PFD report

Ondrej SUHA · Prevention of Future Deaths report

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Issued 30 Mar 2017•Staffordshire South

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
2

Raised in this report

Recipients
1

Named on the report

Responses found
0

Of 1 recipient

Stated actions
0

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

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Concerns raised2

  1. Failure to ensure responding staff have basic resuscitation training
    Part of recurring concern: Failure to ensure staff competence in resuscitationPart of recurring concern: Inadequate staff competence to provide first aid
  2. Lack of Prison Officer training on differences in the night/patrol state
Responses linked to these concerns

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

No linked response statements

No respondent-stated action or position is clearly linked to these concerns.

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

Failure to ensure responding staff have basic resuscitation training

Wider context from the report

“(2) The initial staff responding to the incident did not have first aid training to enable them to attempt resuscitation. Subsequently many staff at HMPOI Brinsford have had this training. However I wonder if basic resuscitation should form part of a Prison Officer's training or indeed if the quotas for staff on duty at any one time in a prison with such training should be reviewed. ”

Is this part of a recurring concern?

Yes — Failure to ensure staff competence in resuscitation; Inadequate staff competence to provide first aid.

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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 Prison Officer training on differences in the night/patrol state

Wider context from the report

“(1) Ondrej was discovered hanging in his cell soon after 9pm. In his evidence the Prison officer who was involved in the initial response indicated that he had just started his first night shift (he was experienced with day shifts) but had no specific training for this. I wonder if standard training for Prison Officers should include some limited information about differences in the regime when the prison is in the night/patrol state. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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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