Recurance · prevention of future deaths reports
Pre-inquest brief
Lack of CPR training among carers
The earlier warning
Charles Evans · 25 Aug 2022 · Joanne Lees, Black Country
“None of the Carers employed at Hibiscus House had any training in CPR.”
judiciary.uk/…/charles-evans-prevention-of-future-deaths-report
What was promised
A published response was found, but no specific action could be extracted with a verified quote.
What recurred
- 18 May 2026 · Jake O'Brien · Michael Pemberton · Identical hazard · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Charles Evans · 25 Aug 2022
“None of the Carers employed at Hibiscus House had any training in CPR.”
Later · Jake O'Brien · 18 May 2026
“No ongoing training had been provided to prison officers since initial training on basic life support or first aid, meaning that officers confronted”
What happened next
No web check of the stated actions has been published for this chain.