Lack of basic life support training among prison officers
Ministry of Justice received 4 coroners' reports about this hazard between 21 Apr 2016 and 18 May 2026.
They came from 4 different coroners in 4 coroner areas. A similar concern was raised again 3 times after the first warning.
A published response was found for 1 of the 3 earlier reports, stating 1 specific action.
The story, report by report
Spacing grows with the time between reports.
“it is a matter of concern that in December 2010 only one of four officers were first aid trained”
Original on judiciary.uk ↗ No published response from Ministry of Justice was found for this report.
- 3 years 2 months laterClosely relatedConfidence 0.90 · higha different coroner
“There was clearly a delay between Mr [name redacted] being found unresponsive by the prison officers and the commencement of CPR by members of the healthcare staff.”
Original on judiciary.uk ↗ No published response from Ministry of Justice was found for this report.
- 5 years 4 months later
Raised again · 2nd time
Stephen Sleaford↗
14 Oct 2024 · I M Cartwright · Leicester City and South Leicestershire
Identical hazardConfidence 0.90 · higha different coroner“basic first aid training (including CPR training) has been omitted from the foundation training programme for those training to be prison officers”
Original on judiciary.uk ↗ Repeated from the earlier report:firstofficers
Ministry of Justice responded, stating 1 specific action.Response (PDF) ↗
“attention. The HMPPS First Aid Policy Framework was re-issued nationally in August 2023. The revised policy highlights the training requirements for Emergency First Aid and First Aid in prisons, including the importance of Governors ensuring that there is an appropriate number of trained staff on duty at all times. To achieve this, a detailed local first aid risk assessment must be produced to determine the number of First Aiders at Work (FAW) and Emergency First Aiders at work (EFAW) required at an”
Stated timescale: August 2023
Web search (Tavily): No evidence found either way
Workplace First Aid 2026: Are You Compliant? | Garland Training ↗ - 1 year 7 months laterIdentical hazardConfidence 0.92 · 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 due to a lack of confidence and unfamiliarity of what to do in a situation when every second can count in promoting the chances of an optimal recovery.”
Original on judiciary.uk ↗ Repeated from the earlier report:trainingprisonofficersbasiclifesupport
Ministry of Justice responded.Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗
- All reports to Ministry of Justice
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.
2016 → 2019Darren McGuin3 years 2 months after Derrick Rose-Fowler · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight that prison officers lacking adequate first‑aid/basic life support training can delay the start of CPR after a prisoner is found unresponsive. The earlier report focuses on first aid training gaps, while the later report notes a lapse in basic life support training for certain staff.
Derrick Rose-Fowler · 21 Apr 2016
“Although on the facts of this case it made no difference to the outcome, the first prison officer on the scene was not first aid trained.”
Original on judiciary.uk ↗ Darren McGuin · 26 Jun 2019
“There was clearly a delay between Mr [name redacted] being found unresponsive by the prison officers and the commencement of CPR by members of the healthcare staff.”
Original on judiciary.uk ↗ 2016 → 2024Stephen Sleaford8 years 6 months after Derrick Rose-Fowler · different coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports highlight a lack of first aid training among prison officers as a safety concern. The earlier report notes insufficient trained officers; the later reports omission of such training from foundation programmes.
Derrick Rose-Fowler · 21 Apr 2016
“it is a matter of concern that in December 2010 only one of four officers were first aid trained”
Original on judiciary.uk ↗ Stephen Sleaford · 14 Oct 2024
“basic first aid training (including CPR training) has been omitted from the foundation training programme for those training to be prison officers”
Original on judiciary.uk ↗ 2019 → 2024Stephen Sleaford5 years 4 months after Darren McGuin · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight that prison officers lack basic life support/first‑aid training, which delays the start of CPR when a prisoner is found unresponsive. The core hazard is the absence of required life‑saving training for officers.
Darren McGuin · 26 Jun 2019
“Prison officers will usually be first on scene, particularly if a prisoner is found in their cell and this lack of basic life support training is leading to a delay in the commencement of CPR.”
