Recurring concern

Failure of emergency response leadership and coordination

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First reported 7 Feb 2014•Latest report 26 Aug 2025

Definition

What this concern includes

Includes failures of leadership, command, role clarity or team coordination within an explicitly identified emergency or life-threatening emergency response.

Not included

Excludes leadership or governance deficiencies unrelated to an emergency response.
Excludes generic training, staffing or communication deficiencies unless the report directly ties them to leadership or coordination of the emergency response.
Excludes failures specific to a separate operational process, hazard or non-emergency incident-management system.

Reports: 16
Individual concerns: 22
Date range: 2014–2025
Stated actions: 35

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care2

Aspray House1

Beech Cliffe Grange1

Beech Cliffe Limited1

Care UK Limited1

College of Policing1

Cygnet Health Care Limited1

Elmley Prison1

Essex Partnership University NHS Foundation Trust1

Faversham House Nursing Home1

First Aid Cover Ltd1

Greater Manchester Police1

Harbour Healthcare Ltd.1

King's Harbour Master1

Leeds Community Healthcare NHS Trust1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

26 Aug2025
Inner North London
Concerns raised1
1. Failure to identify and deploy the available trained first aider
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions 1
1. Position
  Tesco’s own store first-aider provision is considered sufficient; T.S.S officers are not contractually required to provide first aid.
  Stated by T.S.S (Total Security Services) Limited (T.S.SExisting arrangements considered sufficient
AI-generated summary

Gabriella Omolabake Torisheju JAYIESIMI · 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

Gabriella Omolabake Torisheju Jayiesimi suffered seizures and a cardiac arrest at a Tesco supermarket on 24 January 2025 and died a month later from the hypoxic brain injury sustained during the arrest. The concerns included the absence of effective first aid and CPR, failure to recognise that she had stopped breathing, failure to check her pulse or use a defibrillator, and inadequate first-aid training and preparedness among relevant Tesco and security staff.

Read the report on judiciary.uk
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 to identify and deploy the available trained first aider
Wider context from the report
“I heard that it was the duty manager’s choice not to be first aid trained. She said that she did not like blood and was afraid of the responsibility of a paramedic. However, on further exploration she said that she would like to be able to recognise a person not breathing and she would like to be able to administer basic first aid. TSS 4. The TSS security officer was first aid trained, but did not tell anyone that he was first aid trained. He told me repeatedly that his job was simply to do whatever the duty manager told him to do. Despite being the only first aider present, he took no responsibility at scene. He failed to offer Ms Jaiyesimi or the duty manager any meaningful support at all. ”
Source location
Gabriella Omolabake Torisheju JAYIESIMI · Prevention of Future Deaths report
Page 3 · concerns
Open source report
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
Tesco’s own store first-aider provision is considered sufficient; T.S.S officers are not contractually required to provide first aid.

Verbatim wording from the response
“Regarding the relationship between Tesco PLC and T.S.S security officers, we consider it important to clarify that the security officer was not employed as a first-aider and there has never been, nor is there currently, a contractual requirement by Tesco PLC for T.S.S security officers to provide first aid to Tesco employees or members of the public in Tesco stores. This is on the basis that Tesco has its own provision for first-aiders within its stores who are called to any medical emergency. There are no current T.S.S employees who hold a role as a Tesco first-aider.”

