“From the point when the Detention Officer first entered Nicholas’ cell to when CPR was…”

The coroner’s concerns

- From the point when the Detention Officer first entered Nicholas’ cell to when CPR was commenced, 8 minutes and 12 seconds elapsed without CPR being given. Within that timeframe, two Detention Officers and a nurse were present in the cell after 75 seconds had passed. On the evidence, there did not appear to be any shared understanding between the three people in the cell with Nicholas of the urgency of starting CPR on an unresponsive person. There did not appear to be a co-ordinated approach to assisting Nicholas, with the Detention Officers and the nurse not appearing to have defined roles which they understood and undertook. 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. The passage of time before CPR was commenced gives rise to a concern either that the importance of early CPR was not appreciated, or that the communication between detention and medical staff did not facilitate its prompt commencement.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2025-0148

Added to Minute Book

8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0