Emergency responder equipment training
Lack of adequate training for emergency responders on the circumstances and importance of using issued recording equipment.
227 items
14 sources
13 inquiries
Source spread
Where this theme appears
Emergency responder equipment training has been flagged across 14 independent accountability sources:
47 inquiry recs
113 PFD reports
7 committee recs
4 CQC actions
10 HMICFRS recs
3 ICIBI recs
2 PPO recs
22 IOPC recs
7 IMB recs
2 Scottish FAIs
1 Article 2 learning point
1 detention investigation rec
6 PHSO decisions
2 LGO/SPSO decisions
When the same issue appears across inquiries, coroner reports, and regulators independently, it indicates a recurring issue across the public record.
Browse by source
Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.
Inquiry Recommendations (47)
COVID-M3.3 — Fit-Testing Preparedness
Recommendation: The UK government, Scottish Government, Welsh Government and Northern Ireland Executive should work with employers, including health boards and trusts, to review the availability of qualified fit testers and take steps to increase the number of fit testers accordingly. Availability …
Gov response: No formal response published by this government.
Unknown
P1-34 — Equip fire services with smoke hoods
Recommendation: All fire and rescue services be equipped with smoke hoods to assist in the evacuation of occupants through smoke-filled exit routes.
Gov response: The government accepted in principle all the Phase 1 recommendations directed at central government. The Housing Secretary Robert Jenrick presented the formal response to Parliament on 21 January 2020, committing to swift and decisive action …
Accepted
P1-26 — Equipment for BA communication in high-rise buildings
Recommendation: The LFB urgently take steps to obtain equipment that enables firefighters wearing helmets and breathing apparatus to communicate with the bridgehead effectively, including when operating in high-rise buildings.
Gov response: The government accepted in principle all the Phase 1 recommendations directed at central government. The Housing Secretary Robert Jenrick presented the formal response to Parliament on 21 January 2020, committing to swift and decisive action …
Accepted
JB-15.17 — Police medic training on catastrophic haemorrhage
Recommendation: Police medic training should emphasise that, in cases of catastrophic external torso haemorrhage, the immediate action is to apply direct pressure and then progress directly to using haemostatic gauze. Chest seals should only be used where there is no evidence …
Gov response: MPS formally responded on 28 October 2022 (paras 32-34). Senior First Aid Advisor Sue Warner reviewed training September 2021; confirmed no gap. Specific scenario on upper chest/neck catastrophic bleed now included in training.
Accepted
COVID-M2.7 — Statutory Child Rights Impact Assessments
Recommendation: The UK government should introduce legislation to place child rights impact assessments on a statutory footing in England. The Northern Ireland Executive should consider an equivalent provision.
Gov response: No formal response published by this government.
Response Unclear
COVID-M1.8 — Triennial Parliamentary Resilience Reports
Recommendation: The governments of the UK, Scotland, Wales and Northern Ireland should each produce and publish reports to their respective legislatures at least every three years on whole-system civil emergency preparedness and resilience. The reports should include as a minimum: the …
Gov response: No formal response published by this government.
Accepted in Part
In progress
MAI-165 — Ten Second Triage training for frontline staff
Recommendation: The team led by Philip Cowburn has devised a tool that is designed for use by a wide range of emergency responders in a mass casualty situation. It is known as Ten Second Triage. The National Ambulance Resilience Unit, the …
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
In progress
MAI-154 — Training on use of recording equipment
Recommendation: The Home Office, the College of Policing, the National Ambulance Resilience Unit and the Fire Service College should ensure that training is given to all who are issued with such equipment, on the circumstances in which it should be used …
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
In progress
MAI-153 — Use recording equipment during exercises
Recommendation: The Home Office, the College of Policing, the National Ambulance Resilience Unit and the Fire Service College should ensure that, in the course of exercises, such equipment is used by those who would use it in the circumstances of a …
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
In progress
SP8 — Ambulance staff training exercise funding
Recommendation: NHS England should review funding, and consider providing additional resources, to enable all emergency response ambulance staff to participate in appropriate training exercises.
Response Pending
LADB-88 — Ensure unrestricted availability of all standard emergency equipment on passenger trains.
Recommendation: The availability on trains carrying passengers of the items of emergency equipment mentioned in the standard on emergency and safety equipment should be unrestricted (para 14.74).
Unknown
LADB-82 — Test integrating emergency hammers into passenger alarm system for controlled release.
Recommendation: Tests should be carried out into the practicability of building emergency hammers into the passenger alarm system so that they could be released only after an alarm has been activated (para 14.50).
Unknown
P2-38 — Provide water supply system training to all firefighters
Recommendation: That basic training on the structure and operation of the water supply system, including the different types of hydrants in use and their functions, be given to all firefighters. Training should also be given on effective measures to increase water …
Gov response: The National Fire Chiefs Council (NFCC) accepts this recommendation on behalf of all fire and rescue services. NFCC has reviewed the national operational guidance and is surveying fire and rescue services to establish what additional …
Accepted
In progress
P2-37 — Train firefighters on communications loss response
Recommendation: Since radio communications are inherently unreliable in certain environments, we recommend that firefighters be trained to respond appropriately to the loss of communications and to understand how to restore them. (113.61)
Gov response: The National Fire Chiefs Council (NFCC) accepts this recommendation on behalf of all fire and rescue services. NFCC has reviewed the content of national operational guidance and is surveying fire and rescue services to establish …
Accepted
In progress
P1-27 — Command support system operational on all units
Recommendation: Urgent steps be taken to ensure that the command support system is fully operative on all command units and that crews are trained in its use.
Gov response: The government accepted in principle all the Phase 1 recommendations directed at central government. The Housing Secretary Robert Jenrick presented the formal response to Parliament on 21 January 2020, committing to swift and decisive action …
Accepted
P1-7 — Equip fire services to receive electronic plans
Recommendation: All fire and rescue services be equipped to receive and store electronic plans and to make them available to incident commanders and control room managers.
Gov response: The government accepted in principle all the Phase 1 recommendations directed at central government. The Housing Secretary Robert Jenrick presented the formal response to Parliament on 21 January 2020, committing to swift and decisive action …
Accepted
SP10 — Police-ambulance terminology interoperability
Recommendation: Merseyside Police and North West Ambulance Service should review the terminology used in their systems and procedures to ensure shared understanding and interoperability. The College of Policing and the National Ambulance Resilience Unit should undertake a national review to ensure …
Response Pending
FENN-31 — Review LFB protective clothing provision, especially gloves, for personnel
Recommendation: The London Fire Brigade shall review the provision of protective clothing for its personnel, and in particular gloves, in the light of the injuries sustained by fire-fighters at King's Cross.
