Recurance · prevention of future deaths reports
Pre-inquest brief
The earlier warning
Keith Murphy · 25 Mar 2015 · Simon Wickens, Surrey
“Action is required to ensure that Prison Officers and Staff with direct access to prisoners have basic first aid training, CPR training and familiarisation with the use of a defibrillator.”
judiciary.uk/prevention-of-future-death-reports/keith-murphy
What was promised
Stated action 1 · response to Keith Murphy (25 Mar 2015) · stated timescale: as soon as they return to duty
“all but two of the CMs at the prison have been trained, and those two members of staff will be provided with training as soon as they return to duty. HMP Coldingley also uses a monthly closedown of the prisoner regime to provide opportunities for training for the wider staff group and this includes instruction on CPR and on the use of defibrillators.”
Stated action 2 · response to Nicola Lawrence (23 Oct 2018) · stated timescale: none stated
“The Governor at HMP New Hall has reviewed the band/grade and number of staff who need to be trained in first aid, and the number of such staff required on duty at times throughout the day. The prison currently has 40 staff trained in FAW and 48 in EFAW, and these numbers are considered to be sufficient to ensure that an appropriate response can be provided in any emergency situation that may arise at any time.”
judiciary.uk/…/2018-0318-Response-by-HM-Prison-Probation-Servic…
Stated action 3 · response to Ryan Trimmer (21 Jun 2019) · stated timescale: none stated
“The Governors of each prison are required to ensure that there are sufficient numbers of staff trained in first aid on duty, and at HMP Lewes at least two trained nurses and one trained member of prison staff are available at all times. Two on-site first aid trainers will be delivering first aid training to staff as part of the prison's monthly training provision, and a one-day refresher course will be introduced to ensure that training levels are maintained. Custodial Managers (the most senior”
judiciary.uk/…/2019-0215-Response-by-HM-Prison-and-Probabtion-S…
5 further stated actions are listed on the full chain page.
What recurred
- 20 Jul 2015 · Luke Myers · Andre Rebello
- 28 Mar 2017 · John Williams · ME Hassell
- 18 Dec 2017 · Mark Doyle · Heather Williams · Identical hazard · confidence 0.90 (high)
- 23 Oct 2018 · Nicola Lawrence · Jonathan Leach · Identical hazard · confidence 0.90 (high)
- 21 Jun 2019 · Ryan Trimmer · James Healy-Pratt · Identical hazard · confidence 0.95 (high)
- 5 Feb 2024 · Liam Turner · Zak Golombeck · Identical hazard · confidence 0.90 (high)
- 11 Jun 2024 · Daniel Beckford · Priya Malhotra
- 14 Oct 2024 · Stephen Sleaford · I M Cartwright · Identical hazard · confidence 0.90 (high)
- 29 Jul 2025 · Azroy Dawes-Clarke (3) · Ian Brownhill · Identical hazard · confidence 0.95 (high)
- 9 Feb 2026 · Gareth Chumber-Kelly · Jonathan Stevens · Identical hazard · confidence 0.95 (high)
- 21 May 2026 · George Haldenby · Rachael Griffin · Closely related · confidence 0.92 (high)
The clearest link, quoted from both reports:
Earlier · Mark Doyle · 18 Dec 2017
“(4) There is no mandatory first aid training for existing (as opposed to new) prison officers.”
Later · Ryan Trimmer · 21 Jun 2019
“Prison staff are often first responders to medical emergencies of prisoners, but not all have received first aid training.”
What happened next
No evidence found either way · stated action 1
“NSC First Aid, CPR & AED training builds the knowledge, skills and confidence employees need to respond effectively to workplace medical and cardiac”
First Aid, CPR and AED Courses · nsc.org/…/fa-cpr-aed
“Heartsaver First Aid CPR AED teaches participants how to give first aid, perform cardiopulmonary resuscitation, and use an automated external defibrillator”
Heartsaver First Aid CPR AED Training · cpr.heart.org/…/heartsaver-first-aid-cpr-aed-training
“This course is for recertification as well as certification for our new staff who have not yet been through a CPR or First Aid training course.”
Guilford County Sheriff's Office deputies learn CPR · facebook.com/…/1288526569983441
No evidence found does not mean the action did not happen.
No evidence found either way · stated action 2
“Heartsaver First Aid CPR AED Training for Corrections Officers”
Heartsaver First Aid CPR AED Training for Corrections Officers · attentivesafety.com/corrections-officers.html
No evidence found does not mean the action did not happen.
No evidence found either way · stated action 3
“Mental Health First Aid (MHFA) for Corrections Professionals equips staff with the knowledge and skills to identify, understand and respond to mental health and substance use challenges in their peers”
Mental Health First Aid for Corrections Professionals 2026-09-30 · nicic.gov/…/mental-health-first-aid-corrections-professionals-3
No evidence found does not mean the action did not happen.
No evidence found either way · stated action: “Following evidence heard at the inquest, you have raised some concerns regarding the first aid training for staff, particularly in relation to the use of CPR. Thank you for bringing your concern to my attention. As you are aware, the HMPPS First Aid Policy Framework was re-issued nationally in August 2023. The revised policy highlights the training requirements for Emergency First Aid and First Aid in prisons, including the importance of Governors ensuring that there is an appropriate number of”
The promised action regarding first aid training was not confirmed to have been completed by August 2023.
No evidence found does not mean the action did not happen.
No evidence found either way · stated action: “attention. The HMPPS First Aid Policy Framework was re-issued nationally in August 2023. The revised policy highlights the training requirements for Emergency First Aid and First Aid in prisons, including the importance of Governors ensuring that there is an appropriate number of trained staff on duty at all times. To achieve this, a detailed local first aid risk assessment must be produced to determine the number of First Aiders at Work (FAW) and Emergency First Aiders at work (EFAW) required at an”
“The new BS 8599-1:2019+A1:2026 workplace first aid kits standard came into force on 30 April 2026”
Workplace First Aid 2026: Are You Compliant? | Garland Training · chrisgarlandtraining.co.uk/hse-first-aid-requirements-2026-uk
“Workplace first aid is evolving-and employers need to be ready”
Workplace First Aid Has Changed. Are You Ready? · safetyequipment.org/…/workplace-first-aid-has-changed-are-you-r…
No evidence found does not mean the action did not happen.
No evidence found either way · stated action: “HMPPS are currently undertaking a cell design review which is looking at all aspects of cell design, including furniture and fittings, to ensure it takes account of developments in how prisoners are accommodated and improvements in what is currently available on the market. As part of this review, we will explore the possibility of using different materials which meet the stringent fire safety requirements and can also function as anti-ligature for bedding. The review is expected to conclude at”
“The ambition of the 18 month 'Cell Furniture' project was to engage with HMPPS staff and prisoners via co-creation processes to improve safety, functionality, robustness and sustainability of prison furniture that was often destroyed - what prisoners term "flat packed"1”
Made in Prison – Understanding knowledge exchange, co ... · ualresearchonline.arts.ac.uk/…/2021_Gamman%20and%20Caulfield_Ma…
“His Majesty's Prison and Probation Service | Headquarters at [102 Petty France](https://en.wikipedia.org/wiki/102_Petty_France "102 Petty France"), London | | [Executive Agency”
HM Prison and Probation Service - Wikipedia · en.wikipedia.org/wiki/HM_Prison_and_Probation_Service
No evidence found does not mean the action did not happen.