Concerns raised 8 Failure to recognise breathing difficulty and place an unresponsive person in the recovery position View source Failure to relay cardiac-arrest information to the ambulance service View source Failure to identify and deploy the available trained first aider View source Failure to check the pulse of a person in a medical emergency View source Failure to initiate CPR or retrieve a store defibrillator during cardiac arrest View source Lack of CPR and first-aid training among duty managers View source Failure of first-aid training to produce basic first-aid competence View source Unavailability of a Tesco first aider at Colney Hatch View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
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. The report was sent to Security Industry Authority; that does not assign responsibility.
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Security Industry Authority; that does not assign responsibility.
PFD Monitor interpretation Failure to relay cardiac-arrest information to the ambulance service
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Security Industry Authority; that does not assign responsibility.
PFD Monitor interpretation Failure to identify and deploy the available trained first aider
Wider context from the report “I heard that it was the duty manager’s choice not to be first aid trained. She said that she did not like blood and was afraid of the responsibility of a paramedic. However, on further exploration she said that she would like to be able to recognise a person not breathing and she would like to be able to administer basic first aid.
TSS
4. The TSS security officer was first aid trained, but did not tell anyone that he was first aid trained.
He told me repeatedly that his job was simply to do whatever the duty manager told him to do. Despite being the only first aider present, he took no responsibility at scene. He failed to offer Ms Jaiyesimi or the duty manager any meaningful support at all.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Security Industry Authority; that does not assign responsibility.
PFD Monitor interpretation Failure to check the pulse of a person in a medical emergency
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Security Industry Authority; that does not assign responsibility.
PFD Monitor interpretation Failure to initiate CPR or retrieve a store defibrillator during cardiac arrest
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Security Industry Authority; that does not assign responsibility.
PFD Monitor interpretation Lack of CPR and first-aid training among duty managers
Wider context from the report “When Gabriella Jaiyesimi suffered a cardiac arrest –
Tesco
1. There was no Tesco first aider working at Colney Hatch.
2. The TSS security officer was first aid trained, but none of the Tesco staff knew that.
3. All staff, including the TSS security officer, properly understood the Tesco policy of calling the duty manager to assess such an emergency and decide upon the correct course of action, but the duty manager charged with this responsibility had no CPR or first aid training . She told me that most of the Tesco duty managers were not CPR or first aid trained .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Security Industry Authority; that does not assign responsibility.
PFD Monitor interpretation Failure of first-aid training to produce basic first-aid competence
Wider context from the report “The SIA
The security officer had undergone SIA compliant first aid training in order to renew his licence. His first aid at work qualification was in date. He told me that his role as a security officer was to ensure the safety and security of people and merchandise in the store.
5. However, he did not display any understanding of basic first aid procedures . He told me that the first aid training he had received was simply a tick box exercise to enable him to renew his SIA licence.
• When the duty manager specifically asked him to check for breathing, his one attempt to do this was wholly ineffective.
• He never considered checking for a pulse. He told me that he had never been trained to check for a pulse.
• He said that he had not been trained in how to use a defibrillator and so he would not consider fetching one.
• When the staff member on the phone to the ambulance service relayed the instruction to place Ms Jaiyesimi in the recovery position, he did not. He told me that he did not remember being asked to do this. He also told me that he did not remember ever being taught the recovery position.
• Finally, the security officer said that if he did ever see anyone not breathing in the future, he would wait for the arrival of paramedics to attempt to do anything about that.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Security Industry Authority; that does not assign responsibility.
PFD Monitor interpretation Unavailability of a Tesco first aider at Colney Hatch
Wider context from the report “When Gabriella Jaiyesimi suffered a cardiac arrest –
Tesco
1. There was no Tesco first aider working at Colney Hatch.
2. The TSS security officer was first aid trained, but none of the Tesco staff knew that.
3. All staff, including the TSS security officer, properly understood the Tesco policy of calling the duty manager to assess such an emergency and decide upon the correct course of action, but the duty manager charged with this responsibility had no CPR or first aid training. She told me that most of the Tesco duty managers were not CPR or first aid trained.
” 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 Investigate Total Security Services Limited and assess whether the enquiries require regulatory follow-up under the Approved Contractor Scheme.