Unknown
FENN-20 — Produce and maintain up-to-date station plans in LFB-agreed locations
Recommendation: In agreement with the London Fire Brigade, London Underground shall produce and maintain up-to-date station plans, and place them in boxes it has provided, at locations agreed or specified by the London Fire Brigade.
Unknown
FENN-19 — Ensure water gas fire extinguishers are safe near electrical equipment
Recommendation: Water gas fire extinguishers shall be made safe to use in the vicinity of electrical equipment.
Unknown
FENN-15 — Modify London Underground fire equipment to London Fire Brigade standards
Recommendation: London Underground fire equipment shall be modified to London Fire Brigade standards and the amount and type of fire equipment in stations agreed.
Unknown
P2-39 — Establish water undertaker communication protocols
Recommendation: That all fire and rescue services establish and periodically review an agreed protocol with the statutory water undertakers in their areas to enable effective communication between them in relation to the supply of water for firefighting purposes. (113.63)
Gov response: The National Fire Chiefs Council (NFCC) accepts this recommendation on behalf of all fire and rescue services. NFCC and fire service lead officers for water are discussing with water undertakers how to strengthen existing arrangements …
Accepted
P2-36 — Provide firefighters with digital radios
Recommendation: That all fire and rescue services give consideration to providing all firefighters with digital radios. (113.60)
Gov response: The National Fire Chiefs Council (NFCC) accepts this recommendation on behalf of all fire and rescue services. See recommendation 35.
Accepted
In progress
P2-35 — Consider higher power radios for breathing apparatus
Recommendation: That fire and rescue services that continue to use low power intrinsically safe radios as part of breathing apparatus consider reserving them only for situations in which there is a real risk of igniting flammable gases and generally using radios …
Gov response: The National Fire Chiefs Council (NFCC) accepts this recommendation on behalf of all fire and rescue services. NFCC is surveying fire and rescue services to understand what arrangements are currently in place at a local …
Accepted
In progress
CR15 — Joint training exercises plan
Recommendation: HM Coastguard should develop and implement a plan for joint training exercises, to occur at set intervals, with participation by those involved in maritime search and rescue in the English Channel and elsewhere.
Response Pending
CR10 — Equipment and techniques development
Recommendation: HM Coastguard must continue to liaise with search and rescue partners in the UK and abroad to identify opportunities for the development or deployment of equipment and techniques to assist in search and rescue operations.
Response Pending
JB-15.26 — Alternative to life hammer for window entry during armed operations
Recommendation: Consideration should be given by the MPS, Home Office and the NPCC to finding a more suitable solution for smashing windows during the course of an armed operation, so that an officer who is holding a firearm does not need …
Gov response: MPS formally responded on 28 October 2022 (para 39). MPS firearms no longer use glass hammer. Each officer issued extendable X-ball device; each team issued longer device for use at distance.
Accepted
No update 2+ yrs
MAI-116 — Consider freeze-dried plasma for HART operatives
Recommendation: The Department of Health and Social Care, the Faculty of Pre-Hospital Care, the College of Paramedics and the National Ambulance Resilience Unit should consider whether all Hazardous Area Response Team operatives should be deployed with freeze-dried plasma and trained in …
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
In progress
MAI-91 — Review analgesia deployment for firearms officers
Recommendation: The College of Policing and Counter Terrorism Policing Headquarters should review whether firearms officers should be deployed with analgesia and trained in its use, as part of providing Care Under Fire.
Gov response: The Security Industry Authority (SIA) published a formal statement on 17 June 2021 in response to Volume 1 of the Manchester Arena Inquiry. The SIA committed to collaborating with the private security industry, law enforcement, …
Accepted
In progress
MAI-49 — Review analgesia rollout to HART operatives
Recommendation: If the decision is that the regulatory regime should be altered in this way, the National Ambulance Resilience Unit should consider urgently whether the use of such analgesia should be rolled out to all Hazardous Area Response Team and other …
Gov response: The Security Industry Authority (SIA) published a formal statement on 17 June 2021 in response to Volume 1 of the Manchester Arena Inquiry. The SIA committed to collaborating with the private security industry, law enforcement, …
Accepted
In progress
TAYL-F21 — Provide trained personnel and cutting equipment for immediate perimeter fence removal
Recommendation: Suitable and sufficient cutting equipment should be provided by the club at each ground where there are perimeter fences to permit the immediate removal of enough fencing to release numbers of spectators if necessary. Agreement should be reached as to …
Unknown
POPP-A.3 — Home Office to develop more suitable personal radios for police
Recommendation: Early attention should be given by the Home Office Directorate of Telecommunications to consider the practicality of producing a more suitable personal radio for the police.
Unknown
TAYL-I43 — Local authorities to specify ambulance numbers for large crowd matches
Recommendation: The number of ambulances to be in attendance for matches where larger crowds are expected should be specified by the local authority after consultation with the ambulance service and should be made a requirement of the Safety Certificate.
Unknown
TAYL-I42 — Mandate one fully equipped ambulance at matches with over 5,000 spectators
Recommendation: At least one fully equipped ambulance from the appropriate ambulance authority should be in attendance at all matches with an expected crowd of 5,000 or more.
Unknown
TAYL-I41 — Require clubs to employ trained medical practitioners at all matches
Recommendation: The club should employ a medical practitioner to be present at each match and available to deal with any medical exigency at the ground. He should be trained and competent in advanced first aid. He should be present at the …
Unknown
TAYL-I40 — Local authorities to specify first aid rooms and equipment for stadium safety certificates
Recommendation: There should be at each stadium one or more first aid rooms. The number of such rooms and the equipment to be maintained within them should be specified by the local authority after taking professional medical advice and should be …
Unknown
TAYL-I39 — Require clubs to provide one trained first aider per 1,000 spectators
Recommendation: There should be at each stadium at each match at least one trained first aider per 1,000 spectators. The club should have the responsibility for securing such attendance.
Unknown
CR1 — Network flexing risk mitigation
Recommendation: Given the risks associated with HM Coastguard's use of network flexing for small boat search and rescue – whereby its workforce is split between different geographical locations – HM Coastguard must ensure the effectiveness of measures in mitigating them (including …
Response Pending
AG-9 — Maximum Continuous Duty Period for AFOs
Recommendation: The National Police Chiefs' Council (NPCC) and the College of Policing should jointly decide, in the light of independent expert advice, whether there should be a maximum period of time during which authorised firearms officers (AFOs) are permitted to remain …
Gov response: 37. Following discussions with NPCC and the College of Policing, the Government understands that current guidance does not specify a time limit and that there would be significant operational implications of doing so. There are, …
Accepted
No update 2+ yrs
BAHA-14 — Communicating Sight Deprivation Reasons
Recommendation: JDP 1-10 should include guidance that where practicable CPErS should be told the reason why sight deprivation is being applied. Suitable simple phrases in relation to sight deprivation should be included in mission specific language training.
