16 Apr 2026 Adam Ankers · Prevention of Future Deaths report West London
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Concerns raised 1
Difficulty among lay people and ambulance call handlers in recognising signs of agonal breathing or cardiac arrest View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Association of Ambulance Chief Executives Department of Health and Social Care NHS England Resuscitation Council UK South Central Ambulance Service NHS Foundation Trust St John Ambulance The Football Association
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 20
Association of Ambulance Chief Executives
Support national initiatives that increase cardiac-arrest recognition, CPR education and first-aid training.
View source
Association of Ambulance Chief Executives
Support Restart a Heart and related public cardiac-arrest awareness and CPR-education initiatives.
View source
Association of Ambulance Chief Executives
Encourage and support Community First Responders across the ambulance sector to provide early CPR and defibrillation.
View source
NHS England
Use a breathing-rate threshold to support recognition of agonal breathing in NHS Pathways triage.
View source
NHS England
Presume cardiac arrest in NHS Pathways when a person collapses and becomes unconscious during exercise or sport, including when fitting is reported.
View source
NHS England
Work with MPDS and NHS Pathways coding sub-groups to consider further measures supporting recognition of agonal breathing or cardiac arrest.
View source
St John Ambulance
Train CPR participants to recognise agonal breathing and commence CPR when a person is unresponsive and not breathing normally.
View source
St John Ambulance
Incorporate updated national guidance into training so CPR is commenced immediately when someone collapses during exercise and is unresponsive.
View source
South Central Ambulance Service NHS Foundation Trust
Strengthen emergency call-taker training with audible agonal-breathing examples, listening-skills guidance and clinical-escalation emphasis.
View source
South Central Ambulance Service NHS Foundation Trust
Trial the Pre-Sieve Questions Project to reduce pre-sieve questioning and accelerate Nature of Call selection.
View source
South Central Ambulance Service NHS Foundation Trust
Replace the computer-aided dispatch system and use the pilot outcome to inform its pre-sieve question set.
View source
South Central Ambulance Service NHS Foundation Trust
Review another ambulance service’s video-assisted resuscitation guidance pilot to assess whether implementation would benefit local telephone triage.
View source
NHS England
Use a less-than-one-breath-per-ten-seconds threshold in NHS Pathways to support recognition of agonal breathing.
View source
NHS England
Presume collapse with unconsciousness during exercise or sport, including reported fitting, to be cardiac arrest regardless of apparent regular breathing.
View source
NHS England
Work with MPDS and NHS Pathways coding sub-groups to consider further measures helping the public recognise agonal breathing or cardiac arrest.
View source
The Football Association
Revise SCA, first-aid and defibrillator training content to incorporate current guidance, case learning and clearer emergency-response instructions.
View source
The Football Association
Require tutors to reinforce key SCA-response messages and show abnormal-breathing videos at every face-to-face course.
View source
Resuscitation Council UK
Publish simplified guidance directing people to suspect cardiac arrest when an unresponsive person has abnormal breathing.
View source
Resuscitation Council UK
Work with NHS England through NHS Pathways to support standardised dispatch algorithms and telephone-assisted CPR instructions.
View source
Resuscitation Council UK
Strengthen public education campaigns, including an annual Restart a Heart focus on recognising and raising awareness of agonal breathing.
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AI-generated summary
Adam Ankers · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Adam Ankers suffered a cardiac arrest while playing grassroots football on 31 January 2024 due to a previously unidentified inherited cardiac condition, and died in hospital on 4 February 2024 following brain stem death. Agonal breathing and cardiac arrest were not recognised at the pitch or by the 999 call handler, and an AED was brought to the pitch but not used. The report identified concerns about recognition of agonal breathing and cardiac arrest, access to and use of defibrillators, dissemination of sudden cardiac arrest training, cardiac screening, and cascade communication of inherited disease information.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Difficulty among lay people and ambulance call handlers in recognising signs of agonal breathing or cardiac arrest
Wider context from the report “POINT A: That there is difficulty in lay people (trained or not) including ambulance call handlers in understanding the signs of agonal breathing or cardiac arrest
” Source location Adam Ankers · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Support national initiatives that increase cardiac-arrest recognition, CPR education and first-aid training.