Verbatim wording from the response “Investigation into Total Security Services Limited” Source location Response from Security Industry Authority
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require first-aid evidence before licence-linked training and require courses to cover responses to life-threatening bleeding.
Verbatim wording from the response “18. In April 2021 the SIA imposed a new requirement that before attending training leading to a licence linked qualification for Door Supervision or Security Guarding, an individual needed to present evidence that they were competent in First Aid or Emergency First Aid at Work. This extended to individuals as a pre-requisite to the training required before an individual could renew a licence. Later in the year the SIA also required individuals seeking to renew a Door Supervision or Security Guarding licence, to present a valid first aid certificate as a pre-requisite to their top up or refresher training.” Source location Response from Security Industry Authority
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 Follow up with the awarding organisation about potential validity or efficacy issues concerning the security operative’s training qualification.
Verbatim wording from the response “Investigation by the Awarding Organisation Into the Qualification Obtained” Source location Response from Security Industry Authority
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 Further changes to licence-linked qualification specifications are considered unnecessary because existing emergency first-aid training provides the appropriate skills for emergencies.
Verbatim wording from the response “26. The SIA is of the view that the existing L2 Emergency First Aid at Work requirement contains appropriate content to equip a security operative with the skills required to administer emergency first aid. The current specification content includes training on dealing with someone who is potentially unconscious and having a seizure including:” Source location Response from Security Industry Authority
Open published response
12 May 2015 Paul Mc Guigan · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 16 Unavailability of enhanced criminal-record disclosures for overseas armed private security employment View source Lack of recording of pre-conviction disclosures View source Lack of understanding of overseas armed close protection work View source Lack of guidance and transfer arrangements for MAPPA-triggering offenders View source Lack of computer categorisation for close protection occupations View source Lack of clear procedure and funding responsibility for independent forensic psychiatric reports View source Lack of training for officers and civilian employees on disclosure procedures View source Failure to understand and operate the Notifiable Occupation Scheme View source Failure to consider disclosure to employers View source Inadequate and infrequent formal supervision of newly qualified offender managers View source Lack of a national system and contact point for obtaining military information View source Failure to record discussions among key professionals View source Failure of agencies to check and share available information before multi-agency meetings View source Incomplete and unclear procedure for the Common Law Police Disclosure Scheme View source Misunderstanding of residence conditions for offender monitoring View source Lack of recording of offenders' bail conditions View source See 13 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Paul Mc Guigan · 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 Mc Guigan was shot and unlawfully killed by a close protection work colleague on 9 August 2009 while both were working as armed private security contractors in Baghdad. The report identified missed opportunities and failings in managing the offender’s escalating offending behaviour and risk, and stated that G4S had not adequately vetted him before deployment. Concerns also included failures in information sharing, recording bail conditions, police disclosure processes, and the supervision and risk assessment of offenders.
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. The report was sent to Security Industry Authority; that does not assign responsibility.
PFD Monitor interpretation Unavailability of enhanced criminal-record disclosures for overseas armed private security employment
Wider context from the report “I also have a concern that an employer on a private security contract at home has regulated by the SIA and a private security employed overseas [unregulated save for voluntary schemes such as International Code of Conduct for Private Security Service Providers 2010 [ICoC] and accredited certification to the standard ANSI/ SSlS PSC. 1-2012] is not entitled or able to obtain an enhanced CRB and would only ever receive a Standard disclosure on a pre employment check.
It concerns me in particular that in respect of employing on individual on an armed contract then consideration should be given to enabling Private Security Companies a route to obtaining an enhanced disclosure.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Security Industry Authority; that does not assign responsibility.