Gov response: Accepted. Guidance on communicating with CPErS about sight deprivation has been added, including language training requirements.
Accepted
LADB-41 — Utilise simulators for effective signaller training in emergency situations
Recommendation: The use of simulators in providing fully effective training of signallers in dealing with emergencies is endorsed (para 12.15).
Unknown
LADB-38 — Provide signallers with emergency stop options and regular situational briefings on use
Recommendation: The instructions for signallers should provide a set of options, including the use of the CSR (where it is available) either to send an emergency stop message to a particular train or a general stop message. This range of options …
Unknown
AG-7 — Recording of Firearms Operations
Recommendation: During post incident proceedings following a police shooting, NPCC should consider the advantages of: Recordings of the communications of firearms commanders and authorised firearms officers (AFOs); And video recordings from the body-worn video cameras of AFOs and police vehicles involved …
Gov response: 31. The Government understands that body worn video (BWV) is now a requirement for all Armed Response Vehicle officers. Specialist Firearms Officers use BWV when deployed overtly. NPCC have issued guidance to encourage the use …
Accepted
No update 2+ yrs
AG-4 — North West Armed Policing SOP Amendment
Recommendation: The North West Armed Policing Standard Operating Procedure on Weapons and Ammunition should be amended so that it only permits the use of new specialist munitions that have been approved in accordance with the Code of Practice for Armed Policing …
Gov response: 20. The use of CS dispersal canisters by GMP during Operation Shire was a focus of concern for the Inquiry. The CS dispersal canisters had not been through the approval process that includes the identification …
Accepted
14 — Prohibit handcuffing behind back while seated
Recommendation: The Home Office and contractors operating immigration removal centres must ensure that all staff are aware that the technique of handcuffing detained people with their hands behind their back while seated is not permitted, given its association with positional asphyxia.
Gov response: The government has communicated to all IRC and contracted service provider staff that the technique of handcuffing behind backs whilst seated is not permitted.
Accepted
LADB-13 — Endorse adoption of defensive driving teaching and practice by TOCs
Recommendation: The adoption by TOCs of the teaching and practice of defensive driving is endorsed (para 9.39).
Unknown
AG-3 — Code of Practice on New Weapons Approval
Recommendation: The Home Secretary should ensure that the new Code of Practice on Police use of Firearms and Less Lethal Weapons contains an express prohibition on the use of a new weapon system by the police service until the approval process …
Gov response: 16. The Government accepts this recommendation. On 14 January 2020, the Home Secretary approved the revised Code of Practice for Armed Policing and Less Lethal Weapons (LLW). The Code has now been published on The …
Accepted
PFD Reports (113) — showing 50 strongest matches
Edna Wiggett
Concerns: Ambulance dispatch was delayed due to a failure to re-triage and re-classify a patient's case after receiving updated information about increased pain.
Response (East of England Ambulance NHS Trust): • An article was published in the Emergency Operations Centre (EOC) Patient Safety and Experience Newsletter to remind staff to re-triage these types of call. • This will also be …
Responded
Lucy Hannah Rose Bailey
Concerns: Concerns were raised regarding the adherence to or adequacy of guidelines for managing dystocia, which was identified as a known hazard.
Response (South Central Ambulance Service): The South Central Ambulance Service has updated its clinical practice guidance on the management of shoulder dystocia, incorporating advice from specialists in obstetrics and midwifery, and issued it to Medical …
Responded
Jessica Ashton-Pyatt
Concerns: The emergency response was uncoordinated, lacked consultant leadership, and critical equipment like the defibrillator was uncharged with missing pads, compromising immediate patient care.
Overdue
Millie Elizabeth Thompson
Concerns: Nursery staff lacked sufficient and updated paediatric first aid training. Ambulance call-takers misinterpreted breathing, causing incorrect triage, and emergency vehicles were inadequately equipped with paediatric life-saving kits.
Response (Edward Timpson MP): The Department for Education acknowledges the concern about paediatric first aid training and states that it is a statutory requirement for early years providers. They are consulting on reinforcing the …
Response (North West Ambulance Service NHS Trust): NWAS describes its recruitment and training processes for Emergency Medical Dispatchers (EMDs), including a six-week training course and continuing education requirements. All EMDs are required to undergo CPR recertification every …
Response (Department of Health): The Department of Health acknowledges the concerns, notes that training of nursery staff is the DfE's responsibility and NWAS is responsible for selection/training of call takers. They report that NWAS …
Responded
Derek Brierley
Concerns: The suprapubic procedure was performed by a consultant after a long hiatus with inadequate preparation, likely incorrect insertion, and a lack of Trust guidelines for competence and training.
Response (The Pennine Acute Hospitals NHS Trust): The hospital has re-drafted the pathway for managing urinary retention, shared it with A&E staff, initiated a training program for inserting catheters outside of the urology division, and will continue …
Overdue
Albert James Hand
Concerns: The coroner reported concerns about a patient with a head injury waiting over an hour and a half for transport to hospital, insufficient ambulance crews in the Luton and Bedfordshire area, and protocols for dealing with emergency calls potentially putting patients at risk.
Response (East of England Ambulance Service NHS Trust): The East of England Ambulance Service NHS Trust has reviewed its Demand Management Plan, commenced issuing a clinical manual to staff, and is commissioning an upgrade to the Computer Aided …
Responded
Paul Rogerson
Concerns: River safety equipment is inadequate, poorly maintained, and lacks proper warning signs. Gaps exist in police river rescue training, inter-agency communication, and hypothermia first aid, compounded by insufficient equipment checks.
Overdue
Barry James Lewis
Concerns: Critical deficiencies exist in the emergency department, including inadequate availability and consistency of emergency airway equipment, insufficient backup instruments, poor out-of-hours theatre access, and inadequate night staffing.
Response (The Pennine Acute Hospitals NHS Trust): The hospital updated emergency airway packs in A&E, ensuring availability of 'large' instruments. The role of night nurse practitioners was reviewed to ensure involvement in direct care of critically ill …
Responded
Christopher Williams
Concerns: A critical defibrillator failed due to lack of daily checks and no cross-check system. The hospital also lacked a policy for managing sudden or unexpected deaths.