Source location
Response from Total Security Services
Page 2 · response
Published 5 September 2025
Open published response
29 Jul2025
Kent and Medway
Concerns raised1
1. Confusion over which public body has primary responsibility for acute medical emergencies in custodial settings
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 5
1. Action
  Direct HMP Elmley staff to follow local medical-emergency procedures consistently, including responsibilities for resuscitation, restraints and ligature removal.
  Stated by HM Prison and Probation ServiceStated completed
2. Action
  Jointly draft a memorandum of understanding defining agencies’ responsibilities and coordinating joint working during major incidents.
  Stated by Oxleas NHS Foundation TrustStated in progress
3. Action
  Prepare and return SECAmb comments on the memorandum of understanding defining roles and responsibilities for prison incidents.
  Stated by South East Coast Ambulance Service NHS Foundation TrustStated in progress
1. Action
  Add a command-and-control framework for incidents in HM Prison establishments to the SECAmb Incident Response Plan.
  Stated by South East Coast Ambulance Service NHS Foundation TrustStated completed
2. Action
  Arrange a meeting with prison healthcare leads to clarify primacy of care while developing the memorandum of understanding.
  Stated by South East Coast Ambulance Service NHS Foundation TrustStated planned
Respondent positions 3
1. Position
  Healthcare professionals or paramedics, rather than prison staff, are responsible for leading medical interventions beyond first aid or CPR.
  Stated by HM Prison and Probation ServiceRedirects responsibility
1. Position
  Existing arrangements establish Oxleas’ responsibility and leadership for acute medical emergencies, with paramedics supporting Oxleas staff when required.
  Stated by Oxleas NHS Foundation TrustExisting arrangements considered sufficient
2. Position
  Primacy of care in prisons rests with commissioned prison healthcare services, while ambulance staff assume responsibility after handover and departure.
  Stated by South East Coast Ambulance Service NHS Foundation TrustRedirects responsibility
AI-generated summary

Azroy Dawes-Clarke · 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

Azroy Dawes-Clarke died in hospital on 10 November 2021 after an episode of self-strangulation in HMP Elmley, followed by restraint, cardiac and respiratory arrest, and further arrest during conveyance to hospital. The substantive concerns included disproportionate and prolonged restraint, delays in obtaining healthcare assistance and starting CPR, inadequate communication, and uncertainty about responsibility for acute medical emergencies in custodial settings.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Confusion over which public body has primary responsibility for acute medical emergencies in custodial settings
Wider context from the report
“(2) Despite the severity of the incident which occurred in this case, it appeared that there still remains confusion as to which public body would have primary in an acute medical emergency in a custodial setting. ”
Source location
Azroy Dawes-Clarke · Prevention of Future Deaths report
Page 4 · concerns
Open source report
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
Direct HMP Elmley staff to follow local medical-emergency procedures consistently, including responsibilities for resuscitation, restraints and ligature removal.

Verbatim wording from the response
“It is essential that all staff understand their responsibilities when responding to a medical emergency, including actions relating to resuscitation, the use of restraints, and the removal of ligatures. Local procedures are in place at HMP Elmley to support a coordinated and effective response, and staff have been directed to adhere to these consistently.”

Source location
Response from HM Prison & Probation Service
Page 1 · response
Published 30 July 2025
Open published response
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
Jointly draft a memorandum of understanding defining agencies’ responsibilities and coordinating joint working during major incidents.

Verbatim wording from the response
“As part of this collaboration, bronze, silver, and gold command training is being incorporated into the Oxleas service and is currently in the process of being sourced appropriately. Additionally, a memorandum of understanding is being jointly drafted by HMPPS, Kent Fire and Rescue, Oxleas, and SECAMbs to outline each agency's responsibilities and to facilitate coordinated joint working during major incidents.”

Source location
Response from Oxleas NHS Foundation Trust
Page 2 · response
Published 30 July 2025
Open published response
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
Prepare and return SECAmb comments on the memorandum of understanding defining roles and responsibilities for prison incidents.

Verbatim wording from the response
“Importantly, the SECAmb Resilience Team have now completed the development of Site Specific Response Plans (SSRP) for all prison sites within our region, which has included discussion around the use of ‘Code Red and Code Blue’ terminology. These SSRPs provide a predefined attendance protocol for complex prison incidents, including the deployment of a structured command presence at the scene. They are accessible to both the Emergency Operations Centre (EOC) and frontline crews, and offer pre-agreed access, egress, and rendezvous point (RVP) information, along with site-specific risk details that must be considered to ensure a coordinated and informed response to these challenging locations. More broadly, a memorandum of understanding (MOU) is being written between SECAmb, HMP Elmley and Oxleas to articulate roles and responsibilities when attending prisons incidents.”

