PFD report

Ryan Stephen TRIMMER · Prevention of Future Deaths report

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Issued 21 Jun 2019•East Sussex

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
1

Of 1 recipient

Stated actions
8

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 raised2

  1. Failure of the ACCT process to provide effective reviews
    Part of recurring concern: Unreliable ACCT suicide and self-harm prevention processes
  2. Lack of first aid training for frontline prison staff
    Part of recurring concern: Inadequate prison staff training for responding to medical emergenciesPart of recurring concern: Inadequate staff competence to provide first aid
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.8

  1. Action

    Review the provision of first aid in prisons.

    Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 23 August 2019.
  2. Action

    Introduce a one-day first aid refresher course to maintain staff training levels.

    Stated by HM Prison and Probation ServiceStated plannedThe respondent said that this action was planned when they made their response on 23 August 2019.
  3. Action

    Deliver monthly first aid training to prison staff through two on-site trainers.

    Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 23 August 2019.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    Existing arrangements require sufficient first-aid-trained staff on duty, with at least two nurses and one trained prison staff member available at HMP Lewes.

    Stated by HM Prison and Probation ServiceExisting 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

Failure of the ACCT process to provide effective reviews

Wider context from the report

“The ACCT process was ineffective. They jury made a factual finding of inadequate ACCT reviews. The Court heard evidence of the ACCT Pilot Scheme underway in certain other prisons. HMP Lewes should be considered as a priority facility for future extension of the ACCT Pilot Scheme. ”

Is this part of a recurring concern?

Yes — Unreliable ACCT suicide and self-harm prevention processes.

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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 first aid training for frontline prison staff

Wider context from the report

“Prison staff are often first responders to medical emergencies of prisoners, but not all have received first aid training. One frontline prison staff member gave evidence that he had not received training in 16 years of working for HMPS and felt he needed refresher training. ”

Is this part of a recurring concern?

Yes — Inadequate prison staff training for responding to medical emergencies; Inadequate staff competence to provide first aid.

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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

Review the provision of first aid in prisons.

Verbatim wording from the response

“At a national level, since 2016 all new prison officers have completed a mandatory level 3 qualification in Emergency First Aid at Work as part of their Prison Officer Entry Level Training. This includes the application of CPR and the use of a defibrillator. Whilst there is currently no national requirement for all prison staff to be trained in first aid, we are currently reviewing the provision of first aid in prison, and we expect this to result in revisions to first aid policy and training. We have also been working with the Awarding Body on the development of a custodial First Aid awareness course, focusing on key areas and situations that may arise in the prison environment.”

Source location

2019-0215-Response-by-HM-Prison-and-Probabtion-Service
Page 2 · response
Published 23 August 2019

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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

Introduce a one-day first aid refresher course to maintain staff training levels.

Verbatim wording from the response

“Two on-site first aid trainers will be delivering first aid training to staff as part of the prison’s monthly training provision, and a one-day refresher course will be introduced to ensure that training levels are maintained. Custodial Managers (the most senior uniformed grade of staff) and Officer Support Grades (staff that support the duties of Prison Officers) have been provided with this training first, in order to ensure that those covering the Orderly Officer role”

Source location

2019-0215-Response-by-HM-Prison-and-Probabtion-Service
Page 1 · response
Published 23 August 2019

Open published response

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

Deliver monthly first aid training to prison staff through two on-site trainers.

Verbatim wording from the response

“Two on-site first aid trainers will be delivering first aid training to staff as part of the prison’s monthly training provision, and a one-day refresher course will be introduced to ensure that training levels are maintained. Custodial Managers (the most senior uniformed grade of staff) and Officer Support Grades (staff that support the duties of Prison Officers) have been provided with this training first, in order to ensure that those covering the Orderly Officer role”

Source location

2019-0215-Response-by-HM-Prison-and-Probabtion-Service
Page 1 · response
Published 23 August 2019

Open published response

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

Develop a custodial First Aid awareness course with the awarding body.

