“After prison officers and prison staff carry out their induction training which covers…”

The coroner’s concerns

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. During the evidence, a Custodial Manager at HMP the Verne stated that the last time he had first aid or CPR training was in 1991, 35 years ago, when he started as a prison officer. Whilst there is a requirement to have a duty first aider on site 24 hours a day, without all staff being suitably and regularly trained in signs of collapse and administering CPR, there could be a delay in delivering effective CPR as it may take time for the duty first aider to get to the prisoner, and a future death could occur. In prisons without 24 hour healthcare provision, if a prisoner receives treatment at a hospital and is issued with a medication prescription on a FP10 form, this cannot be processed at the prison in the absence of a doctor or prescribing nurse, and pharmacies in hospitals are not always open 24 hours a day for it to be dispensed as TTO medication. This means there will be a delay in prisoners receiving necessary and lifesaving medication over a weekend or bank holiday period until staff are in the prison who can action the prescription. Whilst at HMP The Verne there is now a duty Doctor who can be called upon out of hours to progress such prescriptions, there is a lack of local policy or process to ensure the prison and healthcare staff have an understanding of how to deal with the situation should a FP10 be issued outside of hours when a prescribing health professional is not available in the prison to ensure a prisoner receives necessary medications without delay. Although critical medications are held at the prison in a locked cabinet, not all medication are included and Furosemide, which was critical in George’s care, is one of those that is not held by the prison as a critical medicine. 10. COPIES AND PUBLICATION OF THIS REPORT I have a duty to send a copy of my report to every Interested Person who in my opinion should receive it. I also may send a copy of the report to any other person who I believe may find it useful or of interest. I can confirm I have sent the report to: 1. George’s family 2. Practice Plus Group 3. Dorset County Hospital 4. NHS England 5. Prison and Probation Ombudsman 6. Governor of HMP Guys Marsh 7. Governor of HMP Portland I also have a duty to send a copy of the report to the Chief Coroner. You may make representations to me, the coroner, about the publication of the contents of this report in line with Chief Coroner’s PFD Publication Policy (2026). Any representations will be sent to the Chief Coroner alongside the report. Please refer to box 4 above for additional information relating to the publication of reports and responses. SIGNATURE

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, 2026-0312

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