Source location
Response from South East Coast Ambulance Service
Page 4 · response
Published 30 July 2025
Open published response
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
Add a command-and-control framework for incidents in HM Prison establishments to the SECAmb Incident Response Plan.

Verbatim wording from the response
“Regionally, the SECAmb Medway Operating Unit Leadership team meet with the prison’s healthcare team and governors every quarter and review any incidents or escalations with a view to learning and improving. Building on this, the Medway operating unit team have been invited to CPD events at the prison, and they have offered to provide restraint continuing professional development for the Trust following Azroy’s request which will be explored in relation to ongoing education and development programs for SECAmb staff. At an organisational level, a new section has been added to SECAmb’s Incident Response Plan which provides a comprehensive command-and-control framework for responding to incidents within HM Prison establishments.”

Source location
Response from South East Coast Ambulance Service
Page 5 · response
Published 30 July 2025
Open published response
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
Arrange a meeting with prison healthcare leads to clarify primacy of care while developing the memorandum of understanding.

Verbatim wording from the response
“patients within secure settings like a prison is a key action for the Trust, both in terms of engaging with prison healthcare providers and ensuring that our staff understand where primacy sits.”

Source location
Response from South East Coast Ambulance Service
Page 4 · response
Published 30 July 2025
Open published response
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
Healthcare professionals or paramedics, rather than prison staff, are responsible for leading medical interventions beyond first aid or CPR.

Verbatim wording from the response
“HMPPS policy on responding to medical emergencies is set out in Prison Service Instruction 03/2013. Operational staff are responsible for ensuring that appropriate medical support is summoned promptly – whether from on-site healthcare services or the ambulance service – and for enabling healthcare professionals to access and treat the individual without delay. While prison staff will often be the first on scene, they are not expected to lead medical interventions beyond the scope of first aid or CPR where healthcare professionals or paramedics are present. Their role is to support, facilitate, and assist clinical staff as required.”

Source location
Response from HM Prison & Probation Service
Page 1 · response
Published 30 July 2025
Open published response
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
Existing arrangements establish Oxleas’ responsibility and leadership for acute medical emergencies, with paramedics supporting Oxleas staff when required.

Verbatim wording from the response
“It is recognised that in this very sad incident there may have been confusion regarding primacy in a medical emergency. This incident pre-dates Oxleas NHS Foundation Trust’s delivery of healthcare services at HMP Elmley. The Trust is clear that, as the primary healthcare provider at HMP Elmley, Oxleas NHS Foundation Trust retains responsibility for the care and treatment of prisoners until their departure from custody, regardless of whether this occurs via ambulance or other means, including primacy in an acute medical emergency. There is an inpatient healthcare team at HMP Elmley and staff attend and lead healthcare emergencies as normal practice. Where paramedic support is required, our staff work with paramedics to ensure that their skills are deployed in partnership with the Oxleas staff during the incident.”

Source location
Response from Oxleas NHS Foundation Trust
Page 3 · response
Published 30 July 2025
Open published response
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
Primacy of care in prisons rests with commissioned prison healthcare services, while ambulance staff assume responsibility after handover and departure.

Verbatim wording from the response
“For the sake of clarity, primacy of care within a prison environment rests with commissioned prison healthcare services as each prison will have its own safe systems of work and identified procedures for the provision of emergency care. Ambulance Service staff responding to emergencies within a prison will work in liaison and in conjunction with healthcare teams from that facility in line with their scope of practice and in accordance with SECAmb policies and procedures and will assume responsibility for patient care at the point of handover and departure from that facility. This is particularly important as prison healthcare staff will undertake a lead role in risk assessment processes undertaken in facilities prior to transportation.”

