Emergency responder equipment training
Lack of adequate training for emergency responders on the circumstances and importance of using issued recording equipment.
Source spread
Where this theme appears
This theme appears across 21 independent accountability sources, so the source mix matters as much as the headline total.
51 inquiry recs
113 PFD reports
10 committee recs
1 HSSIB rec
19 CQC actions
10 HMICFRS recs
3 ICIBI recs
2 PPO recs
33 IOPC recs
7 IMB recs
5 Scottish FAIs
1 Article 2 learning point
1 detention investigation rec
1 DHR rec
6 PHSO decisions
2 LGO/SPSO decisions
2 CQC enforcement actions
Browse by source
Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.
Inquiry recommendations(51)— showing 50 strongest matches
86 — Survival suits and life-jackets
Recommendation: The use of small transmitters or detectors on life-jackets in order to assist in the finding of personnel in the dark should be considered. Luminescent strips should be of a colour other than orange (paras 20.33-34).
Unknown
85 — Personal survival equipment for each person
Recommendation: Each individual on board an installation should be provided with:- (i) a personal survival (or immersion) suit; (ii) a life-jacket; (iii) a smoke hood of a simple filter type to exclude smoke and provide protection for at least 10 minutes …
Unknown
COVID-M3.3 — Fit-Testing Preparedness
Recommendation: The UK government, Scottish Government, Welsh Government and Northern Ireland Executive should work with employers, including health boards and trusts, to review the availability of qualified fit testers and take steps to increase the number of fit testers accordingly. Availability …
Gov response: The government agrees with the Inquiry that guidance to employers should emphasise the need to ensure sufficient fit-testing capacity is available. The Health and Safety Executive intends to update its Pandemic preparedness and response guidance …
Accepted
P1-34 — Equip fire services with smoke hoods
Recommendation: All fire and rescue services be equipped with smoke hoods to assist in the evacuation of occupants through smoke-filled exit routes.
Gov response: The government accepted in principle all the Phase 1 recommendations directed at central government. The Housing Secretary Robert Jenrick presented the formal response to Parliament on 21 January 2020, committing to swift and decisive action …
Accepted
P1-26 — Equipment for BA communication in high-rise buildings
Recommendation: The LFB urgently take steps to obtain equipment that enables firefighters wearing helmets and breathing apparatus to communicate with the bridgehead effectively, including when operating in high-rise buildings.
Gov response: The government accepted in principle all the Phase 1 recommendations directed at central government. The Housing Secretary Robert Jenrick presented the formal response to Parliament on 21 January 2020, committing to swift and decisive action …
Accepted
JB-15.17 — Police medic training on catastrophic haemorrhage
Recommendation: Police medic training should emphasise that, in cases of catastrophic external torso haemorrhage, the immediate action is to apply direct pressure and then progress directly to using haemostatic gauze. Chest seals should only be used where there is no evidence …
Gov response: The College of Policing publishes and licences the First Aid Learning Programme (FALP) used by police forces. The programme is endorsed by the NPCC and the Health and Safety Executive (HSE). FALP is made up …
Noted
COVID-M2.7 — Statutory Child Rights Impact Assessments
Recommendation: The UK government should introduce legislation to place child rights impact assessments on a statutory footing in England. The Northern Ireland Executive should consider an equivalent provision.
Gov response: Remains under consideration Child Rights Impact Assessments (CRIAs) are welcomed as a useful tool in embedding the rights of children in strategic planning, policy making and decision making. Their use is already encouraged across government …
Not accepted
COVID-M1.8 — Triennial Parliamentary Resilience Reports
Recommendation: The governments of the UK, Scotland, Wales and Northern Ireland should each produce and publish reports to their respective legislatures at least every three years on whole-system civil emergency preparedness and resilience. The reports should include as a minimum: the …
Gov response: The government agrees with the importance of transparency and ensuring that the wider public sector, private sector and the general public have an understanding of not only the risks that the UK faces but also …
Accepted in part
MAI-165 — Ten Second Triage training for frontline staff
Recommendation: The team led by Philip Cowburn has devised a tool that is designed for use by a wide range of emergency responders in a mass casualty situation. It is known as Ten Second Triage. The National Ambulance Resilience Unit, the …
Gov response: Accepted in full
Accepted
MAI-154 — Training on use of recording equipment
Recommendation: The Home Office, the College of Policing, the National Ambulance Resilience Unit and the Fire Service College should ensure that training is given to all who are issued with such equipment, on the circumstances in which it should be used …
Gov response: Accepted in full
Accepted
MAI-153 — Use recording equipment during exercises
Recommendation: The Home Office, the College of Policing, the National Ambulance Resilience Unit and the Fire Service College should ensure that, in the course of exercises, such equipment is used by those who would use it in the circumstances of a …
Gov response: Accepted in full
Accepted
96 — Special training for fast rescue craft crews
Recommendation: The coxwain and crew of fast rescue craft should receive special training for their duties, along with regular refreshers (para 20.55).
Unknown
SP8 — Ambulance staff training exercise funding
Recommendation: NHS England should review funding, and consider providing additional resources, to enable all emergency response ambulance staff to participate in appropriate training exercises.
Gov response: NHS England and the Department for Health and Social Care (DHSC) are the lead organisations, working with the Emergency Resilience Unit. Progress and next steps: - Work will be carried out to define the required …
Accepted
LADB-88 — Ensure unrestricted availability of all standard emergency equipment on passenger trains.
Recommendation: The availability on trains carrying passengers of the items of emergency equipment mentioned in the standard on emergency and safety equipment should be unrestricted (para 14.74).
Unknown
LADB-82 — Test integrating emergency hammers into passenger alarm system for controlled release.
Recommendation: Tests should be carried out into the practicability of building emergency hammers into the passenger alarm system so that they could be released only after an alarm has been activated (para 14.50).
Unknown
P2-38 — Provide water supply system training to all firefighters
Recommendation: That basic training on the structure and operation of the water supply system, including the different types of hydrants in use and their functions, be given to all firefighters. Training should also be given on effective measures to increase water …
Gov response: The National Fire Chiefs Council (NFCC) accepts this recommendation on behalf of all fire and rescue services. NFCC has reviewed the national operational guidance and is surveying fire and rescue services to establish what additional …
Accepted
P2-37 — Train firefighters on communications loss response
Recommendation: Since radio communications are inherently unreliable in certain environments, we recommend that firefighters be trained to respond appropriately to the loss of communications and to understand how to restore them. (113.61)
Gov response: The National Fire Chiefs Council (NFCC) accepts this recommendation on behalf of all fire and rescue services. NFCC has reviewed the content of national operational guidance and is surveying fire and rescue services to establish …
Accepted
P1-27 — Command support system operational on all units
Recommendation: Urgent steps be taken to ensure that the command support system is fully operative on all command units and that crews are trained in its use.
Gov response: The government accepted in principle all the Phase 1 recommendations directed at central government. The Housing Secretary Robert Jenrick presented the formal response to Parliament on 21 January 2020, committing to swift and decisive action …
Accepted
P1-7 — Equip fire services to receive electronic plans
Recommendation: All fire and rescue services be equipped to receive and store electronic plans and to make them available to incident commanders and control room managers.
Gov response: The government accepted in principle all the Phase 1 recommendations directed at central government. The Housing Secretary Robert Jenrick presented the formal response to Parliament on 21 January 2020, committing to swift and decisive action …
Accepted
80 — Launching TEMPSC clear of the installation
Recommendation: The regulatory body should work with the industry to develop equipment and methods to enable TEMPSC to be launched clear of the installation including where, as on existing installations, they are oriented so as to point along the side of …
Unknown
SP10 — Police-ambulance terminology interoperability
Recommendation: Merseyside Police and North West Ambulance Service should review the terminology used in their systems and procedures to ensure shared understanding and interoperability. The College of Policing and the National Ambulance Resilience Unit should undertake a national review to ensure …
Gov response: DHSC and NHS England support the issues that the recommendations for the North West Ambulance Service (NWAS) are directed towards. However, while NHS England considers local review of procedures and terminology to be important and …
Accepted
FENN-31 — Review LFB protective clothing provision, especially gloves, for personnel
Recommendation: The London Fire Brigade shall review the provision of protective clothing for its personnel, and in particular gloves, in the light of the injuries sustained by fire-fighters at King's Cross.
