Jake O'Brien
18 May 2026 · Coroner Michael Pemberton · Manchester West
This report repeats 6 earlier warnings. See the linked reports.
The coroner's concerns
1. lack of immediate basic life support in ligature situations
“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”
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
“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”
Closely relatedConfidence 0.90 · high
Earlier report
“it is a matter of concern that in December 2010 only one of four officers were first aid trained and in February 2012 one was still untrained”
This report
“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”
Identical hazardConfidence 0.90 · high
Earlier report
“The prison officers did not have even the most basic first aid and cardiopulmonary resuscitation (CPR) training.”
This report
“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”
Identical hazardConfidence 0.92 · high
Earlier report
“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.”
This report
“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.”
Identical hazardConfidence 0.90 · high
Earlier report
“None of the Carers employed at Hibiscus House had any training in CPR.”
This report
“No ongoing training had been provided to prison officers since initial training on basic life support or first aid, meaning that officers confronted”
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
“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”