Nicholas Gedge
11 Mar 2025 · Coroner Oliver Longstaff · West Yorkshire East
The coroner's concerns
1. lack of shared understanding of CPR urgency
“there did not appear to be any shared understanding between the three people in the cell with [the deceased] of the urgency of starting CPR on an unresponsive person”
2. absence of defined roles
“the Detention Officers and the nurse not appearing to have defined roles which they understood and undertook”
3. missing protocols for role definition
“It was not clear whether there were any protocols in place to define the respective roles of detention staff and medical staff attending a medical emergency in a cell”