Verbatim wording from the response

“At a national level, since 2016 all new prison officers have completed a mandatory level 3 qualification in Emergency First Aid at Work as part of their Prison Officer Entry Level Training. This includes the application of CPR and the use of a defibrillator. Whilst there is currently no national requirement for all prison staff to be trained in first aid, we are currently reviewing the provision of first aid in prison, and we expect this to result in revisions to first aid policy and training. We have also been working with the Awarding Body on the development of a custodial First Aid awareness course, focusing on key areas and situations that may arise in the prison environment.”

Source location

2019-0215-Response-by-HM-Prison-and-Probabtion-Service
Page 2 · response
Published 23 August 2019

Open published response

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

Require new prison officers to complete mandatory level 3 Emergency First Aid at Work training, including CPR and defibrillator use.

Verbatim wording from the response

“At a national level, since 2016 all new prison officers have completed a mandatory level 3 qualification in Emergency First Aid at Work as part of their Prison Officer Entry Level Training. This includes the application of CPR and the use of a defibrillator. Whilst there is currently no national requirement for all prison staff to be trained in first aid, we are currently reviewing the provision of first aid in prison, and we expect this to result in revisions to first aid policy and training. We have also been working with the Awarding Body on the development of a custodial First Aid awareness course, focusing on key areas and situations that may arise in the prison environment.”

Source location

2019-0215-Response-by-HM-Prison-and-Probabtion-Service
Page 2 · response
Published 23 August 2019

Open published response

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

Evaluate the revised ACCT pilot to inform development of a new national process.

Verbatim wording from the response

“I note the findings of the jury with regard to the operation of the ACCT process in this case, and it is good to know that you heard evidence about the pilot of the revised version of ACCT. This took place in nine prisons and one immigration removal centre from February to June 2019. The feedback from the sites has been positive, and a formal evaluation of the pilot is currently being undertaken. The findings will inform the development of a new version of ACCT that we intend to roll out nationally in early 2020. In support of this roll out there will be a clear communication strategy, and support mechanisms will be in place to help embed the revised process within each site. It is too early to give a firm date for the new process to be introduced at HMP Lewes, but we have noted your view that this should be a priority.”

Source location

2019-0215-Response-by-HM-Prison-and-Probabtion-Service
Page 1 · response
Published 23 August 2019

Open published response

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

Roll out the revised ACCT process nationally, supported by communications and site-level implementation support.

Verbatim wording from the response

“I note the findings of the jury with regard to the operation of the ACCT process in this case, and it is good to know that you heard evidence about the pilot of the revised version of ACCT. This took place in nine prisons and one immigration removal centre from February to June 2019. The feedback from the sites has been positive, and a formal evaluation of the pilot is currently being undertaken. The findings will inform the development of a new version of ACCT that we intend to roll out nationally in early 2020. In support of this roll out there will be a clear communication strategy, and support mechanisms will be in place to help embed the revised process within each site. It is too early to give a firm date for the new process to be introduced at HMP Lewes, but we have noted your view that this should be a priority.”

Source location

2019-0215-Response-by-HM-Prison-and-Probabtion-Service
Page 1 · response
Published 23 August 2019

Open published response

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 priority first aid training to Custodial Managers and Officer Support Grades.

Verbatim wording from the response

“Two on-site first aid trainers will be delivering first aid training to staff as part of the prison’s monthly training provision, and a one-day refresher course will be introduced to ensure that training levels are maintained. Custodial Managers (the most senior uniformed grade of staff) and Officer Support Grades (staff that support the duties of Prison Officers) have been provided with this training first, in order to ensure that those covering the Orderly Officer role”

Source location

2019-0215-Response-by-HM-Prison-and-Probabtion-Service
Page 1 · response
Published 23 August 2019

Open published response

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 arrangements require sufficient first-aid-trained staff on duty, with at least two nurses and one trained prison staff member available at HMP Lewes.

Verbatim wording from the response

“Your second concern is that whilst prison staff can often be first on scene at a medical emergency, not all have received training in first aid. The Governors of each prison are required to ensure that there are sufficient numbers of staff trained in first aid on duty, and at HMP Lewes at least two trained nurses and one trained member of prison staff are available at all times.”

Source location

2019-0215-Response-by-HM-Prison-and-Probabtion-Service
Page 1 · response
Published 23 August 2019

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