Lack of basic first aid training and CPR training and defibrillator use by Prison Officers and Staff
NHS England received 3 coroners' reports about this hazard between 25 Mar 2015 and 18 May 2026.
They came from 3 different coroners in 3 coroner areas. A similar concern was raised again 2 times after the first warning.
A published response was found for 2 of the 2 earlier reports, stating 1 specific action.
The story, report by report
Spacing grows with the time between reports.
“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.”
Original on judiciary.uk ↗ NHS England responded, stating 1 specific action.Response (PDF) ↗
“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.”
Stated timescale: as soon as they return to duty
Web search (Tavily): No evidence found either way
First Aid, CPR and AED Courses ↗- 2 years laterIdentical hazardConfidence 0.90 · higha different coroner
“The prison officers did not have even the most basic first aid and cardiopulmonary resuscitation (CPR) training.”
Original on judiciary.uk ↗ Repeated from the earlier report:prisonofficersbasicfirsttraining
NHS England responded.Response (PDF) ↗
- 9 years 2 months laterClosely relatedConfidence 0.90 · higha different coroner
“No ongoing training had been provided to prison officers since initial training on basic life support or first aid, meaning that officers confronted with discovery of a ligature situation were unable to provide immediate and basic life support”
Original on judiciary.uk ↗ Repeated from the earlier report:trainingprisonofficersbasicfirst
- All reports to NHS England
Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals.
2015 → 2017John Williams2 years after Keith Murphy · different coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports highlight that prison officers lack basic first aid and CPR training, putting prisoners at risk during medical emergencies. The later report reiterates the same gap despite noting some training efforts.
Keith Murphy · 25 Mar 2015
“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.”
Original on judiciary.uk ↗ John Williams · 28 Mar 2017
“The prison officers did not have even the most basic first aid and cardiopulmonary resuscitation (CPR) training.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“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.”
2015 → 2026Jake O'Brien11 years 2 months after Keith Murphy · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight insufficient first aid/basic life support training for prison officers who have direct contact with prisoners. The earlier report calls for initial training in CPR and defibrillator use, while the later report notes a lack of ongoing training leaving officers unprepared for ligature incidents.
Keith Murphy · 25 Mar 2015
“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.”
Original on judiciary.uk ↗ Jake O'Brien · 18 May 2026
“No ongoing training had been provided to prison officers since initial training on basic life support or first aid, meaning that officers confronted with discovery of a ligature situation were unable to provide immediate and basic life support”
Original on judiciary.uk ↗ 2017 → 2026Jake O'Brien9 years 2 months after John Williams · different coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports highlight that prison officers lack adequate first aid/CPR training, leaving them unable to deliver basic life support in emergencies.
John Williams · 28 Mar 2017
“The prison officers did not have even the most basic first aid and cardiopulmonary resuscitation (CPR) training.”
Original on judiciary.uk ↗ Jake O'Brien · 18 May 2026
“No ongoing training had been provided to prison officers since initial training on basic life support or first aid, meaning that officers confronted with discovery of a ligature situation were unable to provide immediate and basic life support”
Original on judiciary.uk ↗
Stated action · timescale: as soon as they return to duty
“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.”
What happened next: No evidence found either way
The organisation states that training will be provided to two staff members as soon as they return to duty, but no source confirms that this training has been completed or is scheduled.
“NSC First Aid, CPR & AED training builds the knowledge, skills and confidence employees need to respond effectively to workplace medical and cardiac”
“Heartsaver First Aid CPR AED teaches participants how to give first aid, perform cardiopulmonary resuscitation, and use an automated external defibrillator”
“This course is for recertification as well as certification for our new staff who have not yet been through a CPR or First Aid training course.”
No evidence found does not mean the action did not happen.
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
- Each report's concerns were extracted by Nemotron 3 Nano on Nebius Token Factory, each with a quote copied from the report.
- Concerns from reports to NHS England at least six months apart were compared by meaning (Qwen3 embeddings) and wording (TF-IDF).
- The closest pairs were judged by Nemotron 3 Super with reasoning on. Only identical or closely related, with confidence of at least 0.70, are shown.
- Every quote was checked by code as an exact substring of the original text. Names of staff and family are redacted, and the deceased are named by report title only.
| Link | Meaning | Wording | Judge | Coroner |
|---|---|---|---|---|
| 2015 → 2017 | 0.89 | 0.30 | Identical · 0.90 | different |
| 2015 → 2026 | 0.81 | 0.13 | Closely related · 0.90 | different |
| 2017 → 2026 | 0.77 | 0.14 | Identical · 0.90 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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Other chains for NHS England
This shows that a similar concern was raised again after an earlier report. It does not say why, and it is not a finding about any organisation or person. To report an error, see the corrections route.