Caden Stewart

“Physical Education Instructors were unaware of the existence of PSI 58/2011 and the requirements within”

“There was a lack of communication between officers such that the physical education instructors did not inform the escort that [the deceased] needed to see healthcare, the escort did not inform the wing officer in charge that [the deceased] felt unwell and needed to see healthcare, none of the officers responsible for checking [the deceased]'s welfare during patrol state were aware that he had reported feeling unwell and was waiting to see healthcare”

“The wing officer in charge did not check whether [the deceased] had been seen by healthcare at any stage over the following hours nor did he inform his successor on handover that [the deceased] was waiting to see healthcare and had not been seen”