Lack of regular first aid training among custodial staff
Department of Health and Social Care received 2 coroners' reports about this hazard between 18 Jul 2025 and 21 May 2026.
They came from 2 different coroners in 2 coroner areas. A similar concern was raised again 1 time after the first warning.
A published response was found for 1 of the 1 earlier reports, stating 2 specific actions.
The story, report by report
Spacing grows with the time between reports.
“First Aid refresher training is not up to date for all healthcare staff.”
Original on judiciary.uk ↗ Department of Health and Social Care responded, stating 2 specific actions.Response (PDF) ↗Response (PDF) ↗
“I understand your concerns about staffing shortages within the mental health in-reach team at HMP Wandsworth, and how that may have impacted the quality of mental health assessments. I understand from NHS England that, at the time of Mr [name redacted] death, the team had a vacancy for one whole time equivalent staff member, and that this has now been filled. In addition, the internal patient safety investigation into Mr [name redacted] death carried out by Oxleas NHS Foundation Trust, as the healthcare”
Stated timescale: late 2024
“Staffing within the Mental Health In-reach team”
Stated timescale: 15 October 2025
- 10 months laterClosely relatedConfidence 0.90 · higha different coroner
“After prison officers and prison staff carry out their induction training which covers basic first aid training including the delivery of cardio pulmonary resuscitation (CPR), there is no further mandatory refresher training on first aid or CPR.”
Original on judiciary.uk ↗ Repeated from the earlier report:stafftrainingfirstrefresher
Department of Health and Social Care responded.Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗
- All reports to Department of Health and Social Care
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.
2025 → 2026George Haldenby10 months after Patryk Gladysz · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight a lack of ongoing refresher training in first aid/CPR for staff working in custodial settings. The earlier report focuses on healthcare staff, while the later report concerns prison officers and staff.
Patryk Gladysz · 18 Jul 2025
“First Aid refresher training is not up to date for all healthcare staff.”
Original on judiciary.uk ↗ George Haldenby · 21 May 2026
“After prison officers and prison staff carry out their induction training which covers basic first aid training including the delivery of cardio pulmonary resuscitation (CPR), there is no further mandatory refresher training on first aid or CPR.”
Original on judiciary.uk ↗
Stated action · timescale: late 2024
“I understand your concerns about staffing shortages within the mental health in-reach team at HMP Wandsworth, and how that may have impacted the quality of mental health assessments. I understand from NHS England that, at the time of Mr [name redacted] death, the team had a vacancy for one whole time equivalent staff member, and that this has now been filled. In addition, the internal patient safety investigation into Mr [name redacted] death carried out by Oxleas NHS Foundation Trust, as the healthcare”
Stated action · timescale: 15 October 2025
“Staffing within the Mental Health In-reach team”
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 Department of Health and Social Care 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 |
|---|---|---|---|---|
| 2025 → 2026 | 0.78 | 0.23 | Closely related · 0.90 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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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.