Unknown
FENN-20 — Produce and maintain up-to-date station plans in LFB-agreed locations
Recommendation: In agreement with the London Fire Brigade, London Underground shall produce and maintain up-to-date station plans, and place them in boxes it has provided, at locations agreed or specified by the London Fire Brigade.
Unknown
FENN-19 — Ensure water gas fire extinguishers are safe near electrical equipment
Recommendation: Water gas fire extinguishers shall be made safe to use in the vicinity of electrical equipment.
Unknown
FENN-15 — Modify London Underground fire equipment to London Fire Brigade standards
Recommendation: London Underground fire equipment shall be modified to London Fire Brigade standards and the amount and type of fire equipment in stations agreed.
Unknown
P2-39 — Establish water undertaker communication protocols
Recommendation: That all fire and rescue services establish and periodically review an agreed protocol with the statutory water undertakers in their areas to enable effective communication between them in relation to the supply of water for firefighting purposes. (113.63)
Gov response: The National Fire Chiefs Council (NFCC) accepts this recommendation on behalf of all fire and rescue services. NFCC and fire service lead officers for water are discussing with water undertakers how to strengthen existing arrangements …
Accepted
P2-36 — Provide firefighters with digital radios
Recommendation: That all fire and rescue services give consideration to providing all firefighters with digital radios. (113.60)
Gov response: The National Fire Chiefs Council (NFCC) accepts this recommendation on behalf of all fire and rescue services. See recommendation 35.
Accepted
P2-35 — Consider higher power radios for breathing apparatus
Recommendation: That fire and rescue services that continue to use low power intrinsically safe radios as part of breathing apparatus consider reserving them only for situations in which there is a real risk of igniting flammable gases and generally using radios …
Gov response: The National Fire Chiefs Council (NFCC) accepts this recommendation on behalf of all fire and rescue services. NFCC is surveying fire and rescue services to understand what arrangements are currently in place at a local …
Accepted
CR15 — Joint training exercises plan
Recommendation: HM Coastguard should develop and implement a plan for joint training exercises, to occur at set intervals, with participation by those involved in maritime search and rescue in the English Channel and elsewhere.
Gov response: The most recent joint exercise involving all participants simultaneously was at Dover MRCC on 7 December 2023. Representatives from French Coast Guard and SNSM (the French lifeboat service) were present, alongside UK Border Force and …
Accepted
CR10 — Equipment and techniques development
Recommendation: HM Coastguard must continue to liaise with search and rescue partners in the UK and abroad to identify opportunities for the development or deployment of equipment and techniques to assist in search and rescue operations.
Gov response: HMCG recognises the importance of liaising with SAR partners in the UK and abroad and will continue to do so. HMCG meets monthly with the RNLI and has bilateral meetings with international coastal partners such …
Accepted
JB-15.26 — Alternative to life hammer for window entry during armed operations
Recommendation: Consideration should be given by the MPS, Home Office and the NPCC to finding a more suitable solution for smashing windows during the course of an armed operation, so that an officer who is holding a firearm does not need …
Gov response: MPS firearms no longer use a glass hammer to smash windows in the course of an armed operation. Following an internal review and resourcing exercise, each firearms officer has now been issued with an extendable …
Noted
MAI-116 — Consider freeze-dried plasma for HART operatives
Recommendation: The Department of Health and Social Care, the Faculty of Pre-Hospital Care, the College of Paramedics and the National Ambulance Resilience Unit should consider whether all Hazardous Area Response Team operatives should be deployed with freeze-dried plasma and trained in …
Gov response: Accepted in full
Accepted
MAI-91 — Review analgesia deployment for firearms officers
Recommendation: The College of Policing and Counter Terrorism Policing Headquarters should review whether firearms officers should be deployed with analgesia and trained in its use, as part of providing Care Under Fire.
Gov response: Accepted in full
Accepted
MAI-49 — Review analgesia rollout to HART operatives
Recommendation: If the decision is that the regulatory regime should be altered in this way, the National Ambulance Resilience Unit should consider urgently whether the use of such analgesia should be rolled out to all Hazardous Area Response Team and other …
Gov response: Accepted in full
Accepted
TAYL-F21 — Provide trained personnel and cutting equipment for immediate perimeter fence removal
Recommendation: Suitable and sufficient cutting equipment should be provided by the club at each ground where there are perimeter fences to permit the immediate removal of enough fencing to release numbers of spectators if necessary. Agreement should be reached as to …
Unknown
POPP-A.3 — Home Office to develop more suitable personal radios for police
Recommendation: Early attention should be given by the Home Office Directorate of Telecommunications to consider the practicality of producing a more suitable personal radio for the police.
Unknown
TAYL-I43 — Local authorities to specify ambulance numbers for large crowd matches
Recommendation: The number of ambulances to be in attendance for matches where larger crowds are expected should be specified by the local authority after consultation with the ambulance service and should be made a requirement of the Safety Certificate.
Unknown
TAYL-I42 — Mandate one fully equipped ambulance at matches with over 5,000 spectators
Recommendation: At least one fully equipped ambulance from the appropriate ambulance authority should be in attendance at all matches with an expected crowd of 5,000 or more.
Unknown
TAYL-I41 — Require clubs to employ trained medical practitioners at all matches
Recommendation: The club should employ a medical practitioner to be present at each match and available to deal with any medical exigency at the ground. He should be trained and competent in advanced first aid. He should be present at the …
Unknown
TAYL-I40 — Local authorities to specify first aid rooms and equipment for stadium safety certificates
Recommendation: There should be at each stadium one or more first aid rooms. The number of such rooms and the equipment to be maintained within them should be specified by the local authority after taking professional medical advice and should be …
Unknown
TAYL-I39 — Require clubs to provide one trained first aider per 1,000 spectators
Recommendation: There should be at each stadium at each match at least one trained first aider per 1,000 spectators. The club should have the responsibility for securing such attendance.
Unknown
CR1 — Network flexing risk mitigation
Recommendation: Given the risks associated with HM Coastguard's use of network flexing for small boat search and rescue – whereby its workforce is split between different geographical locations – HM Coastguard must ensure the effectiveness of measures in mitigating them (including …
Gov response: HMCG recognises that whilst its national network does provide critical business resilience, small boat operations pose particular challenges due to the nature of multiple interconnected incidents. Since 2021, an extra 24 people (20 Watchkeepers and …
Accepted
AG-9 — Maximum Continuous Duty Period for AFOs
Recommendation: The National Police Chiefs' Council (NPCC) and the College of Policing should jointly decide, in the light of independent expert advice, whether there should be a maximum period of time during which authorised firearms officers (AFOs) are permitted to remain …
Gov response: 37. Following discussions with NPCC and the College of Policing, the Government understands that current guidance does not specify a time limit and that there would be significant operational implications of doing so. There are, …
Accepted
BAHA-14 — Communicating Sight Deprivation Reasons
Recommendation: JDP 1-10 should include guidance that where practicable CPERS should be told the reason why sight deprivation is being applied. Suitable simple phrases in relation to sight deprivation should be included in mission specific language training.
Gov response: I can inform this House that I am accepting in principle all of his recommendations with one reservation.
Accepted in part
LADB-41 — Utilise simulators for effective signaller training in emergency situations
Recommendation: The use of simulators in providing fully effective training of signallers in dealing with emergencies is endorsed (para 12.15).
