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recurance

Darren McGuin

26 Jun 2019 · Coroner Sarah Slater · South Yorkshire (East)

This report repeats 1 earlier warning, and was raised again 2 times later. See the linked reports.

The coroner's concerns

  1. 1. delay in CPR commencement

    “There was clearly a delay between Mr [name redacted] being found unresponsive by the prison officers and the commencement of CPR by members of the healthcare staff”
  2. 2. lack of basic life support training among prison officers

    “Prison officers will usually be first on scene, particularly if a prisoner is found in their cell and this lack of basic life support training is leading to a delay in the commencement of CPR”

Linked reports

Repeats an earlier warningDerrick Rose-Fowler21 Apr 2016 · 3 years 2 months earlier
Closely relatedConfidence 0.90 · high

Earlier report

“Although on the facts of this case it made no difference to the outcome, the first prison officer on the scene was not first aid trained.”
Original on judiciary.uk ↗

This report

“There was clearly a delay between Mr [name redacted] being found unresponsive by the prison officers and the commencement of CPR by members of the healthcare staff.”
Full chain: Lack of basic life support training among prison officers
Raised again laterStephen Sleaford14 Oct 2024 · 5 years 4 months later
Closely relatedConfidence 0.90 · high

This report

“Prison officers will usually be first on scene, particularly if a prisoner is found in their cell and this lack of basic life support training is leading to a delay in the commencement of CPR.”

Later report

“Evidence was heard that the majority of those prison officers who had commenced in their roles prior to 2018 had no first aid/basic life-saving skills and no ability/training in undertaking cardiopulmonary resuscitation ('CPR').”
Original on judiciary.uk ↗
Full chain: Lack of basic life support training among prison officers
Raised again laterJake O'Brien18 May 2026 · 6 years 11 months later
Identical hazardConfidence 0.92 · high

This report

“Prison officers will usually be first on scene, particularly if a prisoner is found in their cell and this lack of basic life support training is leading to a delay in the commencement of CPR.”

Later report

“No ongoing training had been provided to prison officers since initial training on basic life support or first aid, meaning that officers confronted with discovery of a ligature situation were unable to provide immediate and basic life support due to a lack of confidence and unfamiliarity of what to do in a situation when every second can count in promoting the chances of an optimal recovery.”
Original on judiciary.uk ↗
Full chain: Lack of basic life support training among prison officers

Responses

No published response was found on judiciary.uk.

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person. Methodology and responsible use · Report an error