Overdue
Caroline Pilkington
Concerns: North West Ambulance Service staff lack control and restraint training, forcing reliance on police who are not clinically trained, leading to delayed patient care and inappropriate diversion of police resources.
Response (Greater Manchester Police): Greater Manchester Police expresses concern about the increasing demand on police due to gaps in health services, emphasises that officers are trained in restraint but that medical emergencies require different …
Response (North West Ambulance Service NHS Trust): NWAS acknowledges the coroner's concerns but maintains that ambulance staff are not trained nor expected to restrain patients who are acting in a threatening or violent manner, as advanced control …
Response (Department of Health): The Department of Health acknowledges the coroner's concerns but supports the NWAS's collaborative approach with the police in handling patients requiring advanced control and restraint.
Response (Department of Health2): The Department of Health acknowledges the coroner's concerns about NWAS training, but supports the NWAS position that ambulance staff are sufficiently trained and that more advanced restraint training is not …
Responded
Stephen Bedford
Concerns: Ambulance staff training and assessment for life support standards are inconsistent, leading to inappropriate crew deployment for critical patients and inadequate communication of crew capabilities.
Overdue
Desiree Falvo
Concerns: A&E departments lack sufficient clinicians skilled in emergency surgical tracheotomy, indicating inadequate training and cover for critical airway management procedures.
Response (NHS England): NHS England highlights existing training for A&E staff in emergency airway procedures and a review of Emergency Departments. They have agreed that major trauma units have consultants on site 24/7 …
Responded
Joanne Oliver
Concerns: A severe lack of national guidance for critical patient transfer decisions results in insufficient risk assessment protocols covering patient fitness, staff seniority, journey logistics, and post-transfer care.
Overdue
Elizabeth Cooper
Concerns: No specific safety concerns were detailed in the report text, only a general statutory duty to report matters of concern.
Overdue
June Rose
Concerns: A lack of training on the correct dosage and morphine equivalent of fentanyl patches led to an erroneous prescription, contributing to the patient's death through respiratory depression.
Overdue
Hywel Hughes
Concerns: Police training on positional asphyxia is inadequate, and vehicle designs hinder monitoring detainees. The SIA also fails to review restraint-related deaths by door supervisors.
Response (North Wales Police): North Wales Police amended their training materials on positional asphyxia to include snoring as a symptom and added an exercise to demonstrate the dangers of medical emergencies. They also designed …
Overdue
Stephen Amer
Concerns: Concerns relate to the adequacy of support for sole carers, comprehensive mental health risk assessment, and the balance between patient wishes and the broader family's well-being, particularly for those under significant stress.
Response (Hertfordshire County Council): Hertfordshire County Council will develop and introduce a consent form by 20 October 2014 to allow patient information to be shared with social care services. The department has issued a …
Responded
Richard Barker, Ryan Bramwell and Robert Graham
Concerns: Road safety was compromised by vehicles having 'better' tyres on the front, which contributed to aquaplaning. Additionally, police officers were unaware of their statutory power to close roads for safety reasons.
Overdue
Anthony Offord
Concerns: Emergency medical dispatch staff lacked training on respiratory distress signs. Protocols were absent for ambulance crew "stand-offs," considering alternative support, or managing ambulance availability during meal breaks.
Response (Yorkshire Ambulance Service NHs Trust): Yorkshire Ambulance Service reviewed training for EMD staff, clarified management involvement in 'stand off' decisions, and reinforced consideration of alternative support methods. They are also reviewing the meal break policy …
Overdue
Grant Benson and Gordon Davidson
Concerns: Ambulance control failed to accurately locate a severe incident due to inaccurate GPS and a call handler's lack of local knowledge. Inadequate cross-boundary systems prevented effective call transfer or dispatch of a nearby ambulance, causing critical delays.
Response (Fire Rescue Service): County Durham and Darlington Fire and Rescue Service introduced a new mobilising and communications system in December 2014 and reviewed call handling procedures for adjoining emergency services, updating contact information …
Response (North East Ambulance Service NHS Trust): North East Ambulance Service has reviewed processes and systems for cross-border incidents, passed information to the training department to review call handling procedures and clarified the circumstances under which mutual …
Responded
Cameron Laing
Concerns: Soldiers lacked critical understanding of trailer braking systems and safe extraction methods, leading to a fatal accident. The Ministry of Defence irrationally refused to teach alternative maneuvers not in official publications.
Response (Ministry of Defence): The Ministry of Defence improved the training package for DROPS operators qualified to tow the KINGS trailer, supported by a video detailing coupling and uncoupling procedures. The Army will include …
Responded
Barbara Harrison
Concerns: Inappropriate physiotherapy contributed to surgical complications, and critical equipment failed during emergency surgery due to flat batteries, leading to a 'panic situation'. Family members were also distressed by public disclosure of a cardiac arrest.
Overdue
Stephen O’Malley
Concerns: Rescue was delayed due to the standby diver being unable to locate a critical harness c-clip, as pre-dive protocol checks do not include verifying its accessibility.
Response (Sub C Pre Dive Checklist): The response appears to be a pre-dive checklist form.
Response (Sub C): SubC Partner refers to Danish authority findings, states it performs pre-dive checks according to standards and customer approval, and uses certified personnel.
Responded
Steven Jackson
Concerns: A paramedic failed to effectively use the sepsis screening tool, indicating a need for better training for ambulance staff on its use and appropriate patient conveyance to hospital.
Overdue
Eitvydas Zdanys
Concerns: Police officers responding to a road traffic incident lacked basic life support training, rendering them unable to assess or resuscitate a seriously injured motorcyclist.
Response (E Zdanys): The officers involved will shortly receive training on when and how to administer CPR, and all officers will be reminded during their annual refresher training of when it is necessary …
Responded
James Barrett
Concerns: Ineffective missing persons searches were hampered by reliance on volunteer mapping systems rather than a police stand-alone system, and the lack of tracking devices for searchers.
Response (James BARRETT): Hampshire Constabulary has submitted a business case for the purchase of a MAPYEX system. Procurement Services has been requested to provide information to identify a timeline for purchase, training requirements …
Overdue
Philmore Mills
Concerns: Police training for subjects with suspected excited delirium lacks instruction on containment tactics and fails to inform officers that restraint take-down procedures can carry a risk of death, only focusing on minor injuries.
Response (Philmore Mills): The College of Policing will add specific reference to 'containment' to the ABD/PA chapter of the National Personal Safety Manual and clarify that, in certain circumstances, prone restraint carries a …
Overdue
Carl Thompson
Concerns: Life-saving equipment used by lifeguards was defective or missing, including a defibrillator without batteries, causing significant resuscitation delays. There were also concerns about lifeguard training and information provided to holidaymakers.