Unknown
LADB-38 — Provide signallers with emergency stop options and regular situational briefings on use
Recommendation: The instructions for signallers should provide a set of options, including the use of the CSR (where it is available) either to send an emergency stop message to a particular train or a general stop message. This range of options …
Unknown
AG-7 — Recording of Firearms Operations
Recommendation: The National Police Chiefs’ Council (“NPCC”) should, in the formulation of policy, take into account that, when establishing the facts, discharging investigative obligations and ensuring openness and transparency following the discharge of a firearm by a police officer in the …
Gov response: 31. The Government understands that body worn video (BWV) is now a requirement for all Armed Response Vehicle officers. Specialist Firearms Officers use BWV when deployed overtly. NPCC have issued guidance to encourage the use …
Accepted
AG-4 — North West Armed Policing SOP Amendment
Recommendation: The North West Armed Policing Standard Operating Procedure on Weapons and Ammunition should be amended so that it only permits the use of new specialist munitions that have been approved in accordance with the Code of Practice on Police use …
Gov response: 20. The use of CS dispersal canisters by GMP during Operation Shire was a focus of concern for the Inquiry. The CS dispersal canisters had not been through the approval process that includes the identification …
Accepted
14 — Prohibit handcuffing behind back while seated
Recommendation: The Home Office and contractors operating immigration removal centres must ensure that all staff are aware that the technique of handcuffing detained people with their hands behind their back while seated is not permitted, given its association with positional asphyxia.
Gov response: 6.6.3. The Home Office has been working closely with HM Prison and Probation Service (HMPPS), NHS England and the Department of Health and Social Care (DHSC) to ensure expert input into consideration of these recommendations. …
Accepted, fully or in part (not specified)
LADB-13 — Endorse adoption of defensive driving teaching and practice by TOCs
Recommendation: The adoption by TOCs of the teaching and practice of defensive driving is endorsed (para 9.39).
Unknown
Prevention of Future Deaths reports(113)— showing 50 strongest matches
Edna Wiggett
Concerns: The coroner noted a failure to re-triage and re-classify Mrs. Wiggett’s case after a second call reported increased pain, leading to delays in ambulance dispatch.
Response (East of England Ambulance NHS Trust): • The Trust published an article in its Emergency Operations Centre Patient Safety and Experience Newsletter to remind staff to re-triage calls of this type. • The matter will be … (AI summary)
Responded
Lucy Hannah Rose Bailey
Concerns: The coroner identified that paramedic training and guidelines prohibit gentle internal manipulation or traction during childbirth, which may hinder effective assistance in cases of dystocia. Concerns were raised that amending these guidelines could reduce the risk of injury during birth.
Response (South Central Ambulance Service): • A review of the UK ambulance service clinical practice guidance on the management of shoulder dystocia was undertaken. • The guidance was updated with advice and input from specialists … (AI summary)
Responded
Jessica Ashton-Pyatt
Concerns: The response to the patient's admission was uncoordinated and lacked consultant leadership. Additionally, the resuscitation room defibrillator was not charged, and no defibrillation pads were available.
Overdue
Millie Elizabeth Thompson
Concerns: The coroner raised concerns about insufficient paediatric first aid training among nursery staff and expired certifications. Issues were also identified with an ambulance call-taker's misinterpretation leading to incorrect triage, and a lack of suitable paediatric life-saving equipment in emergency ambulances.
Response (Edward Timpson MP): • The government published plans in July 2013 to improve childcare quality and availability. • A public consultation, 'The Regulation of Childcare,' was launched from July to September 2013, which … (AI summary)
Response (North West Ambulance Service NHS Trust): • The Trust maintains a robust and competitive recruitment process for Emergency Medical Dispatchers (EMDs) and continually reviews this process. • All EMDs complete a six-week training course that includes … (AI summary)
Response (Department of Health): • The Department reported that North West Ambulance Service emergency response vehicles are equipped with a range of paediatric emergency equipment. • The Department will share the Regulation 28 report … (AI summary)
Responded
Derek Brierley
Concerns: The coroner identified gaps in Trust guidelines for competence and training for a suprapubic procedure. Concerns were also raised about the performing consultant's infrequent practice and the pre-procedure difficulty in locating necessary equipment.
Response (The Pennine Acute Hospitals NHS Trust): • The pathway for managing urinary retention has been re-drafted. • A training program for supra-pubic catheter insertion has been initiated. • The governance lead for urology will continue to … (AI summary)
Overdue
Albert James Hand
Concerns: Concerns were raised about a patient with a head injury waiting over 90 minutes for ambulance conveyance. The coroner noted insufficient ambulance crews in the area and protocols for emergency calls that may put patients at risk.
Response (East of England Ambulance Service NHS Trust): • The Trust commissioned a Clinical Capacity Review and shared its findings with Clinical Commissioning Groups to address ambulance availability. • The Trust initiated a recruitment drive to increase staff … (AI summary)
Responded
Paul Rogerson
Concerns: The coroner noted inadequate protection, condition, and maintenance of river safety equipment like life buoys and throwing lines, alongside a lack of warning signs. Concerns were also raised regarding North Yorkshire Police training in river rescue protocols, water safety, and hypothermia first aid, and inter-service communication.
Overdue
Barry James Lewis
Concerns: The adequacy and availability of emergency surgical equipment in the ER, including appropriate sizes and out-of-hours theatre access, raised concerns. Also noted were night staffing levels for ODTs and ENT medical cover.
Response (The Pennine Acute Hospitals NHS Trust): • Emergency airway packs in all A&E departments were updated to include large instruments. • Equipment was unified across the trust, with input from ENT clinicians. • The role of … (AI summary)
Responded
Christopher Williams
Concerns: The defibrillator machine was inoperable and had not been checked daily as required. There was no cross-check system or policy for the management of sudden unexpected deaths in place at the hospital.
Overdue
Caroline Pilkington
Concerns: North West Ambulance Service personnel are not trained in control and restraint techniques, leading to calls for police assistance with unwell patients. This can result in clinically unwell patients being handled by non-clinically trained police and delays in hospital transport.
Response (Greater Manchester Police): • Greater Manchester Police's revised officer safety training programme emphasizes recognizing medical risks and treating situations as medical emergencies. • Greater Manchester Police offered to support North West Ambulance Service … (AI summary)
Response (North West Ambulance Service NHS Trust): • North West Ambulance Service (NWAS) stated that advanced control and restraint training for its staff is not feasible or safe due to the specialised nature of the skill and … (AI summary)
Response (Department of Health): • The Department of Health noted the existence of a joint protocol, established in March 2012, between North West Region Police Forces and NWAS for inter-agency working regarding patients requiring … (AI summary)
Response (Department of Health2): • NWAS confirmed that a regional protocol with police forces is in place and under review. • NWAS presented the inquest findings at the North West Police Regional Mental Health … (AI summary)
Responded
Stephen Bedford
Concerns: Concerns were raised regarding the regular assessment of emergency care staff for life support standards, and if paramedics with advanced life support training should be mandated for all Code Red and PPCI transfers. Further issues included training for ECG machines for certain staff, and specific guidance for communicating with relatives.
Overdue
Desiree Falvo
Concerns: Concerns were raised regarding insufficient A&E department cover for emergency surgical tracheotomy and inadequate training for clinicians in this procedure, impacting their skills and confidence.
Response (NHS England): • NHS England stated that A&E senior staff receive Advanced Trauma Life Support (ATLS) training in tracheotomies and needle cricothyroidotomy, repeated every four years. • A review of London Emergency … (AI summary)
Responded
Joanne Oliver
Concerns: The coroner identified a lack of detailed national guidance to assist doctors in making decisions about transferring critically ill patients, particularly concerning the preparation of comprehensive written risk assessments for fitness to travel.
Overdue
Elizabeth Cooper
Concerns: The coroner noted unclear advice on precautions for a genetic condition, particularly for travel, and a lack of a clear pathway for sharing information with family members. Additionally, no information leaflets were available for the patient about fatal consequences or for family about risks and options.
Overdue
June Rose
Concerns: The coroner noted a lack of mandatory or regular refresher training for GPs at a national level regarding the prescription of specific pain relief medications, which could lead to fatal errors.
