PFD report

Anthony George Smith · Prevention of Future Deaths report

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Issued 7 Jun 2023•Lancashire and Blackburn with Darwen

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
1

Raised in this report

Recipients
2

Named on the report

Responses found
1

Of 2 recipients

Stated actions
4

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised1

  1. Lack of available mouth protection for resuscitation
    Part of recurring concern: Unreliable access to barrier devices for emergency resuscitationPart of recurring concern: Unreliable resuscitation preparedness and response during cardiac arrest
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.4

  1. Action

    Issue staff guidance explaining face-shield locations and the importance of using them during CPR.

    Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 13 June 2023.
  2. Action

    Provide resuscitation face shields in first-aid boxes across all HMP Preston residential units.

    Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 13 June 2023.
  3. Action

    Monitor HMP Preston face shields and replenish them when required.

    Stated by HM Prison and Probation ServiceStatus unclearThe respondent did not make the status of this action clear when they made their response on 13 June 2023.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of available mouth protection for resuscitation

Wider context from the report

“(1) An officer attempting resuscitation carried out mouth to mouth resuscitation without the safeguard of mouth protection which was not available in the prison at the time. Mr Smith was a regular drug user who on occasions injected drugs. Performing mouth to mouth resuscitation carried with it the risk of transmission of blood born viruses with possible fatal consequences. (2) The lack of available protection not only carried with it a risk to those who performed resuscitation but potentially also to the person suffering a cardiac arrest in that without protection the would-be resuscitator might decline to provide rescue breaths ”

Is this part of a recurring concern?

Yes — Unreliable access to barrier devices for emergency resuscitation; Unreliable resuscitation preparedness and response during cardiac arrest.

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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

Issue staff guidance explaining face-shield locations and the importance of using them during CPR.

Verbatim wording from the response

“At HMP Preston, face shields have been purchased and added to the existing first aid boxes on all residential units and will be monitored by the Health and Safety Team. A Notice to Staff was also issued in June 2023 to advise staff of the location of the face shields and the importance of using these when administering CPR.”

Source location

Response from HM Prison and Probation Service
Page 1 · response
Published 13 June 2023

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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 resuscitation face shields in first-aid boxes across all HMP Preston residential units.

Verbatim wording from the response

“At HMP Preston, face shields have been purchased and added to the existing first aid boxes on all residential units and will be monitored by the Health and Safety Team. A Notice to Staff was also issued in June 2023 to advise staff of the location of the face shields and the importance of using these when administering CPR.”

Source location

Response from HM Prison and Probation Service
Page 1 · response
Published 13 June 2023

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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

Monitor HMP Preston face shields and replenish them when required.

Verbatim wording from the response

“As you are aware, the First Aid Policy Framework is currently under review and is due to be re-issued by August 2023. The revised policy document will include instructions on the use of face shields including the requirement for all first aid kits in prisons to contain resuscitation face shields and for these to be monitored and replenished when required. The policy also emphasises the training requirements for Emergency First Aid and First Aid at Work, including the importance of using the face masks correctly and of these being available at all times.”

Source location

Response from HM Prison and Probation Service
Page 1 · response
Published 13 June 2023

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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

Reissue the First Aid Policy Framework with face-shield requirements for prison first-aid kits and related CPR guidance.

Verbatim wording from the response

“As you are aware, the First Aid Policy Framework is currently under review and is due to be re-issued by August 2023. The revised policy document will include instructions on the use of face shields including the requirement for all first aid kits in prisons to contain resuscitation face shields and for these to be monitored and replenished when required. The policy also emphasises the training requirements for Emergency First Aid and First Aid at Work, including the importance of using the face masks correctly and of these being available at all times.”

Source location

Response from HM Prison and Probation Service
Page 1 · response
Published 13 June 2023

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026