Overdue
Doreen Mattinson
Concerns: Oxygen was incorrectly administered at a care home, with staff failing to recognise appropriate emergency oxygen levels and positioning. The clinical manager, a registered nurse, lacked training in oxygen administration.
Overdue
Mia Gibson
Concerns: Over-reliance on maternal observations in obstetric emergencies overlooked fetal risk, and ambulance dispatch suffered from poor meal break management and resource shortages. This led to critical delays in emergency response and hospital transfer.
Overdue
Christopher Sears
Concerns: Bus drivers transporting students are not required to have Basic Life Support training or emergency protocols, and BLS is not routinely taught in secondary education.
Response (Department for Education): The DfE intends to consult on a revised version of guidance on school transport in the autumn and will consider whether they should further clarify the description of the training …
Response (Department for Transport): The DfT will reinforce the importance of basic life support training for drivers through targeted communications and social media, and raise the profile of the issue with bus industry and …
Responded
Stephen Hunt
Concerns: Fire and Rescue Services lacked adequate measures for managing heat stress in hot environments, had poor communication protocols, and insufficient training/SOPs for incident role handover, hazard recording, and thermal imaging camera use.
Response (Devon Somerset Fire Rescue Service): DSFRS provides responses to the coroner's questions, but does not describe any specific actions taken or planned by their own service.
Response (Hunt): The Ministry of Justice acknowledges the coroner's concerns regarding legal aid funding but states that funding decisions are made independently and there are no plans to change the current scheme.
Responded
Sydney Neil
Concerns: After a patient collapsed in a GP surgery, there was inadequate ventilation, no suction, and no oxygen provided for 8 minutes, raising concerns about resuscitation expertise and equipment in GP practices.
Response (Wychall Lane Surgery): Following a SUDIC case discussion, the practice incorporated continuous oxygen saturation readings during nebulisation into their acute asthma management protocol and implemented outcomes from a serious case review into their …
Response (NHS England): NHS England acknowledges the concern regarding suction equipment and oxygen at the GP surgery, and highlights ongoing work to improve asthma management in primary care by communicating updated guidelines to …
Response (Birmingham South Central Clinical Commissioning Group): The CCG reviewed guidance on basic equipment requirements for GP practices, including CPR training and equipment such as AEDs and oxygen, and will ensure practices adhere to this guidance via …
Responded
Rosemarie Dees
Concerns: An undetected foreign body airway obstruction could inhibit the use of a supraglottic airway, suggesting laryngoscopy should be a prerequisite for SGA insertion.
Overdue
Ajvir Sandhu
Concerns: Safety concerns include the lack of mandatory parachutes with static lines in certain aircraft and insufficient mandatory spin recovery training on specific light aircraft types for pilots.
Overdue
Rex Hall
Concerns: Paramedic foundation training was deficient in ECG interpretation and recognising atypical myocardial infarction symptoms, leading to missed diagnoses of serious cardiac conditions.
Response (HCPC): The HCPC raised the threshold level of entry to the Register to degree level for paramedics, due to consultation feedback and the need for degree level education and training to …
Responded
Najeeb Katende
Concerns: There were failures to actively cross-check for shockable rhythms and to routinely use defibrillators in AED mode during cardiac arrest incidents, highlighting a need for improved staff training.
Overdue
Russell Sherwood
Concerns: The Fire Service departed a dangerous flood scene without closing the road or leaving warning signs, as their protocols and equipment do not permit road closures, relying solely on other authorities.
Response (South Wales Fire and Rescue Services): The recommendations are being considered as part of its overarching response to the Fire Rescue Services (Emergencies)(Wales)(Amendment) Order 2017, with the outcome of the review reported by the Service's Senior …
Responded
Darren Powney
Concerns: Emergency ambulance staff showed confusion and lack of awareness regarding critical dynamic risk assessment protocols, including a 2016 policy. There was no bespoke policy for a frequent caller, and escalation procedures for confusion were insufficiently rapid.
Response (North East Ambulance Service NHS Trust): The Ambulance Service has disseminated a briefing and memorandum to staff specifying procedures for warning markers on properties, is rolling out THRIVE training to Emergency Operations Centre staff, has provided …
Responded
George French-Russell
Concerns: Inadequate information sharing and unstructured communication between EMAS and hospital staff, combined with paramedics lacking experience and support for complex obstetric emergencies, compromised patient care.
Response (East Midlands Ambulance Service NHS Trust): EMAS has shared a revised handover tool with network partners and plans to implement it across its footprint in May 2018, subject to governance approval; is working to promote the …
Response (Department of Health): The Department of Health references existing NICE guidance and a forthcoming guideline on intrapartum care for high-risk women. It also describes the role of the Healthcare Safety Investigation Branch (HSIB) …
Response (HSIB): HSIB acknowledges receipt of the coroner's concerns but states that the case occurred before their operational start date and therefore does not meet their criteria for investigation. They will use …
Overdue
Bryan Allsop
Concerns: Pilot licensing does not mandate instruction and testing in partial engine power loss scenarios for light aircraft, despite this being a common and challenging factor in crashes.
Overdue
Charles Rashan
Concerns: Police training should emphasize recognizing that struggling to resist arrest can be a struggle to breathe or silent choking, and highlight the need to manage public intervention.
Response (Metropolitan Police Service): The MPS has recommended changes to the Personal Safety Manual, Module 12 'Management of Persons Suspected of Concealing Items in Mouth', now requiring that where possible the subjects head should …
Responded
Jack Riding
Concerns: There were significant delays in defibrillator deployment and ambulance access due to equipment placement, lack of staff direction, and insufficient emergency training, coupled with inadequate medical emergency risk assessments.
Response: The Football Association requests a copy of the Independent Consultant review of Goals Soccer Centre Plc's health and safety processes to inform a substantive response. Goals Soccer Centres Plc plan …
Overdue
Suleyman Yalcin
Concerns: Insufficient refresher training in emergency response driving, police under-resourcing, and inadequate terminology for communicating urgency posed risks during critical incidents.
Response (Metropolitan Police Service): The Metropolitan Police Service provides refresher driver training every three to five years. They will remind staff to clarify the urgency of requests and this will be incorporated in Met …
Response (Metropolitan Police2): The Metropolitan Police Service highlights that all MPS officers now undertake refresher training every 3 to 5 years. The Command and Control Centre (MetCC) has informed all call handlers to …
Responded
Christopher Moss
Concerns: Concerns exist regarding the availability of appropriate equipment, specifically a hooligan bar, for dealing with cell door barricade incidents in prisons, potentially delaying emergency access to inmates.