Source location
Response from South East Coast Ambulance Service
Page 1 · response
Published 30 July 2025
Open published response
29 Jul2025
Kent and Medway
Concerns raised2
1. Failure to establish clear command and control arrangements during critical medical emergencies in custodial settings
2. Failure to establish a communication strategy during critical medical emergencies in custodial settings
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions 2
1. Position
  HM Prison and Probation Service is responsible for leadership, command and control of prison emergencies, including medical emergencies.
  Stated by Department of Health and Social CareRedirects responsibility
1. Position
  The Ambulance Service is expected to provide further detail about paramedics’ role in medical emergencies within prisons.
  Stated by Department of Health and Social CareRedirects responsibility
AI-generated summary

Azroy Dawes-Clarke · 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

Azroy Dawes-Clarke died in hospital after self-ligaturing in HMP Elmley, followed by restraint, cardiac and respiratory arrest, and further arrests during conveyance and hospital treatment. The principal concerns included confused communication and unclear command structures among prison staff, healthcare professionals and paramedics, disproportionate and prolonged restraint, delays in obtaining medical assistance and starting CPR, and inadequate consideration of his breathing and positioning.

Read the report on judiciary.uk
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 to establish clear command and control arrangements during critical medical emergencies in custodial settings
Wider context from the report
“(1) As the jury noted, communication between attending prison staff, healthcare professionals and paramedics was confused. There was confusion as to who had command and control of the medical emergency, which public body took primacy and the difference in roles and responsibilities. Those attending the scene did not establish any sort of communication strategy or command structure. During prevention of future deaths evidence, there remained a lack of clarity and consistency as to how such a situation would be avoided if a critical medical emergency eventuated in a custodial setting again. (2) (3) ”
Source location
Azroy Dawes-Clarke · Prevention of Future Deaths report
Page 4 · concerns
Open source report
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 to establish a communication strategy during critical medical emergencies in custodial settings
Wider context from the report
“(1) As the jury noted, communication between attending prison staff, healthcare professionals and paramedics was confused. There was confusion as to who had command and control of the medical emergency, which public body took primacy and the difference in roles and responsibilities. Those attending the scene did not establish any sort of communication strategy or command structure. During prevention of future deaths evidence, there remained a lack of clarity and consistency as to how such a situation would be avoided if a critical medical emergency eventuated in a custodial setting again. (2) (3) ”
Source location
Azroy Dawes-Clarke · Prevention of Future Deaths report
Page 4 · concerns
Open source report
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
HM Prison and Probation Service is responsible for leadership, command and control of prison emergencies, including medical emergencies.

Verbatim wording from the response
“I can confirm that HM Prison and Probation Service is the public body which takes primacy for the leadership, command and control of an emergency situation in prison, including a medical emergency. Healthcare staff within a prison should respond to and provide any emergency medical treatment, such as CPR, until a paramedic arrives on scene.”

Source location
Response from Department of Health and Social Care
Page 1 · response
Published 30 July 2025
Open published response
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
The Ambulance Service is expected to provide further detail about paramedics’ role in medical emergencies within prisons.

Verbatim wording from the response
“I understand that you have issued a separate Regulation 28 report to the Director General Chief Executive of HM Prison and Probation Service; and one to the Governor at HMP Elmley, Oxleas NHS Foundation Trust and the South East Coast Ambulance Service. I would expect the Ambulance Service to provide more detail about the role of paramedics in medical emergencies within the prison estate.”

Source location
Response from Department of Health and Social Care
Page 2 · response
Published 30 July 2025
Open published response
21 Jul2025
East London
Concerns raised2
1. Delayed and disorganised staff responses to developing emergencies
2. Failure to provide effective leadership of emergency responses
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Deliver lessons-learned, anti-choking, first-aid and competency training to permanent, agency, care and non-care staff, including refresher training.
  Stated by Aspray HouseStated completed
2. Action
  Display a colour-coded choking flow chart in nursing stations and pictorial choking first-aid posters in dining areas.
  Stated by Aspray HouseStated completed
3. Action
  Replace the Home Manager and Deputy Operations Manager involved in the incident with new management.
  Stated by Aspray HouseStated completed
AI-generated summary

