Gareth Chumber-Kelly
9 Feb 2026 · Coroner Jonathan Stevens · North London
This report repeats 6 earlier warnings. See the linked reports.
The coroner's concerns
1. lack of basic life support training for prison officers
“The court heard evidence that the first two officers on the scene failed to provide any form of basic life support despite having received training on how to do so”
2. absence of suicide and self-harm training for prison staff
“The Governor of HMP Pentonville told the court that Suicide and Self harm training for prison staff had been suspended during Covid and had never been re-started notwithstanding that 38% of prisoners arriving at HMP Pentonville said they felt suicidal”
3. lack of refresher CPR training for prison officers
“The Governor of the prison told the court that no refresher CPR training had been provided to prison staff since 2023 notwithstanding the 5 deaths of prisoners by ligature suspension that have occurred since”
Linked reports
Identical hazardConfidence 0.95 · high
Earlier report
“Action is required to ensure that Prison Officers and Staff with direct access to prisoners have basic first aid training, CPR training and familiarisation with the use of a defibrillator.”
This report
“The Governor of the prison told the court that no refresher CPR training had been provided to prison staff since 2023 notwithstanding the 5 deaths of prisoners by ligature suspension that have occurred since.”
Identical hazardConfidence 0.95 · high
Earlier report
“The prison officers did not have even the most basic first aid and cardiopulmonary resuscitation (CPR) training.”
This report
“The Governor of the prison told the court that no refresher CPR training had been provided to prison staff since 2023 notwithstanding the 5 deaths of prisoners by ligature suspension that have occurred since.”
Closely relatedConfidence 0.92 · high
Earlier report
“There is no mandatory first aid training for existing (as opposed to new) prison officers.”
This report
“The Governor of the prison told the court that no refresher CPR training had been provided to prison staff since 2023 notwithstanding the 5 deaths of prisoners by ligature suspension that have occurred since.”
Identical hazardConfidence 0.90 · high
Earlier report
“(1) Some Prison staff had not received any cardiopulmonary resuscitation training. Either as part of initial training or any refresher training.”
This report
“no refresher CPR training had been provided to prison staff since 2023”
Identical hazardConfidence 0.90 · high
Earlier report
“Evidence was heard that the majority of those prison officers who had commenced in their roles prior to 2018 had no first aid/basic life-saving skills and no ability/training in undertaking cardiopulmonary resuscitation ('CPR').”
This report
“The Governor of the prison told the court that no refresher CPR training had been provided to prison staff since 2023 notwithstanding the 5 deaths of prisoners by ligature suspension that have occurred since.”
Identical hazardConfidence 0.90 · high
Earlier report
“Officers who were present during Mr [name redacted] cardio-respiratory arrest had different training with regard to first aid and basic life support.”
This report
“The court heard evidence that the first two officers on the scene failed to provide any form of basic life support despite having received training on how to do so.”