Overdue
Jeremy Sutch
Concerns: Medical evacuation was severely delayed by crew unfamiliarity with a wheelchair extraction stretcher, its incompatibility with ship equipment, and lack of evacuation drills, posing a risk for future survivable injuries.
Response (Vantage Drilling Company): Vantage Drilling Company updated its HSE Manual to include reference to different stretcher types. They also added 'Drill Medivac Chair Type Stretcher' to the Emergency Response Drill Matrix, requiring drills …
Overdue
John Scott
Concerns: No specific concerns text was provided for summarization.
Response (NHS England): NHS Pathways is undertaking a detailed review to determine whether additional discriminators can be used over the phone to enhance the triage process, including utilizing risk factors and specific questions …
Response (South East Coast Ambulance Service NHS Trust): South East Coast Ambulance Service has discussed the coroner's concerns with NHS Pathways, who are reviewing care instructions and considering amendments to the Pathways script for inclusion in version 18 …
Responded
Wayne Rodgers
Concerns: Ambulance services are overstretched, and major event safety planning is insufficient. Deficiencies include lack of on-site medical provision, inadequate crisis management, and unclear safety equipment requirements and racing abandonment criteria.
Response (Cowes Week Limited): Cowes Week Limited is discussing additional ambulance support, reviewing AED placement, reinforcing the necessity of having a sharp knife on board, and reviewing criteria for abandoning racing. The organisation will …
Overdue
Mark Kubiak
Concerns: The patient transfer checklist failed to require essential oxygen supply checks and tug tests. This systemic flaw meant oxygen flow failure went unnoticed during transfer, risking patient safety.
Overdue
David Dooley
Concerns: Police officers' lack of knowledge regarding seafront lifeline locations caused critical delays, and public awareness of sea dangers, particularly under the influence, is insufficient.
Response (Sussex Police): Police CCTV operators will now scan for water safety equipment as part of the initial response where someone has entered the water. Sussex Police will be supporting the summer 'Keeping …
Responded
Committee Recommendations (7)
#24 — Include provisions in Draft Bill for mandatory life-saving training and bandage kits for staff.
Recommendation: The Home Office should include a provision in the Draft Bill to provide mandatory life-saving training to staff to the premises captured by the Bill. The Home Office should also consider providing for mandatory bandage kits on those premises.
No Published Response
#16 — Front-line medical personnel experience poor availability and inadequate shelf life of inventory.
Recommendation: Despite the broader success of the LCST contract, since it began the needs of front- line medical personnel have not been well served. In particular, units have faced poor availability of medical inventory and been supplied with items without sufficient …
Gov response: 5.1 The government agrees with the Committee’s recommendation. Target implementation date: January 2025 5.2 There has been notable transformational change injected into the LCST contract over recent years including a £13.2 million uplift in staff …
Accepted
#5 — Set out how MoD's future inventory management will properly address medical personnel requirements
Recommendation: The MoD failed to consider the needs of its medical operations in outsourcing commodity procurement to Team Leidos and this has created significant risks for front-line personnel. Since the LCST contract began, the inventory needs of front-line medical personnel have …
Gov response: The government agrees with the Committee’s recommendation. recent years including a £13.2 million uplift in staff employed inside the Delivery Partner (Team Leidos) together with additional staff established into key areas of UK Strategic Command. …
Accepted
#26 — ESN programme no longer expects to provide apps essential for key emergency service benefits.
Recommendation: Despite these concerns, all three emergency services did still see a continuing case for ESN. For example, the fire service said that there could be benefits from being able to share drone footage of incidents by ESN providing a common …
Gov response: 5.1 The government agrees with the Committee’s recommendation. Target implementation date: March 2024 5.2 The government agrees with the need to ensure there are clear responsibilities and plans in place for operating ESN when it …
Not Addressed
#18 — MoD's medical supply contract incentives improved project numbers but performance remains below required levels.
Recommendation: The MoD explained that the incentives for the LCST contract were intended to prioritise efficiency, but that medical supplies are a difficult area in which to achieve efficiencies. From 2019, the MoD changed the contract’s incentivisation by taking back a …
Gov response: 5.1 The government agrees with the Committee’s recommendation. Target implementation date: January 2025 5.2 There has been notable transformational change injected into the LCST contract over recent years including a £13.2 million uplift in staff …
Accepted
#17 — General contract targets masked poor medical inventory performance; shelf-life issue now addressed.
Recommendation: This issue arose because the contract applied a general target across all commodity supply.38 However, this meant that lower performance in supplying medical inventory (which generally requires higher performance than other commodities) was masked by better performance elsewhere. In addition, …
Gov response: 5.1 The government agrees with the Committee’s recommendation. Target implementation date: January 2025 5.2 There has been notable transformational change injected into the LCST contract over recent years including a £13.2 million uplift in staff …
Accepted
#23 — Immediate medical assistance from venue staff is crucial after a terrorist attack.
Recommendation: The way in which first responders intervene after a terrorist attack could be the difference between life and death. Those working at the venues or premises captured Terrorism (Protection of Premises) draft Bill 29 by the Draft Bill will most …
No Published Response
CQC Inspection Actions (4)
Sydenham House
Ensure there is an effective system in place for the provision and monitoring of emergency medicines and equipment, in the event of a medical emergency.
Should Do
Oak Tree Manor
Staff knowledge in relation to evacuation in the event of a fire needed to be improved.
Should Do
DMC Church View Practice
Review medical equipment and ensure spare defibrillator pads are available.
Should Do
BMI Southend Private Hospital
The provider should ensure that equipment monitoring and checks are undertaken as required by service policy.