Overdue
Hywel Hughes
Concerns: The coroner identified deficiencies in police training on positional asphyxia and vehicle design affecting detainee monitoring. Concerns describe insufficient Security Industry Authority oversight, training, and auditing for door supervisors regarding restraint dangers and asphyxia risks.
Response (North Wales Police): • North Wales Police amended its first aid, personal safety, and tasar training materials to include snoring as a symptom of positional asphyxia and added a relevant exercise. • North … (AI summary)
Overdue
Stephen Amer
Concerns: The provided document is truncated, and the specific concerns raised by the coroner to prevent future deaths are not present in the available text.
Response (Hertfordshire County Council): • The Council committed to developing and introducing a consent form by 20 October 2014 to facilitate information sharing with social care services. • The department issued a practice instruction … (AI summary)
Responded
Richard Barker, Ryan Bramwell and Robert Graham
Concerns: The coroner raised concerns regarding the practice of placing tyres with less tread depth on the rear of vehicles, which contributed to aquaplaning, and the lack of awareness among police officers about their statutory powers to close hazardous roads.
Overdue
Anthony Offord
Concerns: Concerns include a lack of training for emergency medical dispatch staff on respiratory difficulty signs and the absence of a requirement to inform managers of unilateral crew stand-offs. Additionally, there is no system to automatically consider all alternative support methods during stand-offs.
Response (Yorkshire Ambulance Service NHs Trust): • The Trust described its robust training program for Emergency Medical Dispatch staff, which includes specific training on breathing difficulties. • The Trust is implementing the Joint Decision Model (JDM) … (AI summary)
Overdue
Grant Benson and Gordon Davidson
Concerns: The coroner noted difficulties in accurately locating the incident due to inaccurate GPS information and a call handler lacking local knowledge. Concerns were raised about inadequate systems for cross-boundary call transfers and dispatch between different ambulance services.
Response (Fire Rescue Service): • The Fire Rescue Service conducted a review of policies and procedures for liaising with over-the-border Blue Light Services. • A new mobilising and communications system was introduced in December … (AI summary)
Response (North East Ambulance Service NHS Trust): • The Trust undertook a review of its processes and systems regarding cross-border incidents. • The Trust is reviewing the feasibility of increasing the frequency of Gazetteer and map updates. … (AI summary)
Responded
Cameron Laing
Concerns: The coroner noted soldiers' lack of understanding of Kings Trailer brake release mechanisms and the Packet Commander's insufficient training in coupling. Concerns also highlighted the absence of safer alternative trailer extraction methods and questioned the Ministry of Defence's rationale for this.
Response (Ministry of Defence): • The training package for DROPS operators qualified to tow the KINGS trailer was improved and now includes a video detailing coupling and uncoupling procedures. • The Army Equipment Support … (AI summary)
Responded
Barbara Harrison
Concerns: Concerns were raised regarding physiotherapy that likely contributed to tissue breakdown after surgery, and the unavailability of working fibre optic equipment for intubation during a critical procedure. Nurses also did not promptly identify obvious post-operative swelling.
Overdue
Stephen O’Malley
Concerns: Concerns were raised regarding a delay in rescue because a standby diver could not locate a c-clip on a harness. The coroner questioned if checking this c-clip should be part of pre-dive protocol checks.
Response (Sub C Pre Dive Checklist): • The organisation's pre-dive checklist includes a requirement for checking harness straps. (AI summary)
Response (Sub C): • SubC Partner stated that pre-dive checks, including verification of harness straps (c-clip), were performed on the project in question. • The organisation confirmed that the check of harness straps … (AI summary)
Responded
Steven Jackson
Concerns: The report highlights a paramedic's ineffective use of the sepsis screening tool and identifies a need for effective training for ambulance staff on the tool's application and appropriate patient conveyance to hospital.
Overdue
Eitvydas Zdanys
Concerns: The coroner noted that attending police officers were unable to assess a seriously injured person or commence basic life support. A review of basic life support training for all police officers acting as first responders was suggested.
Response (E Zdanys): • The force launched an investigation into the incident and sought input from a paramedic trainer. • Officers involved in the incident will receive further training on administering CPR. • … (AI summary)
Responded
James Barrett
Concerns: The coroner raised concerns regarding the efficiency of missing persons searches, noting issues with the reliance on volunteer organisations for mapping and the absence of police-controlled stand-alone mapping systems and tracking devices for searchers.
Response (James BARRETT): • A business case was submitted proposing the purchase of a MAPYEX system. • The purchase was recommended for ratification to the Assistant Chief Constable. • Hampshire Constabulary is considering … (AI summary)
Overdue
Philmore Mills
Concerns: The coroner noted gaps in police training regarding the tactical option of containment for subjects with suspected excited delirium. Additionally, restraint training did not include the risk of death from take-down procedures.
Response (Philmore Mills): • The College of Policing produced a national training video reinforcing medical implications of restraint and good practice elements, including containment. • This video is scheduled to form part of … (AI summary)
Overdue
Carl Thompson
Concerns: The coroner identified issues with life-saving equipment, including a lack of suction equipment, a defective ambubag, and an inoperable defibrillator. There were also substantial delays in the arrival of emergency ambulances.
Overdue
Doreen Mattinson
Concerns: The coroner noted issues with oxygen administration, including an incorrect flow rate and improper patient positioning. There was also a lack of staff understanding regarding emergency oxygen use and no evidence of relevant training for the Clinical Manager.
Overdue
Mia Gibson
Concerns: The coroner identified an over-reliance on maternal observations in obstetric emergencies, potentially overlooking fetal distress, and noted significant ambulance resource delays due to meal break management and lack of 'open mic' reports.
Overdue
Christopher Sears
Concerns: The coroner identified a lack of requirements for bus drivers transporting students to have Basic Life Support training or established emergency protocols. Concerns were also raised that Basic Life Support training is not part of the national curriculum for secondary education.
Response (Department for Transport): • The Department for Transport asked the Driver and Vehicle Standards Agency (DVSA) to undertake promotional activity to raise awareness of the relevance of basic life support training for bus … (AI summary)
Response (Department for Education): • The Department for Education (DfE) stated its intention that local authorities ensure school bus drivers and escorts receive training in basic life support skills and emergency protocols. • The … (AI summary)
Responded
Stephen Hunt
Concerns: The coroner raises concerns about fire and rescue services implementing measures to reduce risks from heat exposure and communication loss during operations. There are also concerns regarding the adequacy of procedures, training, and hazard recording for incident management, role handover, and thermal imaging camera use.
Response (Hunt): • The Minister stated that legal aid funding for representation at inquests is not available for non-family members under the current scheme. • The Minister confirmed there are no current … (AI summary)
Responded
Sydney Neil
Concerns: The coroner noted inadequate ventilation, lack of suction, and no oxygen provided for 8 minutes following a collapse in a GP surgery, raising concerns about the level of expertise and equipment for resuscitation in such practices.
Response (Wychall Lane Surgery): • The practice incorporated recommendations for continual oxygen saturation readings and oxygen use during nebulisation for children with acute asthma into its protocol. • A serious case review was carried … (AI summary)
Response (NHS England): • NHS England stated it would not mandate all general practices to purchase and maintain suction facilities. • NHS England indicated it would communicate updated BTS/SIGN asthma guidelines to GP … (AI summary)
Response (Birmingham South Central Clinical Commissioning Group): • The CCG reviewed national guidance and best practice for GP practice resuscitation equipment and has an ongoing programme of contract visits to ensure adherence. • The CCG stated its … (AI summary)
Responded
Rosemarie Dees
Concerns: The coroner noted that an undetected foreign body airway obstruction could inhibit the use of a supraglottic airway (SGA). Requiring a laryngoscopy before SGA use could identify such obstructions, a practice expected to become protocol.
Overdue
Ajvir Sandhu
Concerns: The coroner recommended reviewing regulations for mandatory static line parachutes in certain aircraft types. Concerns were also raised about the lack of mandatory spin recovery training for specific light aircraft used for aerobatics, and ensuring pilot proficiency for these aircraft.
