Prison staff first aid, CPR
Insufficient official training for Operational Support Grades (OSGs), poor monitoring of first aid training logs, and lack of prison-specific unconsciousness recognition training.
Source spread
Where this theme appears
This theme appears across 11 independent accountability sources, so the source mix matters as much as the headline total.
54 PFD reports
1 committee rec
3 HSSIB recs
1 CQC action
21 PPO recs
3 IOPC recs
39 IMB recs
4 Article 2 learning points
4 LGO/SPSO decisions
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(54)— showing 50 strongest matches
Jordan Buckton
Concerns: Concerns were raised regarding inadequate information sharing within the prison about a person's history of self-harm and the lack of follow-up care, including a PHQ9 assessment, after antidepressant medication was prescribed.
Overdue
Reggie John
Concerns: Concerns included insufficient communication between prisons regarding the prisoner's constant watch status, a lack of robust multi-disciplinary ACCT review processes, and instances where the Prison Service Order 2700 policy was not followed, impacting healthcare documentation.
Response (Worcestershire Health Care NHS): • The Trust stated it would ensure appropriate information is communicated to receiving prisons upon prisoner transfer. • The Trust confirmed that expectations for nurses reviewing and documenting Assessment, Care … (AI summary)
Response (HM Prison and Probation Service): • HMP Bristol implemented a system for its safer custody team to contact receiving establishments and escort contractors regarding prisoners on open ACCTs, with these communications recorded on Prison-NOMIS. • … (AI summary)
Overdue
Ryan Clark
Concerns: The coroner noted that the Personal Officer Scheme was not effectively implemented, ACCT checks were not conducted as prescribed, and prison officers lacked full conversancy and regular refresher training in first aid and CPR.
Response (HM Prison and Probation Service): • HMP YOI Wetherby implemented a revised personal officer scheme in October 2013, which includes a 'relief' arrangement and staff briefings. • Staff received briefings on ACCT check timings and … (AI summary)
Response (Leeds City Council): • Leeds Children's Social Work Service and Leeds Youth Offending Service agreed a procedure for sharing information about young persons entering custody. • YOS Court Officers will collate relevant information … (AI summary)
Responded
Abdullahi Sharif Abokar
Concerns: The coroner noted that some staff did not ask Mr Abokar about suicidal thoughts due to a mistaken belief, contrary to training. There were also significant issues with resuscitation procedures, including an unconnected ambubag and oxygen not being switched on.
Response (Camden & Islington NHS Trust): • The Trust commenced a Rapid Improvement Plan for Coral ward, which includes placing a new nurse manager and assessing staff competencies. • A revised Resuscitation Policy was approved, and … (AI summary)
Responded
William Anderson
Concerns: The coroner noted insufficient staff vigilance regarding inmate social gatherings and a lack of training for staff in breathalyser use and emergency codes. Concerns were also raised about unrecorded inmate behaviour in observation books and delays in summoning paramedic assistance.
Overdue
Darren Wright
Concerns: The staff nurse did not know the location for a Code Blue emergency, and prison officers who responded lacked recent CPR training due to resource limitations which created gaps in trained personnel.
Response (Serco): • Serco stated it no longer provides services to HMP Norwich and therefore has no power to implement the recommendations at that location. • Serco stated it would use the … (AI summary)
Response (Ministry of Justice): • The Ministry of Justice stated that HMP Norwich operates within existing first aid regulations, with a risk assessment in place and appropriate staff trained. • It confirmed that a … (AI summary)
Response (Virgin Care Services Limited): • The induction process for new and agency staff has been reviewed and revised to include shadowing time, with a checklist template to be introduced by 31 March 2015 and … (AI summary)
Responded
Keith Murphy
Concerns: The coroner noted a lack of basic first aid, CPR, and defibrillator training for prison officers and staff, alongside insufficient healthcare staff availability outside of core hours.
Response (HM Prison and Probation Service): • HMP Coldingley is implementing the First Aid policy (PSI 0112014), with most Custodial Managers having received training. • The two remaining Custodial Managers at HMP Coldingley will receive first … (AI summary)
Overdue
Luke Myers
Concerns: HMP Liverpool miscalculated a prisoner's extended sentence, which was a likely factor in their death, and the coroner questions if other prisoners sentenced during that period might also have incorrect sentences. Additionally, two prison discipline staff members had significantly outdated first aid training.
Response (Ministry of Justice): • Staff at HMP Liverpool reviewed sentence calculations for the current population. • First aid training is being provided to all Custodial Managers carrying out orderly officer duties. • Operational … (AI summary)
Responded
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
Derrick Rose-Fowler
Concerns: The coroner noted insufficient first aid training for all prison officers, questioned the effectiveness of the prison's anti-bullying policy, and identified a lack of referral of the deceased's mental health and self-harm history to a Multi-Agency Safeguarding Hub (MASH) meeting.