Madeline Reding · 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

Madeline Reding, a 79-year-old nursing-home resident with advanced vascular dementia, became unwell after lunch on 17 May 2024, regurgitated food, developed an upper-airway obstruction and respiratory arrest, and died that afternoon. The inquest identified delayed and disorganised staff responses, including a failure to sound the emergency alarm or make an immediate 999 call, delayed CPR, and ineffective first aid.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Delayed and disorganised staff responses to developing emergencies
Wider context from the report
“1. The inquest found that staff responses to the developing emergency were delayed and disorganised. Despite four registered nurses being present at the scene, no effective leadership of the emergency response was witnessed. ”
Source location
Madeline Reding · Prevention of Future Deaths report
Page 2 · concerns
Open source report
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 to provide effective leadership of emergency responses
Wider context from the report
“1. The inquest found that staff responses to the developing emergency were delayed and disorganised. Despite four registered nurses being present at the scene, no effective leadership of the emergency response was witnessed. ”
Source location
Madeline Reding · Prevention of Future Deaths report
Page 2 · concerns
Open source report
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
Deliver lessons-learned, anti-choking, first-aid and competency training to permanent, agency, care and non-care staff, including refresher training.

Verbatim wording from the response
“Immediately following the incident, an urgent flash Lessons Learnt training session was held with all nursing staff (including the management nurses present at the incident) on 23 May 2025 to reinforce the existing Swallowing Difficulties policy and Basic Life support, Resuscitation and DNARCPR policies and the procedures to be followed in the event of a choking incident. Both policies were subsequently reviewed on 31 July 2024 and noted to be compliant with Resuscitation Council, Royal College of Nursing and CQC guidance.”

Source location
2025-0368 Response from Aspray House Nursing Home
Page 2 · response
Published 23 July 2025
Open published response
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
Display a colour-coded choking flow chart in nursing stations and pictorial choking first-aid posters in dining areas.

Verbatim wording from the response
“Senior management designed a simple to follow colour coded Choking Flow Chart in October 2024 which is compliant with current guidance and which has been placed on display in all nursing stations throughout Aspray House reinforcing the policy, procedure and expectations of how all staff should deal with choking situations – including highlighting that CPR must be attempted if suitable even on residents with a DNAR in place. This has been supplemented with a pictorial Choking First Aid poster for universal understanding which has been displayed in all dining areas.”

Source location
2025-0368 Response from Aspray House Nursing Home
Page 2 · response
Published 23 July 2025
Open published response
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
Replace the Home Manager and Deputy Operations Manager involved in the incident with new management.

Verbatim wording from the response
“The two Duty Lead nurses involved, along with all permanent and agency staff who work at Aspray House have been given extensive training (which we will address in further detail below), whilst the Home Manager and Deputy Operations Manager employed at the time who were involved in the incident (who were also registered nurses at that time) have been replaced with new management.”

Source location
2025-0368 Response from Aspray House Nursing Home
Page 2 · response
Published 23 July 2025
Open published response
7 Jul2025
Manchester West
Concerns raised1
1. Failure of emergency-service first-responder allocation to provide appropriate care for concern-for-welfare emergencies
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 6
1. Action
  Deliver targeted training briefs on Concern for Welfare criteria.
  Stated by North West Ambulance Service NHS TrustStated completed
2. Action
  Review and update national RCRP guidance to clarify risk assessment and address emerging learning.
  Stated by College of PolicingStated in progress
3. Action
  Monitor the impact of RCRP and refine guidance using operational feedback and case reviews.
  Stated by College of PolicingStated in progress
1. Action
  Implement and operate the RCRP policy and partner-agency pathways for assessing concern-for-welfare calls and directing responses.
  Stated by Greater Manchester PoliceStated completed
2. Action
  Deliver initial and refresher RCRP training to relevant staff, including guidance on risk, response protocols and partner-agency referrals.
  Stated by Greater Manchester PoliceStated completed
3. Action
  Implement the inter-agency Gaining Entry Memorandum of Understanding defining responsibility for forced entry when NWAS requires access.
  Stated by Greater Manchester PoliceStated completed
Respondent positions 5
1. Position
  NWAS cannot force entry to properties because it lacks the legal powers and equipment.
  Stated by North West Ambulance Service NHS TrustUnable to act
1. Position
  NWAS is not the expected primary responder to welfare calls involving no confirmed medical need, given its ambulance function.
  Stated by North West Ambulance Service NHS TrustOutside remit
2. Position
  NWAS requires a confirmed location and clear medical need before deploying an ambulance under its Concern for Welfare procedure.
  Stated by North West Ambulance Service NHS TrustExisting arrangements considered sufficient
3. Position
  NWAS is responsible for remotely assessing physical-health concerns and ordinarily providing the appropriate response.
  Stated by Greater Manchester PoliceRedirects responsibility
4. Position
  GMFRS is the primary agency to force entry when NWAS leads a concern-for-welfare incident and requests assistance.
  Stated by Greater Manchester PoliceRedirects responsibility
AI-generated summary

