Recurance · prevention of future deaths reports
Pre-inquest brief
Lack of regular first aid training among custodial staff
The earlier warning
Patryk Gladysz · 18 Jul 2025 · Priya Malhotra, Inner West London
“First Aid refresher training is not up to date for all healthcare staff.”
judiciary.uk/…/patryk-gladysz-prevention-of-future-deaths-report
What was promised
Stated action 1 · response to Patryk Gladysz (18 Jul 2025) · stated 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”
judiciary.uk/…/2025-0364-Response-from-Department-for-Health-an…
Stated action 2 · response to Patryk Gladysz (18 Jul 2025) · stated timescale: 15 October 2025
“Staffing within the Mental Health In-reach team”
What recurred
- 21 May 2026 · George Haldenby · Rachael Griffin · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Patryk Gladysz · 18 Jul 2025
“First Aid refresher training is not up to date for all healthcare staff.”
Later · 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.”
What happened next
No web check of the stated actions has been published for this chain.