Recurance · prevention of future deaths reports
Pre-inquest brief
Lack of basic life support training among prison officers
The earlier warning
Derrick Rose-Fowler · 21 Apr 2016 · John Ellery, Shropshire, Telford and Wrekin
“it is a matter of concern that in December 2010 only one of four officers were first aid trained”
What was promised
Stated action 1 · response to Stephen Sleaford (14 Oct 2024) · stated 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”
judiciary.uk/…/2024-0550-Response-from-HMPPS-received-by-CCO-24…
What recurred
- 26 Jun 2019 · Darren McGuin · Sarah Slater · Closely related · confidence 0.90 (high)
- 14 Oct 2024 · Stephen Sleaford · I M Cartwright · Identical hazard · confidence 0.90 (high)
- 18 May 2026 · Jake O'Brien · Michael Pemberton · Identical hazard · confidence 0.92 (high)
The clearest link, quoted from both reports:
Earlier · 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.”
Later · 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.”
What happened next
No evidence found either way · stated action 1
“The new BS 8599-1:2019+A1:2026 workplace first aid kits standard came into force on 30 April 2026”
Workplace First Aid 2026: Are You Compliant? | Garland Training · chrisgarlandtraining.co.uk/hse-first-aid-requirements-2026-uk
“Workplace first aid is evolving-and employers need to be ready”
Workplace First Aid Has Changed. Are You Ready? · safetyequipment.org/…/workplace-first-aid-has-changed-are-you-r…
No evidence found does not mean the action did not happen.