Overdue
Rex Hall
Concerns: The coroner identified deficiencies in paramedic foundation training, noting a lack of formal testing on 12-lead ECG interpretation and awareness of atypical myocardial infarction signs.
Response (HCPC): • The HCPC stated that the level of learning required for entry to paramedic practice was raised, with all training routes set at degree level from September 2021. • The … (AI summary)
Responded
Najeeb Katende
Concerns: The coroner noted that ambulance staff did not cross-check for a shockable rhythm or routinely use a defibrillator in AED mode. Concerns were raised regarding the need for staff training on these procedures and the interpretation of shockable rhythms.
Overdue
Russell Sherwood
Concerns: The Fire Service unit departed a dangerous flooding scene without ensuring the road was closed or warning signs were left. South Wales Fire and Rescue Service units lack equipment and protocols to close roads, relying on other authorities to do so.
Response (South Wales Fire and Rescue Services): • The Service is considering the recommendations as part of its response to the Fire Rescue Services (Emergencies)(Wales)(Amendment) Order 2017. • The Service is conducting a comprehensive review of its … (AI summary)
Responded
Darren Powney
Concerns: The coroner noted staff confusion regarding an existing ambulance protocol and that dynamic risk assessments did not facilitate crews requesting further information. Concerns were also raised about the absence of bespoke policies for frequent callers and delays in implementing new protocols and training.
Response (North East Ambulance Service NHS Trust): • The Trust reviewed and updated the Joint Operating Procedure (JOP) with local Police forces, incorporating an escalation process for differing risk assessments. • Measures were undertaken to improve frontline … (AI summary)
Responded
George French-Russell
Concerns: EMAS call handlers lacked guidance for rapidly developing labour, and information sharing between Stepping Hill Hospital and EMAS was unstructured. Paramedics also lacked experience for the specific delivery and did not receive sustained expert support.
Response (East Midlands Ambulance Service NHS Trust): • EMAS developed standardised minimum criteria for requesting obstetric support and issued interim guidance to relevant staff. • EMAS enhanced its SBAR communication tool with maternity-specific guidance and shared a … (AI summary)
Response (Department of Health): • The Department of Health made enquiries and was assured that the East Midlands Ambulance Service NHS Trust and the Stockport NHS Foundation Trust are taking steps to make improvements. … (AI summary)
Response (HSIB): • HSIB stated the information provided would contribute to building a wider picture of safety issues in the NHS. • HSIB indicated the information would assist in determining future investigation … (AI summary)
Overdue
Bryan Allsop
Concerns: The coroner noted a lack of mandatory instruction and testing in partial loss of engine power scenarios for light aircraft pilot licenses, despite evidence that these situations present significant challenges and contribute to crashes.
Overdue
Charles Rashan
Concerns: Police training should incorporate how to distinguish a struggle to breathe from resistance, recognise silent choking, and assess breathing in stressful situations. Guidance is also needed for officers on managing assistance from members of the public.
Response (Metropolitan Police Service): • The Metropolitan Police Service (MPS) Emergency Life Support (ELS) training establishes that apparent resistance may mask a medical emergency, particularly concerning positional asphyxia and Acute Behavioural Disturbance. • The … (AI summary)
Responded
Jack Riding
Concerns: The coroner noted significant delays in defibrillator deployment and ambulance personnel reaching the pitch, and insufficient evidence of staff training on emergency procedures and medical emergency risk assessments.
Response: • Goals Soccer Centres plc stated that it did not accept the finding of a significant delay in defibrillator deployment, noting CCTV footage indicated a response time of less than … (AI summary)
Overdue
Suleyman Yalcin
Concerns: The coroner raised concerns about insufficient refresher training for an emergency response driver, police under-resourcing, and inadequate terminology used to convey the urgency of situations.
Response (Metropolitan Police Service): • The Metropolitan Police Service introduced a three to five year refresher training course for response car, covert advanced car, and advanced car drivers in October 2015. • The Metropolitan … (AI summary)
Response (Metropolitan Police2): • The Metropolitan Police Service (MPS) implemented a new driving policy requiring all officers to undertake refresher training every 3 to 5 years. • The MPS completed a restructure to … (AI summary)
Responded
Christopher Moss
Concerns: The coroner noted the need for prisons to ensure appropriate equipment is available for barricade situations, especially for non-dual-opening cell doors. They also identified a need for an audit to confirm this equipment is correctly located within prisons.
Overdue
Jeremy Sutch
Concerns: The coroner identified difficulties during a medical evacuation due to the crew's unfamiliarity with a wheelchair extraction chair and its incompatibility with the vessel's crane and tender, which led to significant delays in transporting the injured person.
Response (Vantage Drilling Company): • Vantage Drilling Company updated its HSE Manual to include specific reference to different stretcher types. • The Emergency Response Drill Matrix was updated to require a 'Drill Medivac Chair … (AI summary)
Overdue
John Scott
Concerns: No specific concerns text was provided for summarization.
Response (NHS England): • NHS Pathways Release 17, deployed from May 2019, provides call handlers with a script to advise callers of an ambulance's estimated arrival time. • NHS Pathways will review the … (AI summary)
Response (South East Coast Ambulance Service NHS Trust): • South East Coast Ambulance Service NHS Trust (SECAmb) has discussed potential script amendments with NHS Pathways during monthly meetings. • SECAmb uses a 'surge script' for calls that may … (AI summary)
Responded
Wayne Rodgers
Concerns: The coroner noted limited ambulance availability on the Isle of Wight, particularly during large events like Cowes Week, and suggested organisers consider employing private medical services on-site. The report also highlights a need to review the Crisis Management Plan, mandatory safety equipment, and criteria for abandoning racing.
Response (Cowes Week Limited): • Cowes Week Limited is discussing additional ambulance support and reviewing options for placing Automated External Defibrillators (AEDs) on larger control vessels, also considering one for the Trinity Landing pontoon. … (AI summary)
Overdue
Mark Kubiak
Concerns: The Thames Valley Transfer Network Checklist does not require oxygen supply checks or a tug test when transferring oxygen to a portable cylinder, which could lead to unnoticed failures in oxygen flow.
Overdue
David Dooley
Concerns: Police officers were unaware of the exact location of life lines on Brighton seafront, which caused a delay in deploying one. The coroner also noted the need for increased public awareness regarding the dangers of entering the sea under the influence of alcohol or drugs.
Response (Sussex Police): • Prompt cards showing the location of coastal throw rings have been distributed to all Police officers and staff on Brighton & Hove Division. • Throw lines were introduced as … (AI summary)
Responded
Select committee recommendations(10)
#25 —
Recommendation: Arctic shipping is concentrated in the European Arctic, in close proximity to the UK. As commercial and private shipping increases in the region, demands on the UK’s maritime search and rescue capabilities are likely to grow. The UK Government should …
Gov response: Partially agree. 24. The UK recognises the importance of close cooperation with the Arctic states and the Arctic Council in relation to search and rescue and disaster preparedness response. We participate in a range of …
Position Not Stated
#51 —
Recommendation: Concerns about provision of PPE to key workers have been a recurring theme during the COVID-19 pandemic. We understand that Border Force’s provision of PPE to its staff has been based on PHE and WHO advice. However, Border Force officials …
Response attribution not verified
#50 —
Recommendation: As passenger numbers rise and interactions between Border Force officers and arrivals increase, it is crucial that there are no lapses in PPE availability for officers on the frontline who have worked admirably in difficult conditions for several months. The …
Response attribution not verified
#24 — Include provisions in Draft Bill for mandatory life-saving training and bandage kits for staff.
Recommendation: The Home Office should include a provision in the Draft Bill to provide mandatory life-saving training to staff to the premises captured by the Bill. The Home Office should also consider providing for mandatory bandage kits on those premises.
Response status not verified
#16 — Front-line medical personnel experience poor availability and inadequate shelf life of inventory.