Elaine TARBUCK · 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

Elaine TARBUCK died after an accidental fall at home, sustaining a head injury and exsanguinating before she was found unresponsive on 29 March 2025. The report identified concerns about the assessment and information gathering by emergency services, delays in arranging forced entry, and the application of the ‘Right Care, Right Person’ policy.

Read the report on judiciary.uk
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 emergency-service first-responder allocation to provide appropriate care for concern-for-welfare emergencies
Wider context from the report
“6. The emergency response had come about because of a new ‘Right Care, Right Person’ policy applied by emergency services that, in fact, delivered as a first responder, the wrong person delivering the wrong care to the deceased’s residence. 7. Prior to the implementation of ‘Right Care, Right Person’ this ‘concern for welfare’ emergency would have been dealt with by the attendance of the police on the scene as first responders who would have been likely to have achieved entry as a result of the concern for welfare. ”
Source location
Elaine TARBUCK · Prevention of Future Deaths report
Page 3 · concerns
Open source report
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
Deliver targeted training briefs on Concern for Welfare criteria.

Verbatim wording from the response
“In response, a number of collaborative measures have been implemented to address this issue and strengthen inter-agency working. These include:”

Source location
Response from North West Ambulance Service NHS Trust
Page 2 · response
Published 16 July 2025
Open published response
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
Review and update national RCRP guidance to clarify risk assessment and address emerging learning.

Verbatim wording from the response
“The College is reviewing the RCRP toolkit to ensure it provides clearer guidance on the assessment of risk in control rooms, including how to handle ambiguous or borderline cases where the threshold for police attendance may not be immediately clear.”

Source location
Response from College of Policing
Page 2 · response
Published 16 July 2025
Open published response
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
Monitor the impact of RCRP and refine guidance using operational feedback and case reviews.

Verbatim wording from the response
“The intent of RCRP is to ensure individuals received the most appropriate care from the most appropriate agency. However, we understand the concerns and recognise that its implementation must be sensitive to the nuances of real-world emergencies. The College continues to monitor the impact of RCRP and is committed to refining the guidance based on operational feedback and case reviews such as this.”

Source location
Response from College of Policing
Page 2 · response
Published 16 July 2025
Open published response
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
Implement and operate the RCRP policy and partner-agency pathways for assessing concern-for-welfare calls and directing responses.

Verbatim wording from the response
“GMP’s RCRP project was developed under the oversight of Greater Manchester’s Deputy Mayor. Each thematic response pathway was agreed prior to launch with relevant partners including (but not limited to) local authorities, health services (including NWAS) and mental health service providers. RCRP was launched in Greater Manchester on the 30th September 2024.”

Source location
Response from Greater Manchester Police
Page 3 · response
Published 16 July 2025
Open published response
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
Deliver initial and refresher RCRP training to relevant staff, including guidance on risk, response protocols and partner-agency referrals.

Verbatim wording from the response
“Right Care, Right Person training”

Source location
Response from Greater Manchester Police
Page 5 · response
Published 16 July 2025
Open published response
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
Implement the inter-agency Gaining Entry Memorandum of Understanding defining responsibility for forced entry when NWAS requires access.