Verbatim wording from the response “We fully support other national initiatives and there are a wealth of national programmes seeking to increase recognition of cardiac arrest, early CPR and defibrillation use. Ambulance services are active in delivering such training to the public. AACE’s out-of-hospital cardiac arrest programme is key in supporting such initiatives including mandating CPR training in schools and the introduction of first aid training for driving tests. We also support Restart a Heart (RSAH) and RSAH Live: annual initiatives led by Resuscitation Council UK (RCUK) and Save a Life Scotland which aim to increase the number of people surviving out-of-hospital cardiac arrests by improving cardiac arrest awareness and CPR education.” Source location Response from Association of Ambulance Chief Executives
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Support Restart a Heart and related public cardiac-arrest awareness and CPR-education initiatives.
Verbatim wording from the response “We fully support other national initiatives and there are a wealth of national programmes seeking to increase recognition of cardiac arrest, early CPR and defibrillation use. Ambulance services are active in delivering such training to the public. AACE’s out-of-hospital cardiac arrest programme is key in supporting such initiatives including mandating CPR training in schools and the introduction of first aid training for driving tests. We also support Restart a Heart (RSAH) and RSAH Live: annual initiatives led by Resuscitation Council UK (RCUK) and Save a Life Scotland which aim to increase the number of people surviving out-of-hospital cardiac arrests by improving cardiac arrest awareness and CPR education.” Source location Response from Association of Ambulance Chief Executives
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Encourage and support Community First Responders across the ambulance sector to provide early CPR and defibrillation.
Verbatim wording from the response “Bystander CPR rates across the English ambulance services continues to be high (>75%) and defibrillator use is improving with the highest recorded use to date in 2024 (2025 data not yet available). To support timely access to CPR and defibrillators, we encourage and support the use of Community First Responders (CFRs) across the ambulance sector. These volunteers are trained in CPR and carry with them defibrillators and respond to 999 calls including cardiac arrests. Often, they can be tasked and arrive before the ambulance and can help in the early recognition of cardiac arrest” Source location Response from Association of Ambulance Chief Executives
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use a breathing-rate threshold to support recognition of agonal breathing in NHS Pathways triage.
Verbatim wording from the response “• A breathing rate of less than one breath every 10 seconds is used as a measure of inadequate breathing as this is a more identifiable and objective marker in remote telephony triage than clinical descriptions of agonal breathing for assessment between a non-clinical health advisor and a member of the public. NHS Pathways introduced this measure in 2020 to support the identification of agonal breathing which was agreed in conjunction with the Resuscitation Council UK.” Source location Response from NHS England 2
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Presume cardiac arrest in NHS Pathways when a person collapses and becomes unconscious during exercise or sport, including when fitting is reported.
Verbatim wording from the response “Additional measures have also been taken following learning from this case. In January 2025, NHS Pathways updated the triage so now anyone who collapses and becomes unconscious during exercise or sport, including those reported to be fitting,” Source location Response from NHS England 2
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with MPDS and NHS Pathways coding sub-groups to consider further measures supporting recognition of agonal breathing or cardiac arrest.
Verbatim wording from the response “NHS England will work with the MPDS and NHS Pathways coding sub-groups to consider whether further measures should be taken to help members of the public recognise the signs of agonal breathing or cardiac arrest.” Source location Response from NHS England 2
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Train CPR participants to recognise agonal breathing and commence CPR when a person is unresponsive and not breathing normally.
Verbatim wording from the response “Part of the training for all undertaking CPR is about agonal breathing. We train people to commence CPR if someone is unresponsive and not breathing normally. Recent changes to national guidance are being brought into training, which is the change that if someone collapses during exercise and is unresponsive CPR commenced immediately.” Source location Response from St John Ambulance
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Incorporate updated national guidance into training so CPR is commenced immediately when someone collapses during exercise and is unresponsive.
Verbatim wording from the response “Part of the training for all undertaking CPR is about agonal breathing. We train people to commence CPR if someone is unresponsive and not breathing normally. Recent changes to national guidance are being brought into training, which is the change that if someone collapses during exercise and is unresponsive CPR commenced immediately.” Source location Response from St John Ambulance
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Strengthen emergency call-taker training with audible agonal-breathing examples, listening-skills guidance and clinical-escalation emphasis.
