Delayed resuscitation due to insufficient staff awareness or training
Oxleas NHS Foundation Trust received 2 coroners' reports about this hazard between 18 May 2016 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.
No published response from Oxleas NHS Foundation Trust was found for the earlier reports.
The story, report by report
Spacing grows with the time between reports.
“Healthcare staff were unaware or did not recognise that Mrs [name redacted] condition required immediate cardiopulmonary resuscitation, the activation of the alarm, and the summoning of an ambulance”
Original on judiciary.uk ↗ No published response from Oxleas NHS Foundation Trust was found for this report.
- 10 years 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:staffresuscitation
Oxleas NHS Foundation Trust responded.Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗
- All reports to Oxleas NHS Foundation Trust
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 → 2026George Haldenby10 years after Ratidzai Sangare · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight a risk of delayed cardiopulmonary resuscitation due to insufficient staff awareness or training.
Ratidzai Sangare · 18 May 2016
“Healthcare staff were unaware or did not recognise that Mrs [name redacted] condition required immediate cardiopulmonary resuscitation, the activation of the alarm, and the summoning of an ambulance”
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 ↗
No published response from Oxleas NHS Foundation Trust was found for this report.
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 Oxleas NHS Foundation Trust 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 → 2026 | 0.65 | 0.04 | Closely related · 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 Oxleas NHS Foundation Trust
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.