Overdue
Benjamin Brown
Concerns: Concerns relate to the auditing of staff conducting 15-minute observations and clozapine prescription, alongside the training of staff in resuscitation for patient collapse.
Overdue
Michelle Barnes
Concerns: Concerns were raised that an ACCT was not opened for an individual given distressing news, despite her being very upset. Instead, a vague instruction to "offer support" was given, with no clear plan or documentation on what support should be provided.
Overdue
Tedros Kahssay
Response (Care UK): • Care UK implemented changes to reception screening templates, including mandatory questions for reviewing Person Escort Records and obtaining consent for general practitioner records. • The prescriptive scoring system for … (AI summary)
Overdue
Antony Abbott
Concerns: The coroner noted that while Custody Officers in Spain are trained in first aid, their training does not include instruction in Cardio Pulmonary Resuscitation (CPR).
Overdue
Ondrej Suha
Concerns: The coroner noted a lack of specific training for a prison officer beginning night shifts, particularly concerning the night patrol regime. Additionally, initial responding staff did not have first aid training, prompting a review of basic resuscitation training for officers and staffing quotas.
Overdue
Mark Doyle
Response (Care UK): • Care UK confirmed the immediate implementation of a Patient Wing Movement Assessment system. • The new system establishes criteria for prisoner transfers from the Substance Misuse Unit, including a … (AI summary)
Overdue
Christopher Talbot
Concerns: The coroner identified inadequate formal training and written guidance for supervising officers, a lack of personal breathing guards for senior officers during resuscitation, and insufficient staff awareness of the specific manner of unnatural deaths.
Response (HM Prison and Probation Service): • Reception staff at HMP Preston have been provided with PSI 07/2015 and given an objective to read and comply with it. • Line managers will monitor staff compliance with … (AI summary)
Overdue
Donald Martin
Concerns: The coroner identifies that a nurse may not fully understand when it is appropriate to carry out CPR on a flat surface and does not know how to deflate patient mattresses in an emergency.
Response (Royal College of Nursing): • Ms Banjoko provided a reflective piece explaining CPR processes and mattress deflation in emergencies. • Ms Banjoko completed basic life support training, including a practical assessment in CPR. • … (AI summary)
Overdue
Nicola Lawrence
Concerns: Some prison staff had not received cardiopulmonary resuscitation training, either initially or as refresher training, despite evidence highlighting its critical importance in early response.
Response (HM Prison Probation Service): • The Governor at HMP New Hall reviewed the number of staff requiring first aid training. • The prison currently has 40 staff trained in First Aid at Work (FAW) … (AI summary)
Responded
Daniel Stokes
Concerns: The coroner noted the jury's view that proper systems were lacking for prison healthcare staff to be trained and authorised to administer diazepam when a prisoner is suffering from controlled drug abuse.
Overdue
Ricardo Holgate
Concerns: Further steps are necessary to improve the management of illicit substance misuse within the prison, including the installation of CCTV on all wings and airport-style scanners. Extending the current Governor's appointment would allow more work to be undertaken to enhance inmate safety.
Response (GS4): • G4S stated that funding for CCTV installation at HMP Birmingham had been approved. • G4S reported that Governor Newton's appointment had been extended. • G4S noted that discussions regarding … (AI summary)
Overdue
Ryan Trimmer
Concerns: The coroner noted inadequate ACCT reviews at HMP Lewes and identified that not all prison staff, who act as first responders, had received first aid training, with one staff member lacking training for 16 years.
Response (HM Prison and Probabtion Service): • A revised version of the ACCT process is undergoing evaluation following a pilot, with national implementation intended for early 2020. • HMP Lewes will introduce monthly first aid training … (AI summary)
Responded
Darren McGuin
Concerns: The coroner noted a delay in CPR commencement and identified that many prison officers lack basic life support training, particularly those employed when it was not mandatory, with no retrospective training provided.
Overdue
Robert Ginn
Response (Care UK): • Care UK mandates annual Intermediate Life Support (ILS) training for employed staff involved in resuscitation, exceeding the Resuscitation Council's three-year cycle. • Care UK issued an alert to all … (AI summary)
Overdue
Daniel Akam
Concerns: Concerns were raised that ACCT observations were not conducted but recorded as completed. The coroner also noted officers' insufficient understanding of ACCT procedures and inadequate training, requiring refresher courses to safeguard vulnerable prisoners.