Verbatim wording from the response “In response to the learning from the inquest hearing into Adam’s death and the concerns that you have raised, the Trust has strengthened the core training currently provided to our ECTs, in addition to the mandated NHS Pathways training. Additional audible examples of different types of agonal (abnormal) breathing that may be displayed have now been included as it was recognised that in this case, Adam’s presentation of agonal breathing was atypical. The importance of using effective listening skills and seeking clinical advice when there is uncertainty has also been emphasised within our core training.” Source location Response from South Central Ambulance Service NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Trial the Pre-Sieve Questions Project to reduce pre-sieve questioning and accelerate Nature of Call selection.
Verbatim wording from the response “The significance of using the ‘no, no, go’ approach is discussed throughout the training that we provide. This will be further supported by our ‘Pre-Sieve Questions Project’ which is being trialled in June 2026. This project will concentrate on reducing the number of pre-sieve questions asked by an ECT regarding a patient’s consciousness level and breathing rate before a Nature of Call (NOC) is selected. The aim of the project is to reduce the time that is taken to select a NOC to a maximum of 15 seconds after a 999 call is answered.” Source location Response from South Central Ambulance Service NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Replace the computer-aided dispatch system and use the pilot outcome to inform its pre-sieve question set.
Verbatim wording from the response “The Trust is currently in the process of replacing its computer aided dispatch (CAD) system and the outcome of the above pilot will help to inform the population of pre sieve questions within the new CAD system. It is not possible to integrate them into the current system due to the limitations of its technology.” Source location Response from South Central Ambulance Service NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review another ambulance service’s video-assisted resuscitation guidance pilot to assess whether implementation would benefit local telephone triage.
Verbatim wording from the response “Telephone triage is a recognised challenge because the person completing the triage is unable to see the patient and / or the scene and it can be hard for a member of public to describe what they are seeing, particularly when they are inadvertently panicked by witnessing an emergency. A recent pilot of video assisted clinical guidance during resuscitation has been undertaken by another ambulance Trust within the UK. The results of this pilot have been shared with SCAS, and we are currently reviewing the results to consider whether implementing this system within SCAS would be of benefit, particularly when there is uncertainty surrounding a patient’s presentation, as there was in Adam’s case.” Source location Response from South Central Ambulance Service NHS Foundation Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use a less-than-one-breath-per-ten-seconds threshold in NHS Pathways to support recognition of agonal breathing.
Verbatim wording from the response “• A breathing rate of less than one breath every 10 seconds is used as a measure of inadequate breathing as this is a more identifiable and objective marker in remote telephony triage than clinical descriptions of agonal breathing for assessment between a non-clinical health advisor and a member of the public. NHS Pathways introduced this measure in 2020 to support the identification of agonal breathing which was agreed in conjunction with the Resuscitation Council UK.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Presume collapse with unconsciousness during exercise or sport, including reported fitting, to be cardiac arrest regardless of apparent regular breathing.
Verbatim wording from the response “Additional measures have also been taken following learning from this case. In January 2025, NHS Pathways updated the triage so now anyone who collapses and becomes unconscious during exercise or sport, including those reported to be fitting,” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with MPDS and NHS Pathways coding sub-groups to consider further measures helping the public recognise agonal breathing or cardiac arrest.
Verbatim wording from the response “NHS England will work with the MPDS and NHS Pathways coding sub-groups to consider whether further measures should be taken to help members of the public recognise the signs of agonal breathing or cardiac arrest.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Revise SCA, first-aid and defibrillator training content to incorporate current guidance, case learning and clearer emergency-response instructions.
Verbatim wording from the response “13. Following the Inquest, the FA has undertaken a review of its IFAIF course and the SCA module to ensure learning from best practice guidelines and this case are fully reflected in the content delivered. A member of the FA’s Medical Team was a contributor to the Resuscitation Council UK ‘Resuscitation on the Field of Play’ Guidelines and the new ‘Resuscitation in Community Sports: A National Best Practice Guide’ (dated April 2026).” Source location Response from The FA
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require tutors to reinforce key SCA-response messages and show abnormal-breathing videos at every face-to-face course.