Original on judiciary.uk ↗ Stephen Sleaford · 14 Oct 2024
“Evidence was heard that the majority of those prison officers who had commenced in their roles prior to 2018 had no first aid/basic life-saving skills and no ability/training in undertaking cardiopulmonary resuscitation ('CPR').”
Original on judiciary.uk ↗ 2019 → 2026Jake O'Brien6 years 11 months after Darren McGuin · different coronerIdentical hazardConfidence 0.92 · high
Identical hazardConfidence 0.92 · highBoth reports highlight that prison officers lack sufficient basic life support/first aid training, which delays their ability to provide immediate life‑saving care when they discover a prisoner in need.
Darren McGuin · 26 Jun 2019
“Prison officers will usually be first on scene, particularly if a prisoner is found in their cell and this lack of basic life support training is leading to a delay in the commencement of CPR.”
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 due to a lack of confidence and unfamiliarity of what to do in a situation when every second can count in promoting the chances of an optimal recovery.”
Original on judiciary.uk ↗ 2024 → 2026Jake O'Brien1 year 7 months after Stephen Sleaford · different coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports highlight that prison officers lack ongoing first aid/CPR training, impairing their ability to deliver immediate life‑saving care.
Stephen Sleaford · 14 Oct 2024
“Evidence was heard that the majority of those prison officers who had commenced in their roles prior to 2018 had no first aid/basic life-saving skills and no ability/training in undertaking cardiopulmonary resuscitation ('CPR').”
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 due to a lack of confidence and unfamiliarity of what to do”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“attention. The HMPPS First Aid Policy Framework was re-issued nationally in August 2023. The revised policy highlights the training requirements for Emergency First Aid and First Aid in prisons, including the importance of Governors ensuring that there is an appropriate number of trained staff on duty at all times. To achieve this, a detailed local first aid risk assessment must be produced to determine the number of First Aiders at Work (FAW) and Emergency First Aiders at work (EFAW) required at an”
2016 → 2026Jake O'Brien10 years 1 month after Derrick Rose-Fowler · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight insufficient first aid or basic life support training among prison officers, which hampers timely emergency response.
Derrick Rose-Fowler · 21 Apr 2016
“it is a matter of concern that in December 2010 only one of four officers were first aid trained and in February 2012 one was still untrained”
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 due to a lack of confidence”
Original on judiciary.uk ↗
No published response from Ministry of Justice was found for this report.
No published response from Ministry of Justice was found for this report.
Stated action · timescale: August 2023
“attention. The HMPPS First Aid Policy Framework was re-issued nationally in August 2023. The revised policy highlights the training requirements for Emergency First Aid and First Aid in prisons, including the importance of Governors ensuring that there is an appropriate number of trained staff on duty at all times. To achieve this, a detailed local first aid risk assessment must be produced to determine the number of First Aiders at Work (FAW) and Emergency First Aiders at work (EFAW) required at an”
What happened next: No evidence found either way
The August 2023 re-issue of the HMPPS First Aid Policy Framework is not referenced in any of the provided sources, which focus on workplace first aid standards from 2026 and later.
“The new BS 8599-1:2019+A1:2026 workplace first aid kits standard came into force on 30 April 2026”
“Workplace first aid is evolving-and employers need to be ready”
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.
- 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 Ministry of Justice 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 |
|---|---|---|---|---|
| 2016 → 2019 | 0.86 | 0.30 | Closely related · 0.90 | different |
| 2016 → 2024 | 0.89 | 0.39 | Identical · 0.90 | different |
| 2019 → 2024 | 0.92 | 0.30 | Closely related · 0.90 | different |
| 2019 → 2026 | 0.85 | 0.31 | Identical · 0.92 | different |
| 2024 → 2026 | 0.83 | 0.19 | Identical · 0.90 | different |
| 2016 → 2026 | 0.82 | 0.11 | Closely related · 0.90 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
Next
Other chains for Ministry of Justice
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.