Overdue
Mark Mallinson
Concerns: The coroner noted that suicide intervention training provided to new police recruits in Sussex Police is not being rolled out to all front-line staff.
Overdue
Brett Marrs
Concerns: The coroner noted insufficient first-aid and resuscitation training for some long-serving prison officers, with no fixed completion date for refresher training. There were also concerns about inconsistent welfare checks by officers during morning cell unlocks, despite management reminders.
Overdue
John Tucker
Concerns: The coroner raised concerns regarding the nature and extent of basic life support and first aid training provided to Gwent police staff, particularly for those in regular contact with individuals who are unwell or injured and may develop respiratory problems.
Overdue
Kevin Lovatt
Concerns: The coroner identified a lack of clear guidance and training for prison staff on the safe use of force when dealing with resistant prisoners who have items in their mouths, which could compromise their breathing.
Response (NHS England): • NHS England stated that the Service Specification for primary care in prisons requires healthcare providers to develop and implement protocols for responding to and managing emergencies. • NHS England … (AI summary)
Overdue
Peggy Copeman
Concerns: The coroner noted staff transporting the patient did not recognise deterioration or call emergency services immediately, and that only one of three staff was CPR trained, contrary to policy. An internal investigation did not identify these issues.
Response (Premier Rescue Ambulance Service Ltd): • Premier Rescue Ambulance Service Ltd. decided that all staff, including drivers, would receive CPR training; an authorised trainer has completed relevant courses, and 12 staff have already received internal … (AI summary)
Responded
Kesia Waller
Concerns: The coroner identified a lack of sufficient training and appropriate tools for staff to respond to a resident found suspended. Additionally, concerns were raised regarding ineffective policy communication, which meant staff did not consistently read or understand crucial updates.
Response (A2Dominion): • The organisation revamped first aid training to include action for suicide, self-harm, and overdose, added preventative training, and is rolling out ligature cutting kits by July 2021. • An … (AI summary)
Responded
Trevor Smith
Concerns: The coroner identified a lack of clear guidance for police to record and cascade relevant information from MARAC meetings to officers, leading to critical information not reaching the firearms team. Concerns were also raised regarding officers' confusion about rescue breaths during CPR and the absence of a policy for appointing a CPR coordinator.
Response (College of Policing): • A national circular will be published to raise awareness of the concerns and recommend forces consider local policy and practice for recording and sharing MARAC information. • The issue … (AI summary)
Response (West Midlands Police): • West Midlands Police has recruited and trained dedicated MARAC minute takers, with MARAC minutes subject to regular dip samples and audits since summer 2021. • The Chief Firearms Instructor … (AI summary)
Responded
Robert Ellery
Concerns: The coroner noted a 19-minute delay in the prison control room providing specific information to the ambulance service, impacting dispatch. There was also no direct communication method between ambulance call centre staff and prison staff providing CPR, which impeded guidance and information exchange.
Response (HMP Cardiff): • A Local Operating Protocol has been devised to assist communication between the Ambulance Service call centre and staff providing basic life support. • The protocol sets out objectives for … (AI summary)
Responded
Khadija Ahmed
Concerns: The teaching assistant was not trained in cardiopulmonary resuscitation (CPR), and no staff member attempted CPR when Khadija became unresponsive. The coroner noted the school would benefit from frequent CPR training for staff.
Response (Swiss Cottage School): • The school confirmed that Basic Life Support with CPR training was organised for 70 members of staff. • The training was scheduled to take place on 12th January and … (AI summary)
Responded
Martin Brown
Concerns: The coroner identified a need for improved training of prison staff in responding to medical emergencies and using the ERIC system. Concerns were also raised regarding liaison between healthcare and ambulance services, and communication between healthcare personnel at emergency scenes and control rooms.
Response (Spectrum at HMP Lancaster Farms): • Spectrum developed and delivered Emergency Response in Custody (ERIC) training presentations to prison staff, with plans for further rollout and ongoing compliance monitoring. • The Head of Healthcare met … (AI summary)
Response (HM Prison and Probation Service): • ERIC cards were distributed to all existing staff in January 2022, and additional ERIC training commenced. • All new staff will receive ERIC training and ERIC cards as part … (AI summary)
Responded
Lewis Johnson
Concerns: The coroner raised concerns about HMP Wealstun's lack of night-time healthcare staff and insufficient CPR and defibrillator training for night patrol officers. There is also no express direction for officers to perform CPR on unresponsive prisoners pending medical arrival.