Verbatim wording from the response “18. The FA has also taken steps to ensure that learning from this case is incorporated into delivery of training by tutors across all in-person courses. Tutors have been advised to promote the relevant points and asked to show a video distinguishing normal breathing from abnormal breathing/agonal breathing at every face-to-face course.” Source location Response from The FA
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish simplified guidance directing people to suspect cardiac arrest when an unresponsive person has abnormal breathing.
Verbatim wording from the response “Recognition of agonal breathing and cardiac arrest is a well-established challenge. Current UK Resuscitation Guidelines (2025) address this through clear and simplified messaging: cardiac arrest should be suspected in any unresponsive person, and if they are unresponsive with abnormal breathing, cardiac arrest should be assumed. The identification of agonal breathing is challenging, and it is well established that it is often mistaken for adequate breathing. Training, therefore, focusses on identifying someone who is not breathing normally, rather than trying to teach those undertaking first aid the varying and often not obvious appearance of agonal breathing.” Source location Response from Resuscitation Council UK
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with NHS England through NHS Pathways to support standardised dispatch algorithms and telephone-assisted CPR instructions.
Verbatim wording from the response “The recognition of cardiac arrest by ambulance service call handlers is also a critical component of the early response. We work closely with NHS England (through NHS Pathways) to support emergency medical dispatch systems to use standardised algorithms which support the prompt identification of cardiac arrest and enable call handlers to provide immediate telephone-assisted CPR instructions. Our systems-level guidance further recommends that ambulance services teach, monitor, and continuously improve cardiac arrest recognition within dispatch centres, recognising this as a key link in the chain of survival⁴. The challenge for an ambulance call taker to correctly recognise cardiac arrest is well established, and a significant amount of work has been undertaken to improve this vital link in the chain of survival.” Source location Response from Resuscitation Council UK
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Strengthen public education campaigns, including an annual Restart a Heart focus on recognising and raising awareness of agonal breathing.
Verbatim wording from the response “RCUK recognises that, despite clear guidance, the recognition of cardiac arrest in real-world settings can remain challenging, particularly in environments such as grassroots sport. In response, RCUK will continue to strengthen its public-facing education campaigns. For example, as part of RCUK’s annual Restart a Heart campaign, this year’s programme will include a focus on recognising and raising awareness of agonal breathing.” Source location Response from Resuscitation Council UK
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Training and education of ambulance staff and the public, including defibrillator use, are outside the organisation’s responsibilities.
Verbatim wording from the response “We must emphasise that as a membership organisation, AACE is not responsible for the training or education of ambulance staff, or the public / lay people. We do, however, believe it is everyone’s responsibility to consider the need for first aid training and how to recognise and help someone in cardiac arrest by being able to perform cardio-pulmonary resuscitation (CPR) and use a defibrillator if available, until professional help arrives.” Source location Response from Association of Ambulance Chief Executives
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Pre-sieve questions cannot be integrated into the current computer-aided dispatch system because of its technological limitations.
Verbatim wording from the response “The significance of using the ‘no, no, go’ approach is discussed throughout the training that we provide. This will be further supported by our ‘Pre-Sieve Questions Project’ which is being trialled in June 2026. This project will concentrate on reducing the number of pre-sieve questions asked by an ECT regarding a patient’s consciousness level and breathing rate before a Nature of Call (NOC) is selected. The aim of the project is to reduce the time that is taken to select a NOC to a maximum of 15 seconds after a 999 call is answered.” Source location Response from South Central Ambulance Service NHS Foundation Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS England will respond on concerns about recognising agonal breathing or cardiac arrest, defibrillator use, and cascade communication of hereditary conditions.
Verbatim wording from the response “In preparing this response, my officials have made enquiries with NHS England officials. They have confirmed that NHS England will respond to you directly on POINT A, POINT C and POINT E.” Source location Response from Department of Health and Social Care
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21 Jun 2024 Kevin Michael Cashin · Prevention of Future Deaths report Manchester North
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Concerns raised 1
Failure to provide training on recognising agonal breathing View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 1
College of Policing
Complete the FALP review and update learning outcomes to cover agonal gasps, cardiac arrest recognition and basic life support.