Recommendation: Despite the broader success of the LCST contract, since it began the needs of front- line medical personnel have not been well served. In particular, units have faced poor availability of medical inventory and been supplied with items without sufficient …
Response attribution not verified
#5 — Set out how MoD's future inventory management will properly address medical personnel requirements
Recommendation: The MoD failed to consider the needs of its medical operations in outsourcing commodity procurement to Team Leidos and this has created significant risks for front-line personnel. Since the LCST contract began, the inventory needs of front-line medical personnel have …
Response attribution not verified
#26 — ESN programme no longer expects to provide apps essential for key emergency service benefits.
Recommendation: Despite these concerns, all three emergency services did still see a continuing case for ESN. For example, the fire service said that there could be benefits from being able to share drone footage of incidents by ESN providing a common …
Response attribution not verified
#18 — MoD's medical supply contract incentives improved project numbers but performance remains below required levels.
Recommendation: The MoD explained that the incentives for the LCST contract were intended to prioritise efficiency, but that medical supplies are a difficult area in which to achieve efficiencies. From 2019, the MoD changed the contract’s incentivisation by taking back a …
Response attribution not verified
#17 — General contract targets masked poor medical inventory performance; shelf-life issue now addressed.
Recommendation: This issue arose because the contract applied a general target across all commodity supply.38 However, this meant that lower performance in supplying medical inventory (which generally requires higher performance than other commodities) was masked by better performance elsewhere. In addition, …
Response attribution not verified
#23 — Immediate medical assistance from venue staff is crucial after a terrorist attack.
Recommendation: The way in which first responders intervene after a terrorist attack could be the difference between life and death. Those working at the venues or premises captured Terrorism (Protection of Premises) draft Bill 29 by the Draft Bill will most …
Response status not verified
HSSIB safety recommendations(1)
NCEPOD recommendations(1)
CQC inspection actions(19)
The Queen Elizabeth Hospital
The service should ensure emergency equipment is checked daily in line with their procedures.
Should Do
UHBW Bristol Campus
The service must ensure staff complete daily checks of emergency equipment.
Must Do
Southmead Hospital
The service should ensure all staff complete daily checks of emergency equipment.
Should Do
Warrington Hospital
The serviceshouldensurethatallstaffcompleteregularsimulationtraining/SkillsandDrillstraining,suchasregular poolevacuationandabductiondrills.
Should Do
The James Cook University Hospital
The service should ensure staff are trained in safe birthing pool evacuation.
Should Do
The James Cook University Hospital
The service must ensure staff complete regular skills and drills training.
Must Do
Alnwick Infirmary
The service must ensure emergency resuscitation trolley equipment checks are carried out consistently.
Must Do
The York Hospital
The service must ensure there are sufficient quantities of cardiotocography (CTGs), central monitoring and telemetry equipment. This was to ensure women and babies are continually assessed and monitored.
Must Do
The York Hospital
The service must review processes for ED staff completing full resuscitation trolley checklists to ensure all specialist live-saving equipment is stocked and in date in the event of an emergency.
Must Do
North Manchester General Hospital
The trust should ensure it continues to improve compliance with paediatric life support training.
Should Do
Fleetwood Hospital
The services should carry out a risk assessment of resuscitation equipment to ensure that there would be no delays in staff bringing the resuscitation bag and oxygen tank to a patient in the event that both were needed as they …
Should Do
Fleetwood Hospital
The trust should consider a review of the need to carry medical emergency equipment when carrying out domiciliary visits.
Should Do
UHBW Bristol Campus
The service should ensure staff are aware of the location of ligature cutters.
Should Do
The James Cook University Hospital
The service should ensure full security of delivery suite and fit for purpose birthing pools and evacuation equipment if water births are to be offered as an option.
Should Do
Kingston Hospital
staff complete regular skills and drillstraining.
Must Do
Sydenham House
Ensure there is an effective system in place for the provision and monitoring of emergency medicines and equipment, in the event of a medical emergency.
Should Do
Oak Tree Manor
Staff knowledge in relation to evacuation in the event of a fire needed to be improved.
Should Do
DMC Church View Practice
Review medical equipment and ensure spare defibrillator pads are available.
Should Do
BMI Southend Private Hospital
The provider should ensure that equipment monitoring and checks are undertaken as required by service policy.
Should Do
HMICFRS recommendations(10)
FRS 2018-19 CoC Recommendations: London Fire Brigade
Cause of concern: The Brigade has a significant backlog of training for staff in risk-critical skills such as incident command and emergency fire engine driving. Some staff haven’t had continuing training in these skills for many years. There is no …
Recommendation
FRS 2018-19 CoC Recommendations: Cornwall Fire and Rescue Service
Cause of concern: We have serious concerns about Cornwall FRS’s response to incidents. The service consistently doesn’t meet target response times for fires, especially in remote areas served by on-call stations. It is sometimes slow to update mobile data terminals …
Recommendation
FRS 2018-19 CoC Recommendations: Cornwall Fire and Rescue Service
Cause of concern: We have serious concerns about Cornwall FRS’s response to incidents. The service consistently doesn’t meet target response times for fires, especially in remote areas served by on-call stations. It is sometimes slow to update mobile data terminals …
Recommendation
FRS 2018-19 CoC Recommendations: Cornwall Fire and Rescue Service
Cause of concern: We have serious concerns about Cornwall FRS’s response to incidents. The service consistently doesn’t meet target response times for fires, especially in remote areas served by on-call stations. It is sometimes slow to update mobile data terminals …
Recommendation
FRS 2023-25 CoC Recommendations: Avon Fire and Rescue Service
Cause of concern: The service still doesn’t have an effective system to make sure it gathers and records relevant and up-to-date risk information to help protect firefighters, the public and property during an emergency. We found examples of the risk …
Recommendation
FRS 2023-25 CoC Recommendations: Avon Fire and Rescue Service
Cause of concern: The service still doesn’t have an effective system to make sure it gathers and records relevant and up-to-date risk information to help protect firefighters, the public and property during an emergency. We found examples of the risk …
Recommendation
FRS 2023-25 CoC Recommendations: Avon Fire and Rescue Service
Cause of concern: The service still doesn’t have an effective system to make sure it gathers and records relevant and up-to-date risk information to help protect firefighters, the public and property during an emergency. We found examples of the risk …
Recommendation
FRS 2023-25 CoC Recommendations: Avon Fire and Rescue Service
Cause of concern: The service still doesn’t have an effective system to make sure it gathers and records relevant and up-to-date risk information to help protect firefighters, the public and property during an emergency. We found examples of the risk …
Recommendation
FRS 2023-25 CoC Recommendations: Avon Fire and Rescue Service
Cause of concern: The service still doesn’t have an effective system to make sure it gathers and records relevant and up-to-date risk information to help protect firefighters, the public and property during an emergency. We found examples of the risk …
Recommendation
FRS 2023-25 CoC Recommendations: Avon Fire and Rescue Service
Cause of concern: The service still doesn’t have an effective system to make sure it gathers and records relevant and up-to-date risk information to help protect firefighters, the public and property during an emergency. We found examples of the risk …
Recommendation
ICIBI immigration recommendations(3)
An inspection of Border Force practice and procedures in relation to firearms …
Conduct a firearms training needs analysis and review of existing national training provision to define the mandatory attendance requirements and to ensure that the quality and availability of training delivery …
An inspection of Border Force operations at south coast seaports
Accelerate the publication of guidance from the consultation on the use of Personal Protective Equipment (PPE). 4.10. Accepted. 4.11. Body armour is only one element of the control measures that …
An inspection of Border Force practice and procedures in relation to firearms …
Introduce a process to record the issue and expiry date of body armour and ensure that body armour is fit for purpose.
PPO death in custody recommendations(2)
The Head of Healthcare
The Head of Healthcare should ensure that nurses respond to emergency code blue incidents with the relevant emergency equipment, including a defibrillator.