Response (HM Prison Probation Service): • HMPPS stated that all prison officers receive emergency first-aid at work (EFAW) training, including CPR, during their entry-level training, and HMP Wealstun's local first aid risk assessment was reviewed … (AI summary)
Overdue
Nathan Forrester
Concerns: The coroner identified a lack of specific training for prison officers on managing CPR for individuals on top bunks. Concerns were also raised regarding the level of CPR and airway management training for nurses working in detention settings.
Response (NHS England): • NHS England stated that HMPPS is responsible for training prison officers and would respond directly to that concern. • NHS England noted that its Service Specification requires healthcare providers … (AI summary)
Response (HM Prison and Probation Service): • New prison officers receive first aid training that covers moving individuals to a hard, flat surface before commencing CPR. • Training in manual handling and movement of prisoners is … (AI summary)
Responded
Jason Williams
Concerns: The coroner noted a lack of national guidance for identifying and caring for vulnerable prisoners, alongside concerns about the implementation and resourcing of the keyworker programme. Irregular record-keeping by prison staff on Prison NOMIS was also highlighted.
Response (NHS England): • NHS England, in conjunction with His Majesty’s Prison and Probation Service and Health Education England, developed a multi-agency training programme for adult safeguarding in secure and detained settings. • … (AI summary)
Response (HM Prison Probation Service): • His Majesty's Prison and Probation Service (HMPPS) stated that its National Social Care Board is developing a workplan to improve safeguarding practice, including specific guidance on self-neglect, and will … (AI summary)
Response (HM Prison Probation Service): • HMP Guys Marsh introduced a Buddy scheme. • HMP Guys Marsh is developing local guidance for prisoners at risk of self-neglect. • HMP Guys Marsh introduced an assurance check … (AI summary)
Responded
Anthony Smith
Concerns: The coroner raised concerns regarding the lack of readily available mouth protection for resuscitation in the prison, which posed a risk of blood-borne virus transmission to officers and could deter the provision of rescue breaths.
Response (HM Prison and Probation Service): • HM Prison and Probation Service stated that the First Aid Policy Framework is under review and will include requirements for resuscitation face shields in all prison first aid kits. … (AI summary)
Responded
Amarjit Singh
Concerns: The coroner noted concerns about the careless completion of a cell sharing risk assessment and the surprisingly low level of first aid understanding among some HMP Pentonville officers. There was also a lack of confirmed guidance for prisoners on how to assist cellmates experiencing a fit.
Response (HM Prison and Probation Service): • HMPPS confirmed that new emergency response guides and pocket cards were issued to all prisons in 2021 and 2022, and the HMPPS National Health and Safety Arrangements for First … (AI summary)
Response (Practice Plus Group): • Practice Plus Group stated that nursing staff receive specialised training on reception processes, including risk assessment forms, and the nurse involved in the incident has revisited this training. • … (AI summary)
Responded
Kane Boyce
Concerns: The coroner identified a practice of staff deliberately ignoring cell bells and a lack of policy regarding isolating power to cells. There was also a failure to follow the 'Under the Influence Policy' and insufficient staff understanding of Prison Service Instruction 64/2011 concerning trigger dates.
Response (Sodexo): • Sodexo stated it requires all cell bells to be answered within 5 minutes and has produced a policy for when it resumes operational management. • The HMPPS Governor has … (AI summary)
Response (HM Prison and Probation Service): • HMPPS issued guidance and a standard template for Early Learning Reviews in 2021. • Workshops were held with Group Safety Leads in July 2022 and April 2024 to enhance … (AI summary)
Responded
Liam Turner
Concerns: It is not mandatory for prison officers to maintain in-date basic first aid training, including CPR. This results in a significant proportion of staff having expired certifications.
Response (HM Prison and Probation Service): • HM Prison and Probation Service re-issued its First Aid Policy Framework in August 2023, which outlines training requirements and mandates local risk assessments. • HMP Manchester issued guidance and … (AI summary)
Responded
Samuel Curless
Concerns: The coroner noted a lack of institutional learning regarding ambulance calls for reported deaths and found officer training on responding to hanging casualties, especially for those receiving online-only training, to be inadequate. Concerns were also raised about officers not receiving timely First Aid refresher training, including specific resuscitation techniques.
Response (College of Policing): • The College of Policing reviewed its First Aid Learning Programme (FALP) through a national working group. • The revised First Aid Learning Programme (FALP) has been published. • Training … (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
Kevin McDonnell
Concerns: Prison staff misunderstood the need for meaningful ACCT observations, treating them as superficial checks, and did not share risk-pertinent information. The coroner also noted failures in securing and retaining accurate documentary evidence after the death.