View source
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AI-generated summary
Kevin Michael Cashin · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
In the early hours of 20 July 2022, Kevin Cashin, who was experiencing an episode of Acute Behavioural Disturbance after ingesting cocaine, was restrained by police after dropping from a first-floor window. He deteriorated, stopped breathing and was later diagnosed with an unsurvivable hypoxic brain injury, dying that morning. The principal concerns were that officers did not recognise his agonal breathing and cardiac arrest promptly, with the Court also concerned that relevant recognition skills were not covered in the stated police first-aid training curricula.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to provide training on recognising agonal breathing
Wider context from the report “(1) The officers did not understand what agonal breathing was or how to recognise it . This included an officer who had completed the enhanced first aid training required to undertake Public Order Medic duties. Their focus had been on the fact that they could see Kevin’s chest moving and they had not appreciated that his gasping was an indicator of breathing difficulties.
(2) The Court heard that the effect of a cocaine induced Acute Behavioural Disturbance episode meant that Kevin’s agonal breathing was at a faster rate than is typical and would have looked more like regular breathing.
(3) The Court heard that there is generally a lack of knowledge on how to recognise when a person is going into a cardiac arrest. The officers had placed reliance on their observation of Kevin’s chest movements and their belief that they could feel his pulse. They had interpreted his lack of muscle tone, facial movements, poor colour and failure to respond to verbal prompts as signs of the effects of drug intoxication rather than indicators that he was in the early stages of cardiac arrest.
(4) It was the opinion of the expert that the most effective way to train responders in recognising agonal breathing and on how to identify when a person is going into a cardiac arrest is through the use of video footage rather than solely power-point presentations.
(5) The Court is concerned that the above is not currently covered in the curriculum for First Aid Learning Programme delivered to all police officers or the Enhanced First Aid Skills delivered to those officers in high risk roles and to public order medics .
” Source location Kevin Michael Cashin · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete the FALP review and update learning outcomes to cover agonal gasps, cardiac arrest recognition and basic life support.
Verbatim wording from the response “The College has conducted a significant review of the FALP, which was completed in August 2023. The updated version of FALP now includes specific reference to recognising agonal gasps – this is within the learning outcome relating to performing basic life support. This is taught within modules 2, 4 and 5, and as such will form part of both initial and annual refresher training for all public facing officers, and those in advanced, high-risk roles.” Source location Response from College of Policing
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Individual forces are responsible for developing FALP learning materials, including video content, under local clinical governance procedures.
Verbatim wording from the response “The College of Policing develop the learning outcomes for FALP and individual forces develop the learning material in line with their local clinical governance procedures. The College of Policing share learning and good practice through various national platforms and will continue to work with Greater Manchester Police and other forces to do so. We encourage forces to use video footage as well as other media.” Source location Response from College of Policing
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The reviewed FALP and new PPST are considered to provide policing with the necessary skills to preserve life and keep the public safe.
Verbatim wording from the response “The main focus of the recent review of FALP was preserving life. The FALP is subject to constant update and review but we are confident that the recent review of FALP and the development of the new PPST provides those in policing with the necessary skills required to preserve life and keep the public safe.” Source location Response from College of Policing
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27 Jun 2019 Edir Frederico Araujo DA COSTA · Prevention of Future Deaths report East London
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Concerns raised 1
Failure to recognise agonal breaths View source
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
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Edir Frederico Araujo DA COSTA · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Edir Frederico Araujo DA COSTA died after his airway became obstructed by a plastic bag containing drugs while he was being restrained by police. The report identified concerns about emergency life-support training, supervision and safety-officer roles during restraint, risks associated with plastic bags and CS spray, recognition of agonal breathing, and communication with the ambulance service.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to recognise agonal breaths
Wider context from the report “(5) The evidence at the Inquest revealed that agonal breaths were likely to have been missed . The officer provided the description of the breaths as looking like “yawning.” The independent expert stated that these were, beyond reasonable doubt, agonal breaths. The MPS is requested to review the training to officers around the recognition of agonal breaths. Within the training, the MPS may wish to incorporate the helpful descriptions provided by the officer in this case.
” Source location Edir Frederico Araujo DA COSTA · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce agonal-breathing video clips into Emergency Life Support training.