The Head of Healthcare
The Head of Healthcare should ensure that all healthcare staff understand their role in an emergency response, including recognising and managing seizures or loss of consciousness in line with current clinical guidelines, and recording actions taken. A local protocol, in …
IOPC learning recommendations(33)
Road traffic collision shortly after police pursuit – Metropolitan Police Service, March …
The IOPC recommends the Metropolitan Police Service establish if car radios fitted in police response vehicle are fit for purpose, are in full working order and the audio function works appropriately. They should also reinforce to officers the necessity to …
Recommendations - National Police Chiefs' Council, December 2024
The IOPC recommends that the National Police Chiefs’ Council (NPCC) should undertake medical testing of the Flexible Lift and Carry System (FLACS) independent of the manufacturer. This should include testing of whether the FLACS can be safely used after a …
Recommendations - Thames Valley Police, May 2025
The IOPC recommends that Thames Valley Police (TVP) should ensure method of entry equipment is available and easily accessible to police officers, so that whenever it may be required, entry can be gained to a property without undue delay. This …
Recommendation - West Midlands Police, August 2020
The IOPC recommends that managing officers at Stechford police station conduct an audit to establish whether additional approved methods of entry kits are required and to formally consider whether such equipment is being suitably located and managed. This recommendation was …
Recommendations - West Midlands Police, July 2023
The IOPC recommends that West Midlands Police (WMP) should review the medical equipment available to officers and stored in police cars to ensure minimum standards of availability are maintained, including consideration of the availability of defibrillators. This follows an IOPC …
Fatal collision following pursuit - Metropolitan Police Service, February 2019
The IOPC recommends that the National Police Chiefs’ Council shares the learning from this investigation with relevant force leads, asking them to ensure that, if any of their fleet vehicles contain life hammers: Their officers understand how and where on …
Fatal collision following pursuit - Metropolitan Police Service, February 2019
The IOPC recommends that the Metropolitan Police Service ensures that: Its officers understand how and where on a vehicle life hammers should be used, and where alternative methods may be more effective.It has a system for making sure that life …
Investigation into response to a concern for welfare - Greater Manchester Police, …
The IOPC recommends that Greater Manchester Police takes steps to make method of entry equipment more readily available to officers when the need for method of entry (MOE) equipment arises. This could include assigning MOE tools to MOE trained officers …
Recommendations - National Police Chiefs' Council, December 2024
The IOPC recommends that the National Police Chiefs’ Council (NPCC) and College of Policing work together to review and update guidance on the use of the Flexible Lift and Carry System (FLACS) following completion of the medical testing recommended in …
Recommendations - West Midlands Police, July 2020
The IOPC recommends that West Midlands Police ensure adequate arrangements / contingencies are in place to ensure medical treatment is available in the event immediate medical assistance is required during pre-planned firearms operations. In this particular instance, immediate ambulance assistance …
Recommendations - West Midlands Police, July 2023
The IOPC recommends that West Midlands Police (WMP) should review the first aid training of WMP officers, to consider whether a single day of training is sufficient to accommodate the necessary teaching for both personal safety and first aid, and …
Recommendations - Nottinghamshire Police, February 2026
The IOPC recommends that Nottinghamshire Police Internet Child Exploitation (ICE) team should always wear body worn video (BWV) on every enforcement visit. This follows an IOPC investigation where Nottinghamshire Police's ICE team attended the address of a man following a …
National recommendations and recommendations made to the Metropolitan Police Service and West …
The IOPC recommends that: The National Police Air Service (NPAS) develops guidance for emergency services call handlers on NPAS helicopter capabilities, making it clear that NPAS helicopters do not have a rescue capability. This guidance should also: - state that …
Road traffic collision following police pursuit – Metropolitan Police Service, November 2019
The IOPC recommends that an update should be sent as soon as possible, to all Metropolitan Police Service vehicle users to advise of the new potential fault within the Cleartone system, whereby the internal battery fails. This should indicate the …
Man died after an attempt to take his own life during a …
The IOPC recommends that all Police forces should consider equipping all operational police vehicles with some form of implement that would be capable of cutting a ligature of a width greater than a few millimetres. Training should also be given …
Man died after an attempt to take his own life during a …
The IOPC recommends that South Wales Police should consider equipping all operational police vehicles with some form of implement that would be capable of cutting a ligature of a width greater than a few millimetres. Training should also be given …
Recommendations - Norfolk and Suffolk Constabularies, October 2024
The IOPC recommends that Suffolk Constabulary ensure the 'downlink' function in the control room is working as expected to enable the transmission of data during a police pursuit. This follows a police pursuit which took place in a large field …
Recommendation - Metropolitan Police Service, December 2025
The IOPC recommends that the Metropolitan Police Service (MPS) should include relevant content on the MPS intranet around the Joint Emergency Services Interoperability Principles (JESIP), promoting the value of JESIP to recruits and providing links to the relevant material. This …
Police officer injured in collision - North Wales Police, February 2017
Any such guidance and/or policy on the modification to convert lights will be based on formalised research and analysis of any proposed method.
Police officer injured in collision - North Wales Police, February 2017
The National Police Chiefs' Council should introduce national guidance and/or policy concerning any potential modifications to convert lights installed on unmarked police vehicles.
Recommendation - West Mercia Police, March 2020
The IOPC recommends that West Mercia Police revises its risk assessment to consider the availability and distribution of water kits, including whether they may be carried in response vehicles. As a result of reviewing a DSI investigation it became apparent …
Traffic pursuit prior to man's death - Metropolitan Police Service, December 2020
The IOPC recommends that the Metropolitan Police Service ensures all information regarding an officer’s driving authorisation level is accurately documented in each officer's driving permit, and both the officer and their line manager ensure this information is kept up to …
Traffic pursuit prior to man's death - Metropolitan Police Service, December 2020
The IOPC recommends that the Metropolitan Police Service make amendments to policy to more clearly define the training required in order for an officer to be authorised to engage in initial phase pursuits. The investigation identified a lack of clarity …
Woman carrying a knife shot by armed officers – Merseyside Police, July …
The IOPC recommends that Merseyside Police reviews the settings on the body worn video (BWV) cameras used by armed officers and considers whether the pre-record functionality, as used in some other forces, should be switched on. This follows an investigation …
Police pursuit before road traffic incident - Cheshire Constabulary, November 2020
The IOPC recommends that Cheshire Constabulary ensures all Roads and Crime Unit vehicles are equipped with defibrillators. If the fleet is expanded further, the IOPC recommends that all relevant equipment is obtained and fitted or placed into the vehicle before …
Recommendation - City of London Police
There is national APP guidance that states that drunk and incapable individuals are in need of medical assistance in hospital and officers should call an ambulance immediately. The IOPC recommends that the City of London Police take steps to satisfy …
Recommendation - Metropolitan Police Service, May 2018
The Police and Driver - Vehicles and Equipment Standard operating procedure (SOP) states where vehicles are fitted with in-car recording equipment, the driver of the police vehicle “must ensure this equipment is working correctly and all cameras are visible through …
Man dies following contact with police - June 2017, Metropolitan Police Service
The College of Policing should seek expert advice to determine the medical implications of using incapacitant spray when a subject is suspected of having an item in their mouth (that may lead to an obstruction to their airway). The College …
Recommendation - Northumbria Police, November 2020
The IOPC recommends that Northumbria Police review its policy in relation to the provision and fitting of dash-cams to response vehicles as soon as possible.
Police response to locate a missing man – Northamptonshire Police, October 2021
The IOPC recommends that Northamptonshire Police should revise its Force Control Room (FCR) training to include content on responding to incidents on major roads. This should include how to input and record locations of incidents reported on fast roads, including …
Recommendation - College of Policing, October 2024
The IOPC recommends that the College of Policing (CoP) consider amending Roads Policing Authorised Professional Practice (APP) to include the dangers associated with driving in convoy during emergency response, particularly when negotiating junctions and to recommend a safe distance between …
National recommendation - National Police Chiefs' Council, November 2020
The IOPC recommends that the National Police Chiefs' Council (NPCC) should issue national guidance that provides clarity to officers about the carrying and use of multi tools when on duty.