Verbatim wording from the response
“Gaining entry on behalf of NWAS”

Source location
Response from Greater Manchester Police
Page 6 · response
Published 16 July 2025
Open published response
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
NWAS cannot force entry to properties because it lacks the legal powers and equipment.

Verbatim wording from the response
“• NWAS does not have the legal powers, nor the equipment to force entry to properties, this should be considered before any call for assistance is made.”

Source location
Response from North West Ambulance Service NHS Trust
Page 1 · response
Published 16 July 2025
Open published response
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
NWAS is not the expected primary responder to welfare calls involving no confirmed medical need, given its ambulance function.

Verbatim wording from the response
“• As an ambulance service, NWAS’s primary function is to prioritise and respond to the medical needs of patients, whether this is face-to-face or via other methods, therefore, it is not expected primary response for those who have no medical need to require our assistance.”

Source location
Response from North West Ambulance Service NHS Trust
Page 2 · response
Published 16 July 2025
Open published response
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
NWAS requires a confirmed location and clear medical need before deploying an ambulance under its Concern for Welfare procedure.

Verbatim wording from the response
“Whilst it is acknowledged that, in the case of Ms Tarbuck, NWAS did deploy a resource following a call made to us, it is important to note that this deployment was not in line with our current procedures for Concern for Welfare incidents.”

Source location
Response from North West Ambulance Service NHS Trust
Page 2 · response
Published 16 July 2025
Open published response
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
NWAS is responsible for remotely assessing physical-health concerns and ordinarily providing the appropriate response.

Verbatim wording from the response
“GMP are not the most appropriate agency to respond to physical health matters. Call Handlers are trained to use the RCRP assessment tool which assists them in identifying whether an incident involves a real and immediate risk to life or risk of serious harm, but they are not trained to triage physical health concerns or identify a suitable operational response to such concerns.”

Source location
Response from Greater Manchester Police
Page 4 · response
Published 16 July 2025
Open published response
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
GMFRS is the primary agency to force entry when NWAS leads a concern-for-welfare incident and requests assistance.

Verbatim wording from the response
“In April 2024, GMP, NWAS and GMFRS signed the “Gaining Entry Memorandum of Understanding”. The purpose of the MoU is to outline a process to guide NWAS in circumstances whereby they need to gain entry into premises to assess patients who require an emergency clinical assessment. Under this MoU, GMFRS are the primary agency to support NWAS when forced entry is required at a premises. GMFRS will utilise their powers under the Fire and Rescue Service Act 2004, specifically Part 2 section 11, which notes:”

Source location
Response from Greater Manchester Police
Page 6 · response
Published 16 July 2025
Open published response
11 Mar2025
West Yorkshire Eastern
Concerns raised2
1. Failure to coordinate detention and medical staff roles during a medical emergency
2. Lack of protocols defining detention and medical staff roles during a medical emergency in a cell
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 5
1. Action
  Review custody contracts, policies and procedures with Leeds Community Healthcare to clarify emergency roles for Detention Officers and Healthcare Professionals.
  Stated by West Yorkshire PoliceStated planned
2. Action
  Expand life-support training with custody-suite simulations and joint scenarios to improve coordination between healthcare professionals and detention officers.
  Stated by Leeds Community Healthcare NHS TrustStated planned
3. Action
  Review the Death in Custody procedure through a clinical working group and strengthen joint reflection with colleagues involved in incidents.
  Stated by Leeds Community Healthcare NHS TrustStated in progress
1. Action
  Include coordination of response in investigations of life-threatening incidents and deaths in custody.
  Stated by Leeds Community Healthcare NHS TrustStated planned
2. Action
  Agree the reviewed procedure with police to define robust coordination of responses in life-threatening situations.
  Stated by Leeds Community Healthcare NHS TrustStated planned
Respondent positions 1
1. Position
  Existing training and emergency procedures appropriately require Detention Officers to provide Basic Life Support and follow Healthcare Professional direction.
  Stated by West Yorkshire PoliceExisting arrangements considered sufficient
AI-generated summary

NICHOLAS OLIVER JAMES GEDGE · 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

Nicholas Oliver James Gedge was found unresponsive in a police station cell on 14 November 2022 and was pronounced deceased at hospital later that day. The principal concerns were the delay in commencing CPR, the lack of a shared understanding and coordinated roles among detention and medical staff, and uncertainty about protocols for responding to medical emergencies in cells.