Response (HM Prison and Probation Service): • HMP Nottingham increased delivery of SASH/ACCT awareness and upskilling training. • HMP Nottingham introduced a ‘trigger’ database for sharing pertinent risk information. • ACCT books are no longer removed … (AI summary)
Responded
Stephen Sleaford
Concerns: The coroner raises concerns about a lack of first aid and CPR training for prison officers, including its omission from new officer foundation training programmes. Additionally, officers routinely permit cell observation panels to be obscured, and there is insufficient guidance on entering cells during emergencies.
Response (HMPPS received by CCO): • HMPPS re-issued its First Aid Policy Framework in August 2023 and confirmed Emergency First Aid is a mandatory part of foundation training for new officers. • HMP Gartree issued … (AI summary)
Responded
Daniel Beckford
Concerns: The first aid training for prison officers lacked clarity on the use of rescue breaths during resuscitation attempts, not aligning with current Resuscitation Council UK advice.
Overdue
Yuri Hatton
Concerns: Concerns included insufficient official training for most Operational Support Grades (OSGs) who are first responders, and inadequate monitoring of first aid training records. The coroner also noted that first aid training on recognising unconsciousness was not prison-specific and new induction instructions had not yet been implemented.
Overdue
Nathan Shepherd
Concerns: The coroner identified gaps in policies and staff training for barricading incidents and agency staff CPR competency. Concerns included environmental risks from mobile furniture and ligature points, and insufficient information sharing between probation services and prisons.
Response (HM Prison and Probation Service): • New Barricade Guidance has been finalised and is scheduled for issue to approved premises staff by August 2025. • A fixed furniture specification is being applied, anti-ligature fire detection … (AI summary)
Responded
Nicholas Gedge
Concerns: A delay of over 8 minutes occurred before CPR was commenced, indicating a lack of shared understanding among staff regarding the urgency of CPR. There were also unclear protocols defining the respective roles of detention and medical staff during a cell medical emergency.
Response (Leeds Community Healthcare NHS Trust): • The Trust expanded life support training for staff to include medical emergency/CPR scenarios and will further expand this to include simulation exercises in custody suites with detention officers. • … (AI summary)
Response (West Yorkshire Police): • West Yorkshire Police stated that Detention Officers receive regular training on their defined role in medical emergencies, including basic life support and taking direction from healthcare professionals. • The … (AI summary)
Responded
HSSIB safety recommendations(3)
Healthcare provision in prisons
HSSIB recommends that HM Prison and Probation Service enhances the existing training delivered to prison officers, to increase their ability to identify medical emergencies that require 999 calls to be made by prisons, thereby reducing the number of calls and …
Safety Recommendation
Healthcare provision in prisons: emergency care response — HSSIB
HSSIB recommends that HM Prison and Probation Service enhances the existing training delivered to prison officers, to increase their ability to identify medical emergencies that require 999 calls to be made by prisons, thereby reducing the number of calls and …
Safety Recommendation
Healthcare provision in prisons: emergency care response — HSSIB
HSSIB recommends that HM Prison and Probation Service, in collaboration with the Association of Ambulance Chief Executives, reviews and amends the design of the medical emergency response card, to better support staff in identifying emergency situations and providing the situational …
Safety Recommendation
CQC inspection actions(1)
PPO death in custody recommendations(21)
The Governor and Head of Healthcare of HMP Sudbury
The Governor and Head of Healthcare should review the provision of first aid training, the deployment of first aid trained officers and, in particular, ensure staff know how and when to deliver cardiopulmonary resuscitation and are confident in using a …
The Governor
The Governor should ensure that staff start CPR without delay when a prisoner has no pulse and stops breathing.
The Governor
The Governor should ensure that operational staff have up-to-date training to administer basic first aid.
The Governor
The Governor should ensure that staff are aware of their responsibilities during medical emergencies and that staff who discover the emergency should call the appropriate medical emergency code immediately.
The Governor
The Governor should ensure that all staff are aware of the importance of starting cardiopulmonary resuscitation at the earliest opportunity and that staff first on the scene of an emergency provide basic life support until qualified health professionals arrive.
The Director of HMP Parc
The Director will wish to remind staff about the need to commence CPR with as little delay as possible.
The Head of Healthcare
The Head of Healthcare should ensure that staff are competent to carry out cardiopulmonary resuscitation in line with national guidance and arrange for additional training as required.
The Approved Premises Manager
ensure that newly appointed staff receive first aid and CPR training before they start work in the AP;
The Governor
The Governor should ensure that staff are aware of their responsibilities during medical emergencies including that: staff who discover the emergency should call the appropriate medical emergency code immediately and start CPR if the prisoner is not breathing; and control …
The Governor
The Governor should ensure that all prison staff are made aware of and understand their responsibilities during medical emergencies, including that staff efficiently communicate the nature of a medical emergency using the appropriate code.