Recommendation - Greater Manchester Police, December 2020
The IOPC recommends that the National Police Chiefs' Council lead for Armed Policing takes steps to ensure that should the Tactical Firearms Commander (TFC) or Operational Firearms Commander (OFC) identify that an officer’s exposure to information or intelligence that is …
IMB individual recommendations(7)
North East Midlands, Yorkshire & Humber STHF (2025)
In the light of delays in ambulance and paramedic attendance following an incident at Swinderby RSTHF, we recommend the use of ‘what3words’ or other precision location tools to aid navigation to places of detention and that lists of such places with the location details be readily available to paramedic crews. This is relevant not just for places such as Swinderby …
NHS / Healthcare Provider
North East Midlands, Yorkshire & Humber STHF (2025)
The IMB would like to have reassurance that centre protocols are to be revised to ensure that explicit procedures are in place to enable healthcare professionals (both internal staff and external paramedics) to attend health emergency incidents as quickly as possible – including the allocation of fast escort staff to facilitate this and the use of locational tools such as …
Other
Charter Flight (2020)
A supply of compression socks must be available on the plane and offered to returnees under the guidance of the paramedics (see paragraph 5.1.1, first bullet).
Other
Wealstun (2021)
Ensure that once approval is given to resume training, refresher training in use of PAVA and rigid-bar handcuffs is given priority (repeat area from 2019/202 report) (para 4.5.6 refers).
Governor / Director
In Progress
Oakwood (2021)
The Director to review the condition and numbers of body worn cameras, to ensure that a reliable body worn camera is available to all relevant staff (see section 4.5).
Governor / Director
Grendon (2021)
Restrictions due to Covid-19 and project work notwithstanding, the Board looks forward to: the delivery of timely training for ACCTs, and control and restraint (see 4.2.4 and 4.4.2)
Governor / Director
Swaleside (2025)
In our 2023-2024 annual report, we stated that the situation with body worn video cameras (BWVCs) needs to rectified, so that all staff can be issued with cameras. The prison response was there are enough BWVCs for operational staff, but the Board believes non-operational staff need to have the opportunity when they come into contact with prisoners. Again, we ask …
HMPPS
Noted
Scottish Fatal Accident Inquiries(5)
Craig Currie, William Carty, Stephen Carty and Thomas Douglas
And further recommends (i) That a register of local assistance which excludes the ambulance service be made up by Strathclyde Police and circulated to the emergency services and that the register includes the names of persons and equipment available to be called upon in an emergency rescue situation. (ii) That in the event of an emergency involving Strathclyde Police and …
Oct 2011
Kevin Michael McGurty
I recommend that Police Scotland and NHS Scotland reconsider their policies in this area. There should if possible be a uniform policy across Scotland, but consideration should be given to equipping all custody stations with AEDs and training officers to make as certain as possible that all officers faced with a situation of a sudden collapse are clearly able to …
Dec 2016
Kaylee Susan McIntosh
That was a defect in a system of working and requires urgent attention. In my view, some form of cross-checking in respect of the issue of lifesaving equipment would be appropriate to prevent the recurrence of the issue of the wrong equipment.
May 2009
Paul Alliston; Martin Johnstone; Christopher Morrison
The MCA is encouraged to pursue its proposal to the International Maritime Organisation that all new abandonment (solid fill) lifejackets should have a minimum 150 Newtons buoyancy, that their testing regime be more robust and realistic and that they be fitted as standard with a retention device and sprayhood. All relevant supervisory bodies should monitor carefully the compliance by the …
Mar 2022
Workplace
3 recs
John Wilson
8.1 A Personal Locator Beacon should form part of the standard safety equipment on single person-operated small fishing vessels, and further that the Personal Locator Beacon should be carried on the person of the crew member whilst at sea. 8.2 Crew members of single person operated fishing vessels should wear Personal Floatation Devices at all times whilst the vessel is …
Feb 2024
Workplace
1 rec
Article 2 learning points(1)
Independent reviews(4)
Kerslake Review — Rec 38
All emergency services should consider developing a capability to give their staff rapid access to basic frameless canvas stretchers to enable rapid movement and evacuation of casualties during terrorist attacks or other high-threat or dynamic-hazard incidents
Policing & Security
Accepted
Angiolini Review — Rec 7
Restraint equipment should be strictly limited and subject to robust monitoring and review. Its use should form part of the mandatory training.
Policing & Security
Accepted
Ockenden Review — Rec 7
Multidisciplinary training. Essential action: Staff who work together must train together. Staff should attend regular mandatory training and rotas. Job planning needs to ensure all staff can attend. Clinicians must not work on labour ward without appropriate regular CTG training and emergency skills training. • All members of the multidisciplinary …
Health & Social Care
Accepted
Kerslake Review — Rec 37
All major transport hubs and public venues should possess and provide immediate access to basic frameless canvas stretchers to enable rapid movement and evacuation of casualties during terrorist attacks or other high-threat or dynamic-hazard incidents
Policing & Security
Accepted
PHSO casework decisions(6)
P-003628 — North East Ambulance Service NHS Foundation Trust
Miss J complained about ambulance call handling delays and insufficient advice for her father's cardiac arrest, believing it reduced his survival chances and caused distress.
NHS in England
Partly Upheld
Jun 2025
P-004167 — Yorkshire Ambulance Service NHS Trust
Mr N complained about an ambulance crew's oxygen management and response to his father's sudden deterioration in hospital, believing his death was avoidable.
NHS in England
Oct 2025
P-003108 — North West Ambulance Service NHS Trust
Miss R complained the Trust failed to deliver CPR for 11 minutes when her sister was in peri-arrest, missing an opportunity for survival, and did not comply with recommendations.
NHS in England
Partly Upheld
Nov 2024
P-003542 — George Eliot Hospital NHS Trust
Mr and Mrs G alleged incorrect antibiotics and unsafe travel advice led to their son's severe wound infection and hospitalisation abroad. They sought financial redress for lost earnings.
NHS in England
May 2025
P-003653 — Shrewsbury and Telford Hospital NHS Trust
Mrs B complained her niece received delayed sepsis treatment, poor communication regarding transfer and family notification, and inadequate care, which she believes led to her death.
NHS in England
Upheld
Jun 2025
P-002726 — South Central Ambulance Service NHS Foundation Trust
Mrs P complained the Trust provided unacceptable care to her son on 11 April 2022, causing her immense distress and potentially impacting his survival chances.
NHS in England
Jun 2024
LGO / SPSO decisions(2)
201302648 — Scottish Ambulance Service
When Mrs Cs husband (Mr C) was taken to hospital by ambulance, the crew could not get the ambulance doors open, and there was a delay getting him to the hospital. Mr C passed away the following month and Mrs C then complained that the Scottish Ambulance Service (the service) …
SPSO (Scottish Public Se…
Health
Upheld
Mar 2014
PSOW-202305260 — Welsh Ambulance Services NHS Trust
Mrs B complained that the Welsh Ambulance Services NHS Trust had failed to respond to a complaint she had made to it in November 2022. The Ombudsman found that the Trust had failed to respond to Mrs B complaint or to regularly provide her with updates during its investigation. The …
PSOW (Public Services Om…
Health
Oct 2023
CQC enforcement actions(2)
Warning Notice: Barts Health NHS Trust
The Care Quality Commission issued three formal warning notices to Barts Health NHS Trust following unannounced inspections at Whipps Cross University Hospital in May and June. The warnings required urgent improvements to protect patients and addressed the hospital's non-compliance with …
Whipps Cross University Hospital
Aug 2013
Warning Notice: South East Coast Ambulance Service NHS Foundation Trust
The Care Quality Commission issued a Warning Notice to South East Coast Ambulance Service NHS Foundation Trust, requiring significant improvements in the quality of its services. This action followed a comprehensive inspection in May, which identified six main areas of …
Jul 2016