Should Do
HMICFRS Recommendations (10)
FRS 2018-19 CoC Recommendations: London Fire Brigade
Cause of concern: The Brigade has a significant backlog of training for staff in risk-critical skills such as incident command and emergency fire engine driving. Some staff haven’t had continuing training in these skills for many years. There is no …
Recommendation
FRS 2018-19 CoC Recommendations: Cornwall Fire and Rescue Service
Cause of concern: We have serious concerns about Cornwall FRS’s response to incidents. The service consistently doesn’t meet target response times for fires, especially in remote areas served by on-call stations. It is sometimes slow to update mobile data terminals …
Recommendation
FRS 2018-19 CoC Recommendations: Cornwall Fire and Rescue Service
Cause of concern: We have serious concerns about Cornwall FRS’s response to incidents. The service consistently doesn’t meet target response times for fires, especially in remote areas served by on-call stations. It is sometimes slow to update mobile data terminals …
Recommendation
FRS 2018-19 CoC Recommendations: Cornwall Fire and Rescue Service
Cause of concern: We have serious concerns about Cornwall FRS’s response to incidents. The service consistently doesn’t meet target response times for fires, especially in remote areas served by on-call stations. It is sometimes slow to update mobile data terminals …
Recommendation
FRS 2023-25 CoC Recommendations: Avon Fire and Rescue Service
Cause of concern: The service still doesn’t have an effective system to make sure it gathers and records relevant and up-to-date risk information to help protect firefighters, the public and property during an emergency. We found examples of the risk …
Recommendation
FRS 2023-25 CoC Recommendations: Avon Fire and Rescue Service
Cause of concern: The service still doesn’t have an effective system to make sure it gathers and records relevant and up-to-date risk information to help protect firefighters, the public and property during an emergency. We found examples of the risk …
Recommendation
FRS 2023-25 CoC Recommendations: Avon Fire and Rescue Service
Cause of concern: The service still doesn’t have an effective system to make sure it gathers and records relevant and up-to-date risk information to help protect firefighters, the public and property during an emergency. We found examples of the risk …
Recommendation
FRS 2023-25 CoC Recommendations: Avon Fire and Rescue Service
Cause of concern: The service still doesn’t have an effective system to make sure it gathers and records relevant and up-to-date risk information to help protect firefighters, the public and property during an emergency. We found examples of the risk …
Recommendation
FRS 2023-25 CoC Recommendations: Avon Fire and Rescue Service
Cause of concern: The service still doesn’t have an effective system to make sure it gathers and records relevant and up-to-date risk information to help protect firefighters, the public and property during an emergency. We found examples of the risk …
Recommendation
FRS 2023-25 CoC Recommendations: Avon Fire and Rescue Service
Cause of concern: The service still doesn’t have an effective system to make sure it gathers and records relevant and up-to-date risk information to help protect firefighters, the public and property during an emergency. We found examples of the risk …
Recommendation
ICIBI Immigration Recommendations (3)
An inspection of Border Force practice and procedures in relation to firearms …
Conduct a firearms training needs analysis and review of existing national training provision to define the mandatory attendance requirements and to ensure that the quality and availability of training delivery …
An inspection of Border Force operations at south coast seaports
Accelerate the publication of guidance from the consultation on the use of Personal Protective Equipment (PPE). 4.10. Accepted. 4.11. Body armour is only one element of the control measures that …
An inspection of Border Force practice and procedures in relation to firearms …
Introduce a process to record the issue and expiry date of body armour and ensure that body armour is fit for purpose.
PPO Death in Custody Recommendations (2)
The Head of Healthcare
The Head of Healthcare should ensure that nurses respond to emergency code blue incidents with the relevant emergency equipment, including a defibrillator.
The Head of Healthcare
The Head of Healthcare should ensure that all healthcare staff understand their role in an emergency response, including recognising and managing seizures or loss of consciousness in line with current clinical guidelines, and recording actions taken. A local protocol, in …
IOPC Learning Recommendations (22)
Fatal collision following pursuit - Metropolitan Police Service, February 2019
The IOPC recommends that the National Police Chiefs’ Council shares the learning from this investigation with relevant force leads, asking them to ensure that, if any of their fleet vehicles contain life hammers: Their officers understand how and where on …
Fatal collision following pursuit - Metropolitan Police Service, February 2019
The IOPC recommends that the Metropolitan Police Service ensures that: Its officers understand how and where on a vehicle life hammers should be used, and where alternative methods may be more effective.It has a system for making sure that life …
National recommendations and recommendations made to the Metropolitan Police Service and West …
The IOPC recommends that: The National Police Air Service (NPAS) develops guidance for emergency services call handlers on NPAS helicopter capabilities, making it clear that NPAS helicopters do not have a rescue capability. This guidance should also: On the night …
Road traffic collision following police pursuit – Metropolitan Police Service, November 2019
The IOPC recommends that an update should be sent as soon as possible, to all Metropolitan Police Service vehicle users to advise of the new potential fault within the Cleartone system, whereby the internal battery fails. This should indicate the …
Man died after an attempt to take his own life during a …
The IOPC recommends that all Police forces should consider equipping all operational police vehicles with some form of implement that would be capable of cutting a ligature of a width greater than a few millimetres. Training should also be given …
Man died after an attempt to take his own life during a …
The IOPC recommends that South Wales Police should consider equipping all operational police vehicles with some form of implement that would be capable of cutting a ligature of a width greater than a few millimetres. Training should also be given …
Recommendation - Metropolitan Police Service, December 2025
The IOPC recommends that the Metropolitan Police Service (MPS) should include relevant content on the MPS intranet around the Joint Emergency Services Interoperability Principles (JESIP), promoting the value of JESIP to recruits and providing links to the relevant material. This …
Police officer injured in collision - North Wales Police, February 2017
Any such guidance and/or policy on the modification to convert lights will be based on formalised research and analysis of any proposed method. Do you accept the recommendation? Yes
Police officer injured in collision - North Wales Police, February 2017
The National Police Chiefs' Council should introduce national guidance and/or policy concerning any potential modifications to convert lights installed on unmarked police vehicles. Do you accept the recommendation? Yes
Recommendation - West Mercia Police, March 2020
The IOPC recommends that West Mercia Police revises its risk assessment to consider the availability and distribution of water kits, including whether they may be carried in response vehicles. As a result of reviewing a DSI investigation it became apparent …
Traffic pursuit prior to man's death - Metropolitan Police Service, December 2020
The IOPC recommends that the Metropolitan Police Service ensures all information regarding an officer’s driving authorisation level is accurately documented in each officer's driving permit, and both the officer and their line manager ensure this information is kept up to …
Traffic pursuit prior to man's death - Metropolitan Police Service, December 2020
The IOPC recommends that the Metropolitan Police Service make amendments to policy to more clearly define the training required in order for an officer to be authorised to engage in initial phase pursuits. The investigation identified a lack of clarity …