The Governor
The Governor should ensure that all prison staff are made aware of, and understand their responsibilities during medical emergencies, including that staff: • understand and use the appropriate emergency code when they discover a medical emergency; and • enter cells …
The Governor
The Governor should ensure that all staff are made aware of and understand their role and responsibilities during medical emergencies, including that they should radio a code blue emergency if they are concerned a prisoner is not breathing and that …
The Governor
The Governor should ensure that all staff understand their responsibilities during a medical emergency, and in particular that: officers fully understand the expectation that preservation of life must take precedence when considering entering a locked cell whether at night or …
The Governor
The Governor should ensure that staff call a medical emergency code as soon as possible if a prisoner appears to be hanging.
The Governor
The Governor should conduct regular emergency response drills to allow staff to practice response requirements, including when to commence CPR.
The Governor
The Governor should ensure that all staff use the medical emergency codes as set out in PSI 03/2013.
The Manager of Elm Bank Approved Premises
The Manager of Elm Bank Approved Premises should ensure that all staff understand their responsibilities during medical emergencies, including that: Staff act promptly in a life-threatening situation. First aid is commenced immediately on discovery of a resident who is unconscious …
The Governor
The Governor should ensure that when staff call a medical emergency code, they provide relevant information about the prisoner’s condition to control room staff so that they can inform the Ambulance Service.
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 …
The Head of Healthcare
The Head of Healthcare should ensure that there is always a registered nurse or a GP present during a medical emergency. Guidance on the role of GPs and senior managers during an emergency should be developed, detailing guidance on leadership, …
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that all staff are fully aware of and understand their responsibilities in a medical emergency, including the use of an emergency response code if a prisoner has chest pains and documenting incidents.
IOPC learning recommendations(3)
Recommendation - College of Policing and National Police Chiefs' Council, August 2019
Officers attended an incident where a young male was found hanging. They did not detect signs of life and did not administer CPR. Responding officers receive ‘Emergency First Aider at Work’ (EFAW) (Module 2) training, in line with the College …
Recommendations - Metropolitan Police Service, November 2018
The IOPC recommends that the MPS may want to consider reviewing and updating the concern for safety Standard Operating Procedure (SOP) to include under the 'first contact' heading 'request London Ambulance Service’ and also 'request if anyone present is medically …
Recommendations - Metropolitan Police Service, November 2018
The IOPC recommends that the MPS may want to consider reviewing and updating the sudden death Standard Operating Procedure (SOP) to include under the 'first contact' heading 'request if anyone present is medically trained to initiate first aid / CPR.’ …
IMB individual recommendations(39)
Heathrow Immigration Removal Centre (2020)
The investment made in the Safer Community Team and the associated working practices should be continued, ensuring that good practice in violence reduction, anti-bullying and the development of a community in which everyone is respected is at the core of the Centre and practiced by all members of the community (See 4.4.12). The Board would support the Centre Manager in …
Governor / Director
Exeter (2021)
As a matter of some urgency support Governors to reduce the backlog in staff training and particularly C&R basic, refresher and advanced training.
HMPPS
Exeter (2022)
Address the backlog in staff training and particularly control and restraint (C&R), basic, refresher and advanced training.
HMPPS
In Progress
Durham (2023)
How will you ensure there are sufficient trained ‘Listeners’ in, and distributed across, the prison, and that they are given access to prisoners requesting support? (4.2.13)
Governor / Director
Standford Hill (2025)
We believe that prison officers should wherever possible be on the wings for greater visibility, and to manage risk rather than in the wing office.
Governor / Director
Berwyn (2022)
The Board is concerned at the lack of sufficient staff, which is the biggest destabilising factor in the prison. We hope to see increased funding to help recruit and retain frontline operational staff.
Other
Channings Wood (2023)
As one manager told the Board in 2021, ‘You can’t achieve OMiC if you can’t achieve key work’. Last year, HM Inspectorate of Prisons stated: ‘The absence of a functioning key worker scheme exacerbated the problems that prisoners told us they faced in getting things done.’ For several reasons (and even under the delivery to priority groups only model) key …
Governor / Director
Bronzefield (2023)
What plans does the prison have to increase the allocation of key workers to prisoners and the number of prisoner/key worker meetings?
Governor / Director
Preston (2024)
The Board recommends reviewing the refresher training and mentoring with regard to pro-social modelling, de-escalation and neurodiversity awareness.
HMPPS
Implemented
East Sutton Park (2025)
Could the Governor investigate making greater use of the incentives scheme, including warnings or other sanctions, to more quickly and effectively respond to instances of challenging behaviour or situations where behaviour falls short of the standards expected by the prison?