Read the report on judiciary.uk
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 to coordinate detention and medical staff roles during a medical emergency
Wider context from the report
“(1) 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. (2) 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. (3) 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. ”
Source location
NICHOLAS OLIVER JAMES GEDGE · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of protocols defining detention and medical staff roles during a medical emergency in a cell
Wider context from the report
“(1) 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. (2) 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. (3) 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. ”
Source location
NICHOLAS OLIVER JAMES GEDGE · Prevention of Future Deaths report
Page 2 · concerns
Open source report
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
Review custody contracts, policies and procedures with Leeds Community Healthcare to clarify emergency roles for Detention Officers and Healthcare Professionals.

Verbatim wording from the response
“3. Nevertheless, the Chief Constable intends to review the contracts, policies and procedures that are in place between Leeds Community Healthcare and the Force, in partnership with Leeds Community Healthcare, to ensure that the respective roles of the Detention Officers and Healthcare Professionals in custody in an emergency situation are sufficiently clear.”

Source location
Response from West Yorkshire Police
Page 2 · response
Published 26 March 2025
Open published response
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
Expand life-support training with custody-suite simulations and joint scenarios to improve coordination between healthcare professionals and detention officers.

Verbatim wording from the response
“• In addition to the organisational mandatory bespoke life support training, LCH will expand the scenario aspect of training to include simulation exercises in the custody suite environment with the aim of improving the co-ordination between LCH staff and detention officers in the event of emergency scenarios.”

Source location
Response from Leeds Community Healthcare NHS Trust
Page 2 · response
Published 26 March 2025
Open published response
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
Review the Death in Custody procedure through a clinical working group and strengthen joint reflection with colleagues involved in incidents.

Verbatim wording from the response
“• A working group consisting of LCH HCP’s, led by a clinical team manager, has commenced to review the Death in Custody (DIC) procedure.”

Source location
Response from Leeds Community Healthcare NHS Trust
Page 2 · response
Published 26 March 2025
Open published response
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
Include coordination of response in investigations of life-threatening incidents and deaths in custody.

Verbatim wording from the response
“• The service will ensure that they include ‘coordination of response’ in the investigation process of incidents where there has been a life-threatening response or a DIC.”

Source location
Response from Leeds Community Healthcare NHS Trust
Page 2 · response
Published 26 March 2025
Open published response
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
Agree the reviewed procedure with police to define robust coordination of responses in life-threatening situations.

Verbatim wording from the response
“• The procedure will be agreed with the police to ensure the coordination of response in life threatening situations is robust.”

Source location
Response from Leeds Community Healthcare NHS Trust
Page 3 · response
Published 26 March 2025
Open published response
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
Existing training and emergency procedures appropriately require Detention Officers to provide Basic Life Support and follow Healthcare Professional direction.

Verbatim wording from the response
“(i) Until the custody Healthcare Professional attends, they are to follow their training and provide Basic Life Support, including giving CPR to people who are not breathing.”

Source location
Response from West Yorkshire Police
Page 2 · response
Published 26 March 2025
Open published response
27 Feb2023
Essex
Concerns raised1
1. Failure to promptly inform and coordinate with the site co-ordinator during emergencies
This report raised 15 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Share emergency-response learning through basic-life-support and grab-bag training, including prompt notification of the Site Coordinator and Doctor.
  Stated by Essex Partnership University NHS Foundation TrustStated in progress
AI-generated summary

Sharon Elizabeth Langley · 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

Sharon Elizabeth Langley, an inpatient with Severe Depressive Disorder and Psychosis, died by immersion in water while unsupervised in an assisted bathroom at Princess Alexandra Hospital on 10 August 2019. The principal concerns included failures in the immediate emergency response, inadequate communication and coