitate a room entry after the call escalation at 11:00. The steps that we are taking to address this are twofold:”

Source location
Response from Unite Students
Page 2 · response
Published 28 January 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 Emergency Control Centre call-handling procedures to improve triage and ensure staff ask questions that establish the basis and potential seriousness of enquiries.

Verbatim wording from the response
“More generally, we are reviewing all our procedures for dealing with calls made to the ECC to effectively triage calls received, and to ensure that appropriate questions are asked to understand the basis and potential seriousness of enquiries.”

Source location
Response from Unite Students
Page 3 · response
Published 28 January 2025
Open published response
14 Oct2024
Berkshire
Concerns raised1
1. Lack of understanding of first aid for unresponsive people
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 4
1. Action
  Deliver extended three-and-a-half-hour in-person basic life support and manual handling refresher training to care staff.
  Stated by AS Chiltern Homecare Ltd T/A Caremark (Three Rivers & ChilternStated completed
2. Action
  Deliver externally provided in-person basic life support training with practical demonstrations, practice and mandatory competency assessments across four staff sessions.
  Stated by AS Chiltern Homecare Ltd T/A Caremark (Three Rivers & ChilternStated planned
3. Action
  Add first aid as a standing agenda item at full-team meetings and regular supervision sessions to discuss incidents, best practice and staff concerns.
  Stated by AS Chiltern Homecare Ltd T/A Caremark (Three Rivers & ChilternStated planned
1. Action
  Discuss the medication concerns policy and first aid procedures with staff at the scheduled December team meeting, including emergency scenarios and policy access.
  Stated by AS Chiltern Homecare Ltd T/A Caremark (Three Rivers & ChilternStated planned
AI-generated summary

Sally Mills · 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

Sally Mills choked on prescribed medication at home on 23 July 2023 after experiencing difficulty swallowing during its administration, and died later that day in hospital. The principal concerns were gaps in first-aid understanding for an unresponsive person and failures to appropriately escalate difficulties encountered during medication administration.

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 understanding of first aid for unresponsive people
Wider context from the report
“(1) First Aid training. The evidence revealed there is still a lack of understanding of providing first aid to those becoming unresponsive. ”
Source location
Sally Mills · 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
Deliver extended three-and-a-half-hour in-person basic life support and manual handling refresher training to care staff.

Verbatim wording from the response
“This was extended to a 3 and a half hour session from 31st October 2024 and also covered manual handling techniques. At present, all members of our care team are in date with their mandatory training which includes refresher training sessions in basic life support. ████████ is responsible for ensuring that all care team members complete the required training within the relevant time frame, and this is managed via People Planner. There”

Source location
Response from Caremark (Chiltern & Tree Rivers)
Page 1 · response
Published 16 October 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
Deliver externally provided in-person basic life support training with practical demonstrations, practice and mandatory competency assessments across four staff sessions.

Verbatim wording from the response
“In person Basic Life Support training from January 2025 We have now engaged the support of an external provider, The Training Centre (London) Ltd to deliver in person Basic Life Support training to our staff. The first session will take place on 21st January 2025. The session will train up to 12 members of staff and as such 4 sessions in total will be arranged at the beginning of 2025. The session will comprise demonstrations, practice of practical skills and a competency assessment at the end. All staff will be required to pass the competency assessment. This session will cover attending to a person who is unresponsive (and breathing, unresponsive and not breathing) and where choking is suspected. Our intention is to seek feedback from the provider as to the frequency of refresher training and format to be adopted moving forwards.”

Source location
Response from Caremark (Chiltern & Tree Rivers)
Page 2 · response
Published 16 October 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
Add first aid as a standing agenda item at full-team meetings and regular supervision sessions to discuss incidents, best practice and staff concerns.

Verbatim wording from the response
“At this stage, we confirm that our basic life support training will be delivered in person from now on both in terms of the induction programme and the refresher sessions. Given the importance of the issue, we have decided to add first aid as an agenda item to all of our full team meetings or regular supervision sessions. We will discuss any issues encountered and talk about the best practices which should be followed. As well as giving care assistants an opportunity to raise any concerns or seek any further clarifications.”

Source location
Response from Caremark (Chiltern & Tree Rivers)
Page 2 · response
Published 16 October 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
Discuss the medication concerns policy and first aid procedures with staff at the scheduled December team meeting, including emergency scenarios and policy access.

Verbatim wording from the response
“Concern 2 - Escalation of issues encountered by Care Assistants Evidence demonstrated efforts have been made in this regard, such as a new checklist and new policy dated September 2023; the evidence revealed a lack of knowledge of the policy and the embedding of it. The care team are the organisation’s eyes and ears on the ground and as such we are reliant on them to communicate their concerns to the office in a timely manner. It became apparent that further work should be undertaken to embed section 2.27 (Raising Concerns) of the Medication Procedures September 2023 (the ‘Policy’) and ensure staff are familiar with and understand its requirements. We have decided that the Policy will also be discussed with staff at the full team meetings held in December.”

Source location
Response from Caremark (Chiltern & Tree Rivers)
Page 2 · response
Published 16 October 2024
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to coordinate cardiac-arrest responses

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.3

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Failure to recognise suspected synthetic cannabinoid intoxication promptly during collapse response

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.3

Concerns raised1

Delays in opening a detainee cell and administering emergency first aid

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.4

Concerns raised2

Delay in bringing the emergency grab bag

Delay in obtaining and attaching the defibrillator

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.3

Concerns raised1

Failure to make an emergency call for an unresponsive patient

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.1

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 recognise breathing difficulty and place an unresponsive person in the recovery position

Concerns raised1

Failure to make 999 calls immediately on discovering an unresponsive person

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.1

Actions described in response 3

Respondent positions 1

Actions described in response 3

Actions described in response 4

Actions described in response 3

Actions described in response 1

Respondent positions 2

Actions described in response 1