Verbatim wording from the response “On 4th July 2019 Sue Warner tasked the MPS Clinical Panel and the National Clinical Panel to identify appropriate video clips which demonstrate agonal breathing which can be shown during ELS (Emergency Life Support) training. The same request was made to the National Police Chiefs Council’s First Aid Forum on 18th July 2019. From 1st October 2019 these video clips will be introduced into the new Emergency Life Support programme to support the existing training.” Source location 2019-0211-Response-by-Metropolitan-Police
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4 Sep 2017 Anthony William McCormack · Prevention of Future Deaths report Manchester City
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Concerns raised 1
Inadequate training of airline staff to recognise cardiac arrest and administer first aid or prompt CPR View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 1
Emirates
Provide initial and annual refresher first-aid and CPR training to cabin crew, including recognition of abnormal breathing as a cardiac-arrest sign.
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AI-generated summary
Anthony William McCormack · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Anthony William McCormack became unwell and collapsed while an aircraft was taxiing at Manchester Airport, later suffering cardiac arrest and dying after resuscitation attempts at Wythenshawe Hospital. The report identified concerns about Emirates staff recognising cardiac arrest and agonal breathing, starting CPR promptly, and procedures when the Tempus system could not provide assistance. It also raised concerns about ambulance response targets and the availability of only one paramedic at Manchester Airport.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Inadequate training of airline staff to recognise cardiac arrest and administer first aid or prompt CPR
Wider context from the report “• The adequacy of the training of Emirates staff in respect of the recognition of possible cardiac arrest and signs thereof including agonal breathing and the administration of appropriate first aid/prompt CPR
” Source location Anthony William McCormack · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide initial and annual refresher first-aid and CPR training to cabin crew, including recognition of abnormal breathing as a cardiac-arrest sign.
Verbatim wording from the response “First Aid and CPR training is undertaken by all Emirates cabin crew both as part of their initial training and also on an annual basis as refresher training on medical procedures. The CPR training conducted by Emirates in each of these instances meets the rigorous standards set by leading international bodies, including the International Liaison Committee on Resuscitation (ILCOR), the American Heart Association (AHA) and the European Resuscitation Council. This training includes information on the recognition of abnormal breathing as a sign of cardiac arrest and this is reflected in the Emirates Operating Manuals and training materials covering this issue.” Source location 2017-0241-Response-by-Emirates
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing training, manuals and ongoing monitoring of resuscitation developments are considered sufficient; no additional cardiac-arrest training action is proposed.
Verbatim wording from the response “First Aid and CPR training is undertaken by all Emirates cabin crew both as part of their initial training and also on an annual basis as refresher training on medical procedures. The CPR training conducted by Emirates in each of these instances meets the rigorous standards set by leading international bodies, including the International Liaison Committee on Resuscitation (ILCOR), the American Heart Association (AHA) and the European Resuscitation Council. This training includes information on the recognition of abnormal breathing as a sign of cardiac arrest and this is reflected in the Emirates Operating Manuals and training materials covering this issue.” Source location 2017-0241-Response-by-Emirates
Open published response
27 Apr 2016 Caragh Melling · Prevention of Future Deaths report Inner North London
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Concerns raised 1
Lack of a triage tool to recognise agonal or inadequate breathing View source
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Caragh Melling · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Caragh Melling collapsed at home after an episode of dizziness and died shortly after arriving at hospital following unsuccessful resuscitation attempts. The ambulance call triage failed to recognise her agonal breathing, and the report raised concerns that the NHS Pathways system lacked a tool to identify inadequate breathing and that it was unclear whether action was being taken to address this.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of a triage tool to recognise agonal or inadequate breathing
Wider context from the report “(1) I heard evidence from the Ambulance Trust that a previous triage system included a tool which could recognise the presence of agonal or inadequate breathing. The call handler would record every point at which the patient was noted to inspire. The tool would then alert the call handler to the presence of inadequate breathing.
The Ambulance Trust noted that their current triage system, NHS Pathways, does not include this tool . They have instituted a local ‘workaround’; a question that asks whether the patient’s breathing is ‘noisy’. If this is answered affirmatively, agonal breathing is presumed and the call categorised as the fastest response time being required (R1).
I heard evidence that NHS Pathways were contacted in 2014 to raise the absence of the breathing analysis tool as being a cause for concern. No action appears to have been taken. I also understand that the Medical Director of the Ambulance Trust has again raised concerns at the national level but it is unclear whether any action is being taken.
