Prison CPR guidance
Flawed CPR guidance in prisons, specifically the inclusion of rigor mortis as an exclusion criterion, leading to missed resuscitation opportunities.
17 items
3 sources
Source spread
Where this theme appears
Prison CPR guidance has been flagged across 3 independent accountability sources:
6 PFD reports
10 PPO recs
1 Article 2 learning point
When the same issue appears across inquiries, coroner reports, and regulators independently, it indicates a recurring issue across the public record.
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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.
PFD Reports (6)
Peter Mackie
Concerns: Inadequate numbers of first aiders and healthcare staff were available across prison sites, compounded by a lack of clear guidance for staff on when and how to commence CPR.
Response (HM Prison and Probation Service): HMP Grendon and Springhill are working to increase the number of trained first aid staff, a new risk assessment will be completed to ensure appropriate levels of staff are identified …
Responded
Noreen Porter
Concerns: Care home staff failed to perform CPR, indicating a complete absence of processes or procedures for emergency resuscitation.
Response (Bupa): Bupa acknowledges that CPR was not carried out when it should have been. Following the incident, Ardenlea Grove Nursing Home has reappraised procedures and processes for life support, and has …
Responded
Darren Adams
Concerns: Nursing staff misdiagnosed post-mortem conditions due to inadequate training in identification, and resuscitation guidance documents contained confusing definitions, risking proper emergency response.
Response (Practice Plus Group): Practice Plus Group has mandated training on the identification of hypostasis and rigor mortis, using scenario-based simulations, and will raise concerns about confusing terminology in existing guidance with NHS England.
Response (Resuscitation Council UK): Resuscitation Council UK acknowledges the concerns but states that detailed training in the recognition of rigor mortis and hypostasis is outside the scope of RCUK training courses, though they encourage …
Responded
Cristofaro Priolo
Concerns: Improper food preparation, unassessed feeding techniques, and inadequate staff training in choking first aid and CPR led to unsafe feeding practices and a failure to recognise and respond to cardiac arrest.
Response (BUPA Care Services): Following the incident, The Highgate Care Home investigated and revisited the investigation, and introduced measures including using smaller cutlery, ensuring residents are sitting upright whilst eating, reviewing menus with Speech …
Responded
Paul Day
Concerns: Prison CPR guidance, particularly the inclusion of rigor mortis as an exclusion, is inappropriate for untrained staff in non-24-hour healthcare facilities, risking missed opportunities for life-saving resuscitation.
Response (HM Prison and Probation Service): HM Prison and Probation Service acknowledges concerns about CPR guidance and will review and revise the guidance regarding rigor mortis as a sign of death, following advice from the Resuscitation …
Responded
James Capstick
Concerns: Persistent concerns about care quality and unreliable patient notes were noted at Westmorland Court. A registered nurse's failure to perform basic life checks and CPR correctly highlighted training deficiencies and lack of defibrillator availability.
Response (NMC): The NMC acknowledges the concerns and states they have passed information to their Employer Link Service and New Referrals team to make enquiries and will investigate concerns within their remit. …
Response (Westmorland Court Care Home): Westmorland Court Care Home states that a number of improvements have taken place since the death, including implementing a Quality Improvement Plan with the ICB and Westmorland and Furness Council. …
Response (CQC): The CQC acknowledges the concerns raised and outlines actions taken following previous notifications, including a targeted inspection. They state that mandating defibrillators in care homes falls outside their remit but …
Responded
PPO Death in Custody Recommendations (10)
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that staff understand the circumstances in which resuscitation is inappropriate in accordance with European Resuscitation Council Guidelines.
The Governor and the Head of Healthcare
The Governor and the Head of Healthcare should ensure that staff are given clear guidance about the circumstances in which resuscitation is inappropriate in line with European Resuscitation Council Guidelines.
The Director of HMP Peterborough and Head of Healthcare
Staff should be given clear guidance about the circumstances in which resuscitation is inappropriate in line with the Resuscitation Council Guidelines.
The Governor of HMP Highpoint
The Governor will wish to consider Highpoint’s local safer custody policy to ensure it reflects Resuscitation Council (UK) guidelines regarding the futility of CPR when there is clear evidence of rigor mortis.
The Head of Healthcare
The Head of Healthcare should ensure that staff, including agency staff, understand when not to perform cardiopulmonary resuscitation in accordance with European Resuscitation Council Guidelines.
The Director and Head of Healthcare of HMP Peterborough
The Director and Head of Healthcare should ensure that all staff are given clear guidance about and understand the circumstances in which resuscitation is inappropriate in line with European Resuscitation Council guidelines.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that staff are given clear guidance about the circumstances in which resuscitation is inappropriate in accordance with European Resuscitation Council Guidelines.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that staff are given clear guidance about the circumstances in which resuscitation is inappropriate in accordance with European Resuscitation Council Guidelines.
The Governor
The Governor should ensure that all staff are given clear guidance about and understand the circumstances in which resuscitation is inappropriate in line with European Resuscitation Council guidelines.
The Governor of HMP Leyhill
The Governor should ensure that all staff are aware of the location of defibrillators and that they understand how to access and use them during a medical emergency.