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recurance

Sean Williams

20 Feb 2026 · Coroner Ian Potter · Inner North London

The coroner's concerns

  1. 1. inadequate first aid training and procedures

    “the Serco first aid training was inadequate; it did not include a video of a seizure; it did not sufficiently emphasise the urgency of potentially life saving measures such as use of the recovery position; the Serco assessment of the first aid knowledge and competence of its staff was inadequate; Serco failed to provide clear guidance on the emergency button procedures; Serco's policy appeared to conflict with its training slides about whether staff should or are even permitted to drive a casualty direct to hospital; Serco gave insufficient emphasis on urgency and the paramount importance of preserving life”

Responses

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

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