Wealstun Prison

Justice · Prison or young offender institution

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First report 2 Dec 2022•Latest report 2 Dec 2022

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports: 1
Published responses: 0%
Concerns addressed: 0
Stated actions: 0

Concerns and recipient responses

Statements from Wealstun Prison linked to the concerns in each report. Select any concern, action or position to view the source wording.

2 Dec2022
West Yorkshire Eastern
Concerns raised12
1. Failure to assess an unresponsive prisoner and consider CPR before death is certified
2. Failure to consider defibrillator use during a cardiac emergency
3. Delays in providing CPR after cardiac arrest
1. Failure to consider placing an unresponsive prisoner in the recovery position
2. Failure to provide annual refresher training in CPR and defibrillator use for night patrol staff
3. Failure to train OSG officers to carry out CPR
4. Failure of prison officers to initiate or coordinate CPR in an emergency
5. Foreseeable self-harm emergencies among prisoners
6. Lack of overnight healthcare staff in the prison
7. Failure to train night patrol staff to respond effectively to ligature or other self-harm incidents
8. Outdated defibrillator training for prison officers
9. Lack of express instruction to carry out CPR pending the arrival of qualified medical professionals
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
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

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026

Reports, concerns and published responses

Reports over time

Concerns raised12

Failure to assess an unresponsive prisoner and consider CPR before death is certified

Failure to consider defibrillator use during a cardiac emergency

Delays in providing CPR after cardiac arrest

Failure to consider placing an unresponsive prisoner in the recovery position

Failure to provide annual refresher training in CPR and defibrillator use for night patrol staff

Failure to train OSG officers to carry out CPR

Failure of prison officers to initiate or coordinate CPR in an emergency

Foreseeable self-harm emergencies among prisoners

Lack of overnight healthcare staff in the prison

Failure to train night patrol staff to respond effectively to ligature or other self-harm incidents

Outdated defibrillator training for prison officers

Lack of express instruction to carry out CPR pending the arrival of qualified medical professionals