Keith John MURPHY · Prevention of Future Deaths report

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Issued 25 Mar 2015•Surrey

Published report and response evidence

This report’s concerns and statements found in recipients’ published responses. Statements are included even where no link to an individual concern is recorded. A link shows an evidence connection; it does not assign responsibility.

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Concerns
4

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
2

Described in responses

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.

Report evidence summary

Concerns raised4

  1. Lack of defibrillator-use familiarisation for prison officers and staff with direct access to prisoners
    Part of recurring concern: Inadequate staff training and familiarisation in defibrillator use
  2. Limited availability of healthcare staff beyond 7am–6.30pm
    Part of recurring concern: Insufficient out-of-hours healthcare availability
  3. Lack of basic first aid training for prison officers and staff with direct access to prisoners
    Part of recurring concern: Inadequate staff competence to provide first aid

Stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.2

  1. HM Prison and Probation Service and NHS England

    Provide wider staff instruction on CPR and defibrillator use during monthly prisoner-regime closedowns.

  2. HM Prison and Probation Service and NHS England

    Train all Custodial Managers in first aid to ensure trained staff are always available.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. HM Prison and Probation Service and NHS England

    The prison population is not considered to require on-site healthcare staffing outside normal hours.

    Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
  2. HM Prison and Probation Service and NHS England

    Existing out-of-hours healthcare arrangements are considered sufficient to meet the needs of the prison population.

    Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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 defibrillator-use familiarisation for prison officers and staff with direct access to prisoners

Wider context from the report

“1. Action is required to ensure that Prison Officers and Staff with direct access to prisoners have basic first aid training, CPR training and familiarisation with the use of a defibrillator. ”

Is this part of a recurring concern?

Yes — Inadequate staff training and familiarisation in defibrillator use.

Open source report

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

Limited availability of healthcare staff beyond 7am–6.30pm

Wider context from the report

“2. Action is required to ensure someone from Healthcare is available beyond the current arrangement of 7am – 6.30pm to provide an ”

Is this part of a recurring concern?

Yes — Insufficient out-of-hours healthcare availability.

Open source report

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 basic first aid training for prison officers and staff with direct access to prisoners

Wider context from the report

“1. Action is required to ensure that Prison Officers and Staff with direct access to prisoners have basic first aid training, CPR training and familiarisation with the use of a defibrillator. ”

Is this part of a recurring concern?

Yes — Inadequate staff competence to provide first aid.

Open source report

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 CPR training for prison officers and staff with direct access to prisoners

Wider context from the report

“1. Action is required to ensure that Prison Officers and Staff with direct access to prisoners have basic first aid training, CPR training and familiarisation with the use of a defibrillator. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Provide wider staff instruction on CPR and defibrillator use during monthly prisoner-regime closedowns.

Verbatim wording from the response

“This policy is being implemented at HMP Coldingley. In order to ensure that a trained member of staff is always available, all Custodial Managers (CMs) are being trained. At present, all but two of the CMs at the prison have been trained, and those two members of staff will be provided with training as soon as they return to duty. HMP Coldingley also uses a monthly closedown of the prisoner regime to provide opportunities for training for the wider staff group and this includes instruction on CPR and on the use of defibrillators.”

Source location

2015-0120-Response-by-NOMS
Page 1 · response
Published 25 March 2015

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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

Train all Custodial Managers in first aid to ensure trained staff are always available.

Verbatim wording from the response

“First Aid training for prison staff PSI 01/2014 First Aid describes the process for ensuring effective provision of first aid that enables NOMS to discharge its duty of care to its employees, to prisoners and to visitors to our premises. Governors are required to ensure that at all times such a number of suitably trained first aiders as is sufficient and appropriate for the circumstances at their prison is available. A First Aid risks/needs assessment is undertaken by the local Health and Safety Advisor to determine the appropriate numbers. Governors must ensure that first aiders are trained to levels which are appropriate for the circumstances and hold a valid certificate of competence in either First Aid at Work (FAW) or Emergency First Aid at Work (EFAW).”

Source location

2015-0120-Response-by-NOMS
Page 1 · response
Published 25 March 2015

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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

The prison population is not considered to require on-site healthcare staffing outside normal hours.

Verbatim wording from the response

“The size (531) and nature of the population at the prison, which is composed of prisoners who have been assessed by staff in other prisons as suitable to be accommodated at HMP Coldingley, is not believed to require the provision of on-site healthcare staffing out of hours. A recent Health Needs Assessment, commissioned through the NHS England South East Health and Justice commissioning team, confirms that the existing healthcare arrangements meet the needs of the prisoner population at the establishment.”

Source location

2015-0120-Response-by-NOMS
Page 2 · response
Published 25 March 2015

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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

Existing out-of-hours healthcare arrangements are considered sufficient to meet the needs of the prison population.

Verbatim wording from the response

“needs of the prisoner as appropriate. This arrangement is considered to be equivalent to what is available in the community. Where prisoners are perceived to require access to emergency and lifesaving care the local Ambulance Trust (South East Coast Ambulance NHS) is called for an emergency response.”

Source location

2015-0120-Response-by-NOMS
Page 2 · response
Published 25 March 2015

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

Official responses located
2/2

Data last updated 7 September 2026