2 Dec 2022 Lewis Steven Johnson · Prevention of Future Deaths report West Yorkshire Eastern
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Concerns raised 12 Failure to assess an unresponsive prisoner and consider CPR before death is certified View source Failure to consider defibrillator use during a cardiac emergency View source Delays in providing CPR after cardiac arrest View source Failure to consider placing an unresponsive prisoner in the recovery position View source Failure to provide annual refresher training in CPR and defibrillator use for night patrol staff View source Failure to train OSG officers to carry out CPR View source Failure of prison officers to initiate or coordinate CPR in an emergency View source Foreseeable self-harm emergencies among prisoners View source Lack of overnight healthcare staff in the prison View source Failure to train night patrol staff to respond effectively to ligature or other self-harm incidents View source Outdated defibrillator training for prison officers View source Lack of express instruction to carry out CPR pending the arrival of qualified medical professionals View source See 9 more concerns
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AI-generated summary
Lewis Steven Johnson · 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
Lewis Steven Johnson was found unresponsive with a neck ligature at HMP Wealstun on 12 December 2019 and later died in hospital following a further cardiac arrest. The report raised concerns about the absence of overnight healthcare staff and the prison officers’ delayed and inadequate response, including lack of CPR, defibrillator use and consideration of the recovery position.
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 Wealstun Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to assess an unresponsive prisoner and consider CPR before death is certified
Wider context from the report “(5) The officer acting as ████████ attended the cell but did not think about CPR , believing Mr Johnson to be already dead (notwithstanding that none of the discipline officers present had any medical qualifications to certify death ). He had undertaken defibrillator training “many years ago”.
” 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 Wealstun Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to consider defibrillator use during a cardiac emergency
Wider context from the report “(6) The four prison officers present in the cell did not discuss the need for CPR. The possibility of using a defibrillator was not mentioned . Mr Johnson was left in the cell in a seated position without the wisdom of placing him in the recovery position being considered.
” 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 Wealstun Prison; that does not assign responsibility.
PFD Monitor interpretation Delays in providing CPR after cardiac arrest
Wider context from the report “(7) The medical evidence available at the Inquest indicated “Effective CPR more than doubles the chance of someone surviving a cardiac arrest ”. Furthermore, the Resuscitation Council UK advises “provide chest compressions as soon as possible after cardiac arrest is confirmed ”.
” 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 Wealstun Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to consider placing an unresponsive prisoner in the recovery position
Wider context from the report “(6) The four prison officers present in the cell did not discuss the need for CPR. The possibility of using a defibrillator was not mentioned. Mr Johnson was left in the cell in a seated position without the wisdom of placing him in the recovery position being considered .
” 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 Wealstun Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to provide annual refresher training in CPR and defibrillator use for night patrol staff
Wider context from the report “(8) The value of all night patrol staff (particularly in a prison without 24 hour healthcare provision) being trained to provide effective CPR and use a defibrillator competently was recognised at the inquest, along with the wisdom of this being refreshed annually .
” 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 Wealstun Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to train OSG officers to carry out CPR
Wider context from the report “(4) The OSG officer who encountered the situation involving Mr Johnson around 04:45 had not been trained to carry out CPR .
” 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 Wealstun Prison; that does not assign responsibility.
PFD Monitor interpretation Failure of prison officers to initiate or coordinate CPR in an emergency
Wider context from the report “(6) The four prison officers present in the cell did not discuss the need for CPR . The possibility of using a defibrillator was not mentioned. Mr Johnson was left in the cell in a seated position without the wisdom of placing him in the recovery position being considered.
” 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 Wealstun Prison; that does not assign responsibility.
PFD Monitor interpretation Foreseeable self-harm emergencies among prisoners
Wider context from the report “(2) The incidence of self-harm incidents amongst prisoners (both in 2019 and today) make such emergencies foreseeable .
” 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 Wealstun Prison; that does not assign responsibility.
PFD Monitor interpretation Lack of overnight healthcare staff in the prison
Wider context from the report “(1) HMP Wealstun does not have nurses or other healthcare staff in the prison during the night .
” 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 Wealstun Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to train night patrol staff to respond effectively to ligature or other self-harm incidents
Wider context from the report “(3) In the absence of healthcare staff being immediately available, the night patrol staff should be trained to respond effectively to ligature or other self-harm incidents .
” 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 Wealstun Prison; that does not assign responsibility.
PFD Monitor interpretation Outdated defibrillator training for prison officers
Wider context from the report “(5) The officer acting as ████████ attended the cell but did not think about CPR, believing Mr Johnson to be already dead (notwithstanding that none of the discipline officers present had any medical qualifications to certify death). He had undertaken defibrillator training “many years ago” .
” 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 Wealstun Prison; that does not assign responsibility.
PFD Monitor interpretation Lack of express instruction to carry out CPR pending the arrival of qualified medical professionals
Wider context from the report “(9) The inquest noted that there is currently no express direction in PSI 03/2013 or other instruction to carry out CPR pending the arrival of paramedics or other qualified medical professional , when a prisoner is found in an unresponsive condition following a ligature incident .
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations