Recurance · prevention of future deaths reports
Pre-inquest brief
Delayed staff training on cell entry and emergency communications
The earlier warning
Luke Pearce · 16 May 2024 · Kelly Dixon, Staffordshire and Stoke on Trent
“relevant training and guidance to equip staff to understand when and how to enter a cell in a medical emergency”
judiciary.uk/…/luke-pearce-prevention-of-future-deaths-report
What was promised
A published response was found, but no specific action could be extracted with a verified quote.
What recurred
- 8 Jul 2025 · George Emmett · Crispin Butler · Identical hazard · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Luke Pearce · 16 May 2024
“relevant training and guidance to equip staff to understand when and how to enter a cell in a medical emergency”
Later · George Emmett · 8 Jul 2025
“The evidence of OSG [REDACTED] did not appear to demonstrate familiarity with the processes set out in this policy at the time of [the deceased]'s death”
What happened next
No web check of the stated actions has been published for this chain.