Governor / Director
Noted
Foston Hall (2020)
The need for further improvement in the use of body worn cameras during violent incidents (see paragraph 4.5.3).
Governor / Director
Noted
Foston Hall (2020)
The rise in the use of force (see paragraph 4.5.1).
Governor / Director
Noted
Foston Hall (2020)
The high rate of violent incidents – in particular, the level of assaults on staff (see paragraph 4.3.2).
Governor / Director
Noted
Exeter (2020)
Will the Governor consider deploying dedicated staffing in the CSU to provide night cover and/or increase viewing access to CCTV in the CSU so that it can be viewed from the A2/3 wing offices? (See paragraph 5.2.2).
Governor / Director
Whitemoor (2021)
Will the Governor the Governor please ensure that the key worker scheme which has the potential to make a very positive contribution to staff/prisoner relations is resourced appropriately and supported from the top down to do the job it was created to do?
Governor / Director
Stoke Heath (2021)
The Board urges the Governor to give priority to his plans to re-introduce a full key worker programme as soon as restrictions allow. The Board believes that this will be a critical tool for the successful transition to a normal regime.
Governor / Director
In Progress
Durham (2021)
Use of force is disproportionate in the age groups 18–21 and 22–29. Other than actively pursuing the young adult strategy, what else can be done to address the behaviour of this demographic (4.4.9)?
Governor / Director
Wayland (2022)
The Board recommends that prison officer training is reviewed to include deeper and more extensive training on key work and staff/prisoner relationships.
HMPPS
Guys Marsh (2022)
The cornerstone of offender management in custody (OMIC) is the importance of the key worker and prisoner relationship. Current staffing levels simply do not allow for the effective delivery of OMIC. leading to pressures elsewhere in the system. How can the Prison Service ensure the successful delivery of OMIC?
HMPPS
Belmarsh (2022)
Will the prison ensure adequate time is ring-fenced for key worker duties to ensure the compliance rate for key worker sessions meets the required level (see section 5.3 Staff-prisoner relationships, key workers)?
Governor / Director
Whatton (2023)
Will the Governor ensure that key working remains a priority and the correct level of engagement with prisoners is maintained?
Governor / Director
Eastwood Park (2024)
There were 1039 use of force incidents in the reporting year, double that of last year. What will the Prison Service do to reduce the number?
HMPPS
Implemented
Peterborough (2025)
In November 2024, the men’s prison was re-roled to hold more than 80% remand prisoners, taking them from the Luton and Bedford catchment. What steps is the Prison Service taking to ensure that the prison is resourced in a timely fashion to deal with this significantly changed role that HMP Peterborough has been required to take on?
HMPPS
Implemented
Whitemoor (2020)
Will the minister re-examine the dispersal system under which Whitemoor holds genuinely high-risk and dangerous men alongside those who could be held in less restrictive conditions, where they would be less vulnerable to pressures, could benefit from a wider range of opportunities to progress, and perhaps be located closer to their families?
Ministry of Justice
In Progress
Cardiff (2020)
We applaud the establishment in its efforts to maintain key worker sessions during the restricted regime but would ask that consideration be given to whether the cross-deployment of key workers affected the incidence of self-harm (see paragraph 5.3.1).
Governor / Director
In Progress
Brixton (2020)
as prisons return to a more normal regime, it is made a priority and funding is made available to provide all men in resettlement prisons with an activity that will reduce their risk of reoffending on release.
HMPPS
In Progress
Werrington (2022)
How will you improve relationships between officers and young people so that they are sustained and meaningful?
Governor / Director
Oakwood (2022)
The Board asks that the Director reviews communication in relation to access to education and courses available. The Board also asks that consideration is given for prisoners who share a cell to be given access to a space to undertake coursework.
Governor / Director
Lincoln (2023)
There are ongoing issues with kit collection and distribution. Can sufficient kit items be provided for those arriving in reception, to cover until the first change on the wing? Can an effective system be put in place to ensure the laundry that is sent out from the wings matches that which is returned in both condition and numbers?
Governor / Director
Lewes (2023)
Will the Governor ensure that there are working washing machines and dryers on all wings to enable men to change their clothes regularly, and that men arriving into reception always receive two sets of kit?
Governor / Director
Thameside (2024)
The Board would welcome more robust accountability of processes that continue to affect prisoners’ lives on a day-to-day basis, such as property and the incentives scheme process, as this plays a significant part in reducing prisoner perception of unfairness, causing frustration and sometimes leading to acts of violence or self-harm.