Woman carrying a knife shot by armed officers – Merseyside Police, July …
The IOPC recommends that Merseyside Police reviews the settings on the body worn video (BWV) cameras used by armed officers and considers whether the pre-record functionality, as used in some other forces, should be switched on.This follows an investigation into …
Police pursuit before road traffic incident - Cheshire Constabulary, November 2020
The IOPC recommends that Cheshire Constabulary ensures all Roads and Crime Unit vehicles are equipped with defibrillators. If the fleet is expanded further, the IOPC recommends that all relevant equipment is obtained and fitted or placed into the vehicle before …
Recommendation - City of London Police
There is national APP guidance that states that drunk and incapable individuals are in need of medical assistance in hospital and officers should call an ambulance immediately. The IOPC recommends that the City of London Police take steps to satisfy …
Recommendation - Metropolitan Police Service, May 2018
The Police and Driver - Vehicles and Equipment Standard operating procedure (SOP) states where vehicles are fitted with in-car recording equipment, the driver of the police vehicle “must ensure this equipment is working correctly and all cameras are visible through …
Man dies following contact with police - June 2017, Metropolitan Police Service
The College of Policing should seek expert advice to determine the medical implications of using incapacitant spray when a subject is suspected of having an item in their mouth (that may lead to an obstruction to their airway). The College …
Recommendation - Northumbria Police, November 2020
The IOPC recommends that Northumbria Police review its policy in relation to the provision and fitting of dash-cams to response vehicles as soon as possible. Do you accept the recommendation? Yes
Police response to locate a missing man – Northamptonshire Police, October 2021
The IOPC recommends that Northamptonshire Police should revise its Force Control Room (FCR) training to include content on responding to incidents on major roads. This should include how to input and record locations of incidents reported on fast roads, including …
Recommendation - College of Policing, October 2024
The IOPC recommends that the College of Policing (CoP) consider amending Roads Policing Authorised Professional Practice (APP) to include the dangers associated with driving in convoy during emergency response, particularly when negotiating junctions and to recommend a safe distance between …
National recommendation - National Police Chiefs' Council, November 2020
The IOPC recommends that the National Police Chiefs' Council (NPCC) should issue national guidance that provides clarity to officers about the carrying and use of multi tools when on duty. Do you accept the recommendation? Yes
Recommendation - Greater Manchester Police, December 2020
The IOPC recommends that the National Police Chiefs' Council lead for Armed Policing takes steps to ensure that should the Tactical Firearms Commander (TFC) or Operational Firearms Commander (OFC) identify that an officer’s exposure to information or intelligence that is …
IMB Recommendations (7)
North East Midlands, Yorkshire & Humber STHF (2025)
In the light of delays in ambulance and paramedic attendance following an incident at Swinderby RSTHF, we recommend the use of ‘what3words’ or other precision location tools to aid navigation to places of detention and that lists of such places with the location details be readily available to paramedic crews. This is relevant not just for places such as Swinderby …
NHS / Healthcare Provider
North East Midlands, Yorkshire & Humber STHF (2025)
The IMB would like to have reassurance that centre protocols are to be revised to ensure that explicit procedures are in place to enable healthcare professionals (both internal staff and external paramedics) to attend health emergency incidents as quickly as possible – including the allocation of fast escort staff to facilitate this and the use of locational tools such as …
Other
Charter Flight (2020)
A supply of compression socks must be available on the plane and offered to returnees under the guidance of the paramedics (see paragraph 5.1.1, first bullet).
Other
Wealstun (2021)
Ensure that once approval is given to resume training, refresher training in use of PAVA and rigid-bar handcuffs is given priority (repeat area from 2019/202 report) (para 4.5.6 refers).
Governor / Director
Oakwood (2021)
The Director to review the condition and numbers of body worn cameras, to ensure that a reliable body worn camera is available to all relevant staff (see section 4.5).
Governor / Director
Grendon (2021)
Restrictions due to Covid-19 and project work notwithstanding, the Board looks forward to: the delivery of timely training for ACCTs, and control and restraint (see 4.2.4 and 4.4.2)
Governor / Director
Swaleside (2025)
In our 2023-2024 annual report, we stated that the situation with body worn video cameras (BWVCs) needs to rectified, so that all staff can be issued with cameras. The prison response was there are enough BWVCs for operational staff, but the Board believes non-operational staff need to have the opportunity when they come into contact with prisoners. Again, we ask …
HMPPS
Scottish Fatal Accident Inquiries (2)
Paul Alliston; Martin Johnstone; Christopher Morrison
The MCA is encouraged to pursue its proposal to the International Maritime Organisation that all new abandonment (solid fill) lifejackets should have a minimum 150 Newtons buoyancy, that their testing regime be more robust and realistic and that they be fitted as standard with a retention device and sprayhood. All relevant supervisory bodies should monitor carefully the compliance by the …
Mar 2022
Workplace
3 recs
Scotland
John Wilson
I recommend that crew members of single person operated fishing vessels wear Personal Locator Beacons and Personal Floatation Devices at all times whilst the vessel is at sea.
Mar 2024
Workplace
1 rec
Scotland
PHSO Casework Decisions (6)
P-003628 — North East Ambulance Service NHS Foundation Trust
Miss J complains about the Trust’s handling of calls about her father after he collapsed and a delay in starting CPR.
NHS in England
Partly Upheld
Jun 2025
P-004167 — Yorkshire Ambulance Service NHS Trust
Mr N complains that an ambulance crew failed to recognise that his father's oxygen supply had stopped when they were with him in a hospital's emergency department. He believes they should have taken more action.
NHS in England
Oct 2025
P-003108 — North West Ambulance Service NHS Trust
Miss R complains it took the Trust 11 minutes to start CPR when her sister had suffered from a pulmonary embolism.
NHS in England
Partly Upheld
Nov 2024
P-003542 — George Eliot Hospital NHS Trust
Mr and Mrs G complain that in October 2023, staff at the Trust prescribed incorrect antibiotic medication to their son after a pre-treated deep cut to his thigh becoming swollen. Mr and Mrs G also say the doctor told them it would be acceptable for their son to travel abroad …
NHS in England
May 2025
P-003653 — Shrewsbury and Telford Hospital NHS Trust
Mrs B complains about the care and treatment provided to her late niece, Miss F, on 15 and 16 February 2023 when treating her in the ED and when transferring her to another hospital.
NHS in England
Upheld
Jun 2025
P-002726 — South Central Ambulance Service NHS Foundation Trust
Mrs P complains about the care provided to her son when he was unresponsive in April 2022.
NHS in England
Jun 2024
LGO / SPSO Decisions (2)
201302648 — Scottish Ambulance Service
When Mrs Cs husband (Mr C) was taken to hospital by ambulance, the crew could not get the ambulance doors open, and there was a delay getting him to the hospital. Mr C passed away the following month and Mrs C then complained that the Scottish Ambulance Service (the service) …
SPSO (Scottish Public Se…
Health
Upheld
Mar 2014
PSOW-202305260 — Welsh Ambulance Services NHS Trust
Mrs B complained that the Welsh Ambulance Services NHS Trust had failed to respond to a complaint she had made to it in November 2022. The Ombudsman found that the Trust had failed to respond to Mrs B complaint or to regularly provide her with updates during its investigation. The …
PSOW (Public Services Om…
Health
Oct 2023