George Haldenby
21 May 2026 · Coroner Rachael Griffin · Dorset
This report repeats 8 earlier warnings. See the linked reports.
The coroner's concerns
1. lack of regular first aid training among prison staff
“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”
2. delayed medication administration for prisoners after hospital discharge
“In prisons without 24 hour healthcare provision, if a prisoner receives treatment at a hospital and is issued with a medication prescription on a FP10 form, this cannot be processed at the prison in the absence of a doctor or prescribing nurse, and pharmacies in hospitals are not always open 24 hours a day for it to be dispensed as TTO medication”
3. inadequate stock of essential cardiac medication in prison
“Although critical medications are held at the prison in a locked cabinet, not all medication are included and Furosemide, which was critical in [the deceased]'s care, is one of those that is not held by the prison as a critical medicine”
Linked reports
Closely relatedConfidence 0.90 · 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
“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.”
Closely relatedConfidence 0.90 · high
Earlier report
“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”
This report
“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.”
Closely relatedConfidence 0.92 · high
Earlier report
“There is no mandatory first aid training for existing (as opposed to new) prison officers.”
This report
“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.”
Identical hazardConfidence 0.90 · high
Earlier report
“Some Prison staff had not received any cardiopulmonary resuscitation training. Either as part of initial training or any refresher training.”
This report
“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.”
Closely relatedConfidence 0.90 · high
Earlier report
“Prison staff are often first responders to medical emergencies of prisoners, but not all have received first aid training.”
This report
“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.”
Closely relatedConfidence 0.90 · high
Earlier report
“It is not mandatory for prison officers to have basic first aid training (which includes the provision of CPR) which is in-date. Once a prison officer's three-year period has expired, whilst they may be reminded by the prison establishment that their certification is no longer live, it is not mandatory for them to renew this.”
This report
“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.”
Closely relatedConfidence 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
“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.”
Closely relatedConfidence 0.90 · high
Earlier report
“First Aid refresher training is not up to date for all healthcare staff.”
This report
“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.”