PFD Monitor interpretation Lack of recording of pre-conviction disclosures
Wider context from the report “It is clear that within GMP there was no recording anywhere as to when / if any pre convictions disclosures were made . It is important that there is a system of recording in this scenario and also to whom the disclosure is made. At present no-one can provide any information as to the number of detail of pre-conviction disclosures. In addition this means that officers who may be dealing with someone who has been arrested have no way of knowing if such a pre-conviction disclosure has ever been made.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Security Industry Authority; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding of overseas armed close protection work
Wider context from the report “In addition I have a concern that there is a complete lack of understanding by the Police and Probation / NOMS as to what close protection work overseas involves and in particular when this involves work on armed contracts .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Security Industry Authority; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance and transfer arrangements for MAPPA-triggering offenders
Wider context from the report “It concerns me to ensure that there is clear guidance given by NOMS to the private community rehabilitation companies [e.g. in Manchester Purple Futures] as to assessment of risk and for offenders who then do trigger MAPPA concerns that should be being supervised or assessed for eligibility under MAPPA to be transferred to be supervised by the National Probation Service.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Security Industry Authority; that does not assign responsibility.
PFD Monitor interpretation Lack of computer categorisation for close protection occupations
Wider context from the report “In respect of the GMP computer system and in respect of occupations that are regulated and require licensing by the SIA, there is no categorisation on the computer for “CLOSE PROTECTION” . Indeed the Court heard that there was some confusion and lack of understanding from many people as to what this occupation actually meant. Close protection work is a separate category of employment within the UK that the SIA regulates and the police system should reflect the occupations subject to regulation. It is important that the police and NOMS have a clear understanding as to what close protection work is to inform risk and risk assessment.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Security Industry Authority; that does not assign responsibility.
PFD Monitor interpretation Lack of clear procedure and funding responsibility for independent forensic psychiatric reports
Wider context from the report “It concerns me that there is not a clear practice and procedure operating within the Court or probation system, including funding responsibility, for obtaining an Independent Forensic Psychiatric Report , particularly in circumstances where a defendant is remanded on bail in the community.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Security Industry Authority; that does not assign responsibility.
PFD Monitor interpretation Lack of training for officers and civilian employees on disclosure procedures
Wider context from the report “At present in respect of a replacement scheme in respect of clarifying the Common Law Police Disclosure Scheme I heard evidence as to the process GMP are undergoing in respect of a revised Procedure relating to Notifiable Occupations but this is far from complete and less than clear as to how it will operate and the training that will be given to officers / GMP civilian employees . The Court was also advised that at no stage has legal advice been taken from the force in-house legal team on the proposed scheme, even though this is a difficult legal area.
It is important that GMP and all forces have a recognised procedure in respect of having a scheme but also training officers to operate that scheme. It is imperative also that the SIA understand how and when each police force will be making disclosures under the Common Law Police Disclosure Scheme.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Security Industry Authority; that does not assign responsibility.
PFD Monitor interpretation Failure to understand and operate the Notifiable Occupation Scheme
Wider context from the report “In my judgment there was a complete misunderstanding by GMP in respect of the operation of the Notifiable Occupation Scheme HOC 6/2006 .
Of immense concern also the complete failure for a period of approximately 18 months to make any post conviction notifications under the Notifiable Occupation Scheme , which was it transpired, formally withdrawn by the Home Secretary Theresa May MP in March 2015.
I heard and received evidence from the SIA that they were not aware that a regulatory gap existed in respect of the Police’s understanding of the scheme and notifications to themselves . The evidence I heard suggests that such a gap exists at GMP and has done so for in excess of 18 months.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Security Industry Authority; that does not assign responsibility.
PFD Monitor interpretation Failure to consider disclosure to employers
Wider context from the report “In respect of the period of time when Post conviction disclosures were made [before this “back office” function ceased 18 months ago] these were only ever disclosures made to the Regulatory body and consideration never appears to have been given within GMP to disclosure to employers . Given the lack of understanding as to whom some regulatory bodies have responsibility for, this is important.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Security Industry Authority; that does not assign responsibility.
PFD Monitor interpretation Inadequate and infrequent formal supervision of newly qualified offender managers
Wider context from the report “I heard evidence that the Offender Manager was newly qualified and her formal supervision was inadequate and infrequent . This concerns me. It is important that newly qualified offender managers receive appropriate formal supervision .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Security Industry Authority; that does not assign responsibility.
PFD Monitor interpretation Lack of a national system and contact point for obtaining military information
Wider context from the report “My concern is to ensure that there is a system, protocol and point of contact for every offender manager nationally [including the private rehabilitation companies now operating as offender managers] that is well known as to who to contact to within the Ministry of Defence to obtain military information .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Security Industry Authority; that does not assign responsibility.
