Prison CPR guidance
Flawed CPR guidance in prisons, specifically the inclusion of rigor mortis as an exclusion criterion, leading to missed resuscitation opportunities.
Source spread
Where this theme appears
This theme appears across 5 independent accountability sources, so the source mix matters as much as the headline total.
6 PFD reports
10 PPO recs
1 Article 2 learning point
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.
Prevention of Future Deaths reports(6)
Peter Mackie
Concerns: Concerns were raised regarding the insufficient number of first aiders available at Springhill site, particularly at night, and potential delays in healthcare staff moving between prison sites. There is also a lack of clear guidance for staff on when to commence CPR.
Response (HM Prison and Probation Service): • HMP Grendon and Springhill are working to increase the number of trained first aid staff, with a new risk assessment system for 24-hour cover to be operational within 12 … (AI summary)
Responded
Noreen Porter
Concerns: Care home staff did not perform CPR when the deceased collapsed, and there was no process or procedure in place to ensure resuscitation during an emergency.
Response (Bupa): • Focussed supervisions were carried out with all nursing staff to cover Bupa's policy on CPR and the circumstances in which it must be commenced. • Bupa's policies on resuscitation … (AI summary)
Responded
Darren Adams
Concerns: Nursing staff exhibited insufficient understanding to accurately diagnose hypostasis and rigor mortis, which management agreed needed better coverage in life support training. Additionally, definitions within the CPR guidance document for prisons were found to be confusing.
Response (Practice Plus Group): • The Intermediate Life Support training curriculum was amended to include a theoretical session on identifying rigor mortis and lividity, and mandatory decision-making scenarios. • Additional education days featuring resuscitation … (AI summary)
Response (Resuscitation Council UK): • Resuscitation Council UK has shared its response with the National Offender Management Service, Royal College of Nursing, and Royal College of General Practitioners. • Resuscitation Council UK has offered … (AI summary)
Responded
Cristofaro Priolo
Concerns: The coroner identified concerns regarding the improper preparation of food, inadequate feeding practices by carers, and staff's failure to provide appropriate choking first aid. There were also significant issues with nursing staff not recognising cardiac arrest or performing effective CPR, indicating a need for frequent training.
Response (BUPA Care Services): • Bupa will implement a UK-wide process to quality assure food prior to leaving the kitchen and review related policies and training. • Additional materials and a competency check will … (AI summary)
Responded
Paul Day
Concerns: The coroner noted concerns that prison officers in facilities without 24-hour healthcare are not trained to assess rigor mortis, a condition included in CPR guidance, which risks missed opportunities for resuscitation.
Response (HM Prison and Probation Service): • HM Prison and Probation Service stated it would undertake a review of its CPR guidance. • HM Prison and Probation Service stated it would issue a revised version of … (AI summary)
Responded
James Capstick
Concerns: Concerns were raised about the quality and documentation of care at Westmorland Court, including unreliable resident notes, a nurse's actions during resuscitation, and the absence of a defibrillator.
Response (NMC): • The NMC confirmed that its investigations into the registered nurse's conduct are ongoing, having shared the PFD concerns with the investigating team and contacted relevant parties for information. • … (AI summary)
Response (Westmorland Court Care Home): • The care home implemented a Quality Improvement Plan in conjunction with the ICB and Westmorland and Furness Council, which has concluded. • All senior staff and registered nurses have … (AI summary)
Response (CQC): • CQC followed up on a local authority safeguarding investigation, which included staff refresher training and actions regarding the registered nurse. • CQC conducted a targeted inspection on 13 October … (AI summary)
Responded
PPO death in custody recommendations(10)
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that staff understand the circumstances in which resuscitation is inappropriate in accordance with European Resuscitation Council Guidelines.
The Governor and the Head of Healthcare
The Governor and the Head of Healthcare should ensure that staff are given clear guidance about the circumstances in which resuscitation is inappropriate in line with European Resuscitation Council Guidelines.
The Director of HMP Peterborough and Head of Healthcare
Staff should be given clear guidance about the circumstances in which resuscitation is inappropriate in line with the Resuscitation Council Guidelines.
The Governor of HMP Highpoint
The Governor will wish to consider Highpoint’s local safer custody policy to ensure it reflects Resuscitation Council (UK) guidelines regarding the futility of CPR when there is clear evidence of rigor mortis.
The Head of Healthcare
The Head of Healthcare should ensure that staff, including agency staff, understand when not to perform cardiopulmonary resuscitation in accordance with European Resuscitation Council Guidelines.
The Director and Head of Healthcare of HMP Peterborough
The Director and Head of Healthcare should ensure that all staff are given clear guidance about and understand the circumstances in which resuscitation is inappropriate in line with European Resuscitation Council guidelines.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that staff are given clear guidance about the circumstances in which resuscitation is inappropriate in accordance with European Resuscitation Council Guidelines.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that staff are given clear guidance about the circumstances in which resuscitation is inappropriate in accordance with European Resuscitation Council Guidelines.
The Governor
The Governor should ensure that all staff are given clear guidance about and understand the circumstances in which resuscitation is inappropriate in line with European Resuscitation Council guidelines.
The Governor of HMP Leyhill
The Governor should ensure that all staff are aware of the location of defibrillators and that they understand how to access and use them during a medical emergency.