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recurance

Keith Murphy

25 Mar 2015 · Coroner Simon Wickens · Surrey

A similar concern from this report was raised again 10 times later. See the linked reports.

The coroner's concerns

  1. 1. lack of basic first aid training and CPR training and defibrillator use by Prison Officers and Staff

    “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.”

Linked reports

Raised again laterJohn Williams28 Mar 2017 · 2 years later
Identical hazardConfidence 0.90 · high

This report

“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.”

Later report

“The prison officers did not have even the most basic first aid and cardiopulmonary resuscitation (CPR) training.”
Original on judiciary.uk ↗
Full chain: Lack of basic first aid training and CPR training and defibrillator use by Prison Officers and Staff
Raised again laterMark Doyle18 Dec 2017 · 2 years 9 months later
Identical hazardConfidence 0.90 · high

This report

“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.”

Later report

“(4) There is no mandatory first aid training for existing (as opposed to new) prison officers.”
Original on judiciary.uk ↗
Full chain: Lack of basic first aid training and CPR among prison officers
Raised again laterNicola Lawrence23 Oct 2018 · 3 years 7 months later
Identical hazardConfidence 0.90 · high

This report

“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.”

Later report

“Some Prison staff had not received any cardiopulmonary resuscitation training. Either as part of initial training or any refresher training.”
Original on judiciary.uk ↗
Full chain: Lack of basic first aid training and CPR among prison officers
Raised again laterRyan Trimmer21 Jun 2019 · 4 years 3 months later
Identical hazardConfidence 0.90 · high

This report

“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.”

Later report

“Prison staff are often first responders to medical emergencies of prisoners, but not all have received first aid training.”
Original on judiciary.uk ↗
Full chain: Lack of basic first aid training and CPR among prison officers
Raised again laterLiam Turner5 Feb 2024 · 8 years 10 months later
Identical hazardConfidence 0.90 · high

This report

“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.”

Later report

“It is not mandatory for prison officers to have basic first aid training (which includes the provision of CPR) which is in-date.”
Original on judiciary.uk ↗
Full chain: Lack of basic first aid training and CPR among prison officers
Raised again laterStephen Sleaford14 Oct 2024 · 9 years 7 months later
Closely relatedConfidence 0.90 · high

This report

“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.”

Later report

“Evidence was heard that after April 2024, basic first aid training (including CPR training) has been omitted from the foundation training programme for those training to be prison officers,”
Original on judiciary.uk ↗
Full chain: Lack of basic first aid training and CPR among prison officers
Raised again laterAzroy Dawes-Clarke (3)29 Jul 2025 · 10 years 4 months later
Identical hazardConfidence 0.95 · high

This report

“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.”

Later report

“Officers who were present during Mr [name redacted] cardio-respiratory arrest had different training with regard to first aid and basic life support.”
Original on judiciary.uk ↗
Full chain: Lack of basic first aid training and CPR among prison officers
Raised again laterGareth Chumber-Kelly9 Feb 2026 · 10 years 11 months later
Identical hazardConfidence 0.95 · high

This report

“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.”

Later report

“The Governor of the prison told the court that no refresher CPR training had been provided to prison staff since 2023 notwithstanding the 5 deaths of prisoners by ligature suspension that have occurred since.”
Original on judiciary.uk ↗
Full chain: Lack of basic first aid training and CPR among prison officers
Raised again laterJake O'Brien18 May 2026 · 11 years 2 months later
Closely relatedConfidence 0.90 · high

This report

“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.”

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”
Original on judiciary.uk ↗
Full chain: Lack of basic first aid training and CPR training and defibrillator use by Prison Officers and Staff
Raised again laterGeorge Haldenby21 May 2026 · 11 years 2 months later
Closely relatedConfidence 0.90 · high

This report

“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.”

Later report

“After prison officers and prison staff carry out their induction training which covers basic first aid training including the delivery of cardio pulmonary resuscitation (CPR), there is no further mandatory refresher training on first aid or CPR.”
Original on judiciary.uk ↗
Full chain: Lack of basic first aid training and CPR among prison officers

Responses

2015-0120-Response-by-NOMS.pdf ↗· His Majesty's Prison and Probation Service

Stated action · 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.”
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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