Governor / Director
Noted
Leicester (2024)
Can the Governor develop a revised scheme that is deliverable within the resources available, which is predictable and routine and targets those most in need of attention and support?
Governor / Director
Durham (2024)
How will you ensure that prisoners are offered the minimum kit they are entitled to?
Governor / Director
Usk and Prescoed (2025)
The Board has observed that, due to strategies aimed at reducing overcrowding, the profile of prisoners at HMP Prescoed has changed, and some prisoners now lack sufficient time before release to gain ROTL. Additionally, this situation requires an expanded offering of purposeful activities. What are the specific plans and resources being put in place to address these challenges?
HMPPS
In Progress
Lowdham Grange (2023)
The Board feels that the amendments to the Parole Board rules, which came into force in July 2022, are denying opportunities for prisoners who are seeking transfer to open conditions or moving towards release. The Board would like to see the opinions and recommendations of prison and probation staff being given due consideration when such decisions are made.
Ministry of Justice
Lowdham Grange (2023)
The Board believes there should be a renewed focus and energy on reviewing the sentences of indeterminate sentenced (IPP) prisoners, as this recommendation from the Justice Select Committee was not accepted.
Ministry of Justice
Forest Bank (2023)
What further support can be given to assist the prison in managing the onward movement of prisoners who intentionally disrupt transfers and are not accepted on the normal transport of the receiving establishment?
HMPPS
Isis (2024)
What alternative methods are there for bringing urgent but not emergency issues to the attention of officers?
Governor / Director
Isis (2024)
How will the Minister allocate the necessary resources for this age group in HMP/YOI Isis?
Ministry of Justice
Implemented
Article 2 learning points(4)
— LP 6
I recommend that NOMS checks whether provision and deployment of first aid staff and equipment at Ranby are now at an acceptable level.
NOMS
— LP 2
We ask the Governor of Chelmsford and HMPPS what arrangements are in place to ensure that all prison staff who may be first on scene in a medical emergency are adequately trained to provide immediate care.
The Governor
Accepted
— LP 15
We recommend that HMPPS and HMCTS review and report on their progress in implementing the recommendations on Court Custody made by the Inspectorate in 2015. We recommend specifically that: Automated external defibrillators should be provided in all courthouses, accessible to the custody and court staff, who should be instructed in …
HMPPS and HMCTS
Accepted
— LP 6
We recommend that consideration should be given to locating defibrillators accessible to court custody staff and ensuring that all staff are competent to recognise the circumstances when they should be used and to use them. (It may be practicable to provide defibrillators in conjunction with the courts – see Recommendation …
HMPPS
Accepted
Independent reviews(2)
Harris Review: Deaths in Custody — Rec 83
All Healthcare staff must be trained to the minimum level of the Immediate Life Support Course of the Resuscitation Council with scenarios adapted to suit the prison environment. All prison staff must also be trained to a minimum of basic life support level.
Justice & Legal
Jones: Patronising Disposition Review — Rec 16
It has been submitted to me that the medical evidence presented at the fresh inquests may make a useful contribution to the content of additional training for police officers, prison staff and others whose job can involve the restraint of others – in particular in order to reduce the incidence …
Policing & Security
LGO / SPSO decisions(4)
201203731 — Scottish Prison Service
Mr C, who is a prisoner, was placed on report for refusing to work. He was found guilty of this charge at a disciplinary hearing but complained that the adjudicator would not listen to him and denied him the right to present evidence in his defence. He also said the …
SPSO (Scottish Public Se…
Prisons
Not Upheld
Jul 2013
201303515 — Scottish Prison Service
Mr C, who is a prisoner, complained that the prison did not follow procedures when they downgraded him from less secure conditions to more secure. He also complained about the prison’s handling of his complaint. Prisons are entitled to decide to downgrade a prisoner when evidence is available to suggest …
SPSO (Scottish Public Se…
Prisons
Not Upheld
Jun 2014
201507573 — Scottish Prison Service
Mr C said his complaints about swearing and the use of insulting language by prison staff had not been properly investigated. We found that the steps taken to investigate and respond to the complaints Mr C made were reasonable in the circumstances. There was a lack of evidence to corroborate …
SPSO (Scottish Public Se…
Prisons
Not Upheld
Feb 2017
201105247 — Scottish Prison Service
Mr C, who is a prisoner, was reported for possessing a mobile telephone. He pled guilty at his disciplinary hearing and the adjudicator imposed a punishment. Following this, Mr C submitted a disciplinary appeal form. He said he was appealing on the grounds that he felt protocol was not fully …
SPSO (Scottish Public Se…
Prisons
Not Upheld
Aug 2012