” Source location Caragh Melling · Prevention of Future Deaths report
Open source report
27 May 2015 Yusuf ABDISMAD · Prevention of Future Deaths report Inner North London
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Concerns raised 1
Insufficient training of 111 call handlers in recognising agonal breathing View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Yusuf ABDISMAD · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Yusuf died from meningococcal septicaemia after his mother called 999 and was advised to call 111; by the time the London Ambulance Service arrived, he was in cardiac arrest. The principal concern was that the emergency medical dispatcher used a potentially confusing method to assess whether Yusuf was conscious, alongside difficulties recognising possible signs of meningitis.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Insufficient training of 111 call handlers in recognising agonal breathing
Wider context from the report “During the 111 call, Yusuf’s mother said at one point that Yusuf was not breathing. Rather than responding to this as a red flag that required immediate paramedic attendance and asking for London Ambulance Service to be notified, the LCW call handler felt she wanted to probe further.
Evidence in court from the 111 service was that call handlers would benefit from further training in recognisingagonal breathing . I appreciate that 111 is not intended as an emergency service, but they are likely from time to time to take calls that are or become urgent.
” Source location Yusuf ABDISMAD · Prevention of Future Deaths report
Open source report
21 May 2015 Barbara Patterson · Prevention of Future Deaths report Northumberland (North)
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Concerns raised 1
Failure of the Pathways system to prompt CPR advice for patients with agonal breathing View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Barbara Patterson · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Barbara Patterson suffered a cerebral stroke at home on 1 January 2015, fell from a stair lift, and died at Wansbeck Hospital on 2 January 2015. The substantive concerns included the failure to provide timely CPR advice, a fault in the Pathways system relating to agonal breathing, ambulance dispatch and delayed arrival, and wider ambulance service capacity issues.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of the Pathways system to prompt CPR advice for patients with agonal breathing
Wider context from the report “2. During the inquest evidence was given that the Pathways system, a computerised system piloted in the North East and since rolled out for use by 6 other Healthcare Trusts nationally, has a fault in that it does not advise non clinical call handlers to issue CPR advice unless a patient has stopped breathing . This fails to recognise the need for CPR in cases of Agonal (heavy/noisy breathing which is insufficient to sustain life) . This fault was pointed out to Pathways by the Clinical Section Manager for North East Ambulance Service NHS Foundation Trust, prior to the latest update being installed in early 2014 (Update 9). Pathways refused to amend the system. That fault remains in place to date .
” Source location Barbara Patterson · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct a comprehensive NEAS inspection covering call-handler support, ambulance dispatch, arrival-time breaches, and patient handover procedures.
Verbatim wording from the response “The CQC intend to carry out a planned comprehensive inspection of North East Ambulance Service (NEAS) as part of its ongoing inspection process. During this inspection we will investigate to what extent and degree call handlers are supported by systems and procedures already in place. We will also require NEAS to furnish oral and written evidence to demonstrate that they understand their role and responsibilities in relation to call handlers and that they provide regular monitoring to ensure that the system is functioning at an appropriate level.” Source location 2015-0198-Response-by-Care-Quality-Commission
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require NEAS to provide evidence of how it is mitigating risks in the Pathways system and working with the Pathways programme to improve it.
Verbatim wording from the response “As recognised in your report, the Pathways system is a National Programme, piloted in the North East, which has been introduced in other areas of the country. We have written to NEAS to instruct them to submit evidence of how they are mitigating the risk within the Pathways system and also how they are working with Pathways to improve the system.” Source location 2015-0198-Response-by-Care-Quality-Commission
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS Pathways disputes that the system is faulty, stating it already identifies noisy breathing as requiring CPR advice.
Verbatim wording from the response “NHS Pathways has provided a response to your concerns (attached) which includes an overview of the CDSS system, how it is implemented, reviewed and updated and the amendments that are made to supporting information on breathing assessment. Noisy breathing is already identified as a major airway compromise that requires an emergency response and appropriate CPR advice. NHS Pathways believes the call-handler might have failed to pick up the cues which should have led to this advice being given.” Source location 2015-0198-Response-by-Department-of-Health
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.