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.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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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 Tesco PLC; 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 Tesco PLC; 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 Tesco PLC; 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 Tesco PLC; 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 Tesco PLC; 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 Tesco PLC; 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 Tesco PLC; 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 Tesco PLC; 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
Concerns raised 1 Lack of mandatory safety advice for paddleboard purchasers at retail sale View source
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
Emma Louise Powell · 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
Emma Louise Powell got into difficulties while paddleboarding at Conwy Morfa on 14 July 2022 and was recovered after being submerged for more than ten minutes. The inquest evidence raised concerns that she was not wearing life-saving equipment, used an inappropriate ankle leash in fast-flowing water, and had received no safety advice at the point of sale about safety vests or leash positioning.
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 Tesco PLC; that does not assign responsibility.
PFD Monitor interpretation Lack of mandatory safety advice for paddleboard purchasers at retail sale
Wider context from the report “The evidence at inquest indicated that Miss Powell had purchased a paddleboard from Tesco at Llandudno Junction on the evening of the 14th of July 2022, that she had taken it to Conwy Morfa and had thereafter used it in an unsafe manner, whereby she did not wear any life saving equipment and the safety leash on the board was by way of an ankle leash which was inappropriate for the fast flowing water.
The evidence further indicated that at the point of sale, there was no safety advice or guidance provided in relation to either the advisory wearing of a safety vest, or the need to be aware that the positioning of a safety leash should take into account the environment/water conditions where the paddleboard is to be used as per the below information:
Unless action is taken to improve the provision of information to purchasers of paddleboards and/or to regulate the sale of paddleboards to ensure that the provision of advice of this nature becomes a mandatory requirement at the point of retail sale , then there is an ongoing risk that further accidents will occur and that lives may be lost as a result .
” Open source report
Concerns raised 2 Unofficial pedestrian crossing point with risk of pedestrian-vehicle near-misses View source Obstruction of visibility between pedestrians and vehicles at a pedestrian crossing point View source
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
Ming Tsung CHEUNG · 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
Ming Tsung CHEUNG, a student at Warwick University, was struck and killed by a lorry while crossing Lynchgate Road, Coventry. The crossing point was reportedly used by many pedestrians, with evidence of near-misses, and a large Tesco sign obscured the views of the pedestrian and lorry driver.
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 Tesco PLC; that does not assign responsibility.
PFD Monitor interpretation Unofficial pedestrian crossing point with risk of pedestrian-vehicle near-misses
Wider context from the report “I heard evidence that the point where Miss Cheung crossed the road was used by many pedestrians and had developed into an unofficial crossing point . Anecdotally there was some evidence of near-misses in terms of pedestrians being hit by vehicles . I heard evidence that a large Tesco sign obscured the view of Miss Cheung and the lorry driver. It may be that removal of the bottom wooden panels of the sign would be sufficient although I await to hear your response.
” 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 Tesco PLC; that does not assign responsibility.
PFD Monitor interpretation Obstruction of visibility between pedestrians and vehicles at a pedestrian crossing point
Wider context from the report “I heard evidence that the point where Miss Cheung crossed the road was used by many pedestrians and had developed into an unofficial crossing point. Anecdotally there was some evidence of near-misses in terms of pedestrians being hit by vehicles. I heard evidence that a large Tesco sign obscured the view of Miss Cheung and the lorry driver . It may be that removal of the bottom wooden panels of the sign would be sufficient although I await to hear your response.
” Open source report
Includes reports addressed to a minister or senior office-holder acting for this organisation.
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations