Recurance · prevention of future deaths reports
Pre-inquest brief
Delayed resuscitation due to insufficient staff awareness or training
The earlier warning
Ratidzai Sangare · 18 May 2016 · Selena Lynch, London South
“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”
judiciary.uk/prevention-of-future-death-reports/ratidzai-sangare
What was promised
No published response from Oxleas NHS Foundation Trust was found for the earlier reports.
What recurred
- 21 May 2026 · George Haldenby · Rachael Griffin · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · 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”
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.