PFD Monitor interpretation Failure to record discussions among key professionals
Wider context from the report “In addition I heard evidence and it concerns me that in advance of the Multi Agency meeting convened due to concerns as to the Offenders risk, key professionals had had discussions, telephone calls and meetings and I was concerned by the failure to record and document these important discussions , to ensure clarity, understanding and consistency. It is important when key professionals have discussions that these are documented and recorded .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Security Industry Authority; that does not assign responsibility.
PFD Monitor interpretation Failure of agencies to check and share available information before multi-agency meetings
Wider context from the report “It is important irrespective of who is the lead agency at a Multi Agency Meeting that each agency invited to attend checks information held on systems and records to which they have access and provides all this information to a multi agency meeting to ensure that a full and informed assessment of risk takes place and the fullest possible informed information sharing.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Security Industry Authority; that does not assign responsibility.
PFD Monitor interpretation Incomplete and unclear procedure for the Common Law Police Disclosure Scheme
Wider context from the report “At present in respect of a replacement scheme in respect of clarifying the Common Law Police Disclosure Scheme I heard evidence as to the process GMP are undergoing in respect of a revised Procedure relating to Notifiable Occupations but this is far from complete and less than clear as to how it will operate and the training that will be given to officers / GMP civilian employees. The Court was also advised that at no stage has legal advice been taken from the force in-house legal team on the proposed scheme, even though this is a difficult legal area.
It is important that GMP and all forces have a recognised procedure in respect of having a scheme but also training officers to operate that scheme. It is imperative also that the SIA understand how and when each police force will be making disclosures under the Common Law Police Disclosure Scheme.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Security Industry Authority; that does not assign responsibility.
PFD Monitor interpretation Misunderstanding of residence conditions for offender monitoring
Wider context from the report “I also heard evidence that a GMP officer believed that Bail with a condition of residence was different to “bail live and sleep each night”. It is of concern that there is a misunderstanding within GMP as to what a condition of residence means and how this relates to the monitoring of offenders .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Security Industry Authority; that does not assign responsibility.
PFD Monitor interpretation Lack of recording of offenders' bail conditions
Wider context from the report “I heard evidence that in respect of GMP systems and processes there was nowhere on the GMP computer system where bail conditions are recorded , although this used to be possible. It is of concern that there is no system of recording on the GMP computer of offenders bail conditions so that this information can be known by officers and appropriately shared.
” Open source report
2 Jul 2014 Mr Hywel Llewelyn Hughes · Prevention of Future Deaths report North West Wales
View report summary
Concerns raised 11 Lack of required training or knowledge on restraint and asphyxia dangers View source Failure to audit accredited door-supervisor training on restraint and asphyxia View source Deaths related to or following restraint by door supervisors View source Failure to review restraint-related deaths for licensing and responsibility lessons View source Failure of existing bubble-car design to enable easy monitoring of rear-seat detainees View source Failure to integrate asphyxia training into restraint training View source Failure of new bubble-car design to enable officers to hear detainees’ breathing difficulties View source Repeated coronial concern about door-supervisor training on restraint and asphyxia View source Uncertainty about completion of physical intervention training by licensed door supervisors View source Lack of police training guidance on the significance of snoring during positional asphyxia View source Lack of a first-aid qualification requirement for door-supervisor licensing View source See 8 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Mr Hywel Llewelyn Hughes · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mr Hywel Llewelyn Hughes was forcibly removed from a nightclub, restrained face down by door staff, and later declared deceased in hospital on 3 May 2003. The inquest concluded that the medical cause of death was traumatic asphyxia and that police actions were inappropriate and more probably than not contributed more than minimally to his death. Concerns included training and monitoring of detainees during restraint and transport, and shortcomings in the licensing, training, auditing and review of door supervisors.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Security Industry Authority; that does not assign responsibility.
PFD Monitor interpretation Lack of required training or knowledge on restraint and asphyxia dangers
Wider context from the report “(6) The SIA’s standards of conduct, training and levels of supervision issued pursuant to their statutory responsibilities under section 1(2)(e) of the 2001 Act, namely the “Specification for Learning and Qualifications for Door Supervisors” (Feb 2010) and the “Specifications for Learning and Qualifications for Physical Intervention Skills” (Aug 2010), do not include a requirement for training or knowledge on the dangers inherent in restraint, specific modes of restraint, positional asphyxia or traumatic asphyxia .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Security Industry Authority; that does not assign responsibility.
PFD Monitor interpretation Failure to audit accredited door-supervisor training on restraint and asphyxia
Wider context from the report “(7) The SIA does not audit the training provided to door supervisors by accredited training providers , particularly on issues of restraint and asphyxia (traumatic and positional).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Security Industry Authority; that does not assign responsibility.
PFD Monitor interpretation Deaths related to or following restraint by door supervisors
Wider context from the report “(4) Twenty deaths apparently related to and/or following restraint by door supervisors have occurred since the introduction in 2004 of (rolled out) compulsory licensing of door supervisors, by the Security Industry Authority (“SIA”) (established by the Private Security Act 2001, in 2003). There have been four restraint related deaths involving twelve door supervisors (all of whom have been charged with either murder or manslaughter) since April 2013, that is, following the introduction (in February 2013) of mandatory training as a condition for the awarding (or renewal) of a licence to work as a door supervisor anywhere in the UK.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Security Industry Authority; that does not assign responsibility.
PFD Monitor interpretation Failure to review restraint-related deaths for licensing and responsibility lessons
Wider context from the report “(5) The SIA does not undertake any review or inquiry into those deaths indicated by Inquest or criminal findings to be related to restraint by door supervisors to determine whether there are any lessons to be learnt in so far as their licensing or other responsibilities are concerned.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Security Industry Authority; that does not assign responsibility.
PFD Monitor interpretation Failure of existing bubble-car design to enable easy monitoring of rear-seat detainees
Wider context from the report “(2) The design of the ‘bubble cars’ in existence at the time of Mr Hughes’ death and apparently still in use pending their phasing out, is such that the condition of a detainee held in the rear of the vehicle may not be easily monitored (because of the presence of a Perspex screen that may affect the ability to see and hear a detainee ).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Security Industry Authority; that does not assign responsibility.
PFD Monitor interpretation Failure to integrate asphyxia training into restraint training
Wider context from the report “(8) The mandatory training that door supervisors are required to undertake as a condition of the award of a licence by the SIA does not integrate training on asphyxia into the training on restraint (it is addressed by a limited and discrete element ).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Security Industry Authority; that does not assign responsibility.
PFD Monitor interpretation Failure of new bubble-car design to enable officers to hear detainees’ breathing difficulties
Wider context from the report “(3) The design of the new ‘bubble cars’ may impede an officer’s ability to hear a detainee (and thus identify irregularities or difficulties in breathing ) because of the presence of a (albeit smaller) Perspex screen .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Security Industry Authority; that does not assign responsibility.
PFD Monitor interpretation Repeated coronial concern about door-supervisor training on restraint and asphyxia
Wider context from the report “(11) There have already been four ‘Rule 43’ reports to the SIA by Coroners concerning the training of door supervisors on restraint and asphyxia .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Security Industry Authority; that does not assign responsibility.
PFD Monitor interpretation Uncertainty about completion of physical intervention training by licensed door supervisors
Wider context from the report “(10) It is not clear that all persons presently working as door supervisors have yet undertaken physical intervention training (it appears that those who already have a licence will only be required to undertake ‘top training’ when they seek renewal of a licence ).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Security Industry Authority; that does not assign responsibility.
PFD Monitor interpretation Lack of police training guidance on the significance of snoring during positional asphyxia
Wider context from the report “(1) The training on positional asphyxia presently provided to police officers by the North Wales Police Force does not include guidance on the significance of ‘snoring’ and in particular that it is not inconsistent with deep unconsciousness and obstruction to breathing .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Security Industry Authority; that does not assign responsibility.
PFD Monitor interpretation Lack of a first-aid qualification requirement for door-supervisor licensing
Wider context from the report “(9) The licensing requirements for door supervisors do not include a requirement for a first aid qualification .
” Open source report
Includes reports addressed to a minister or senior office-holder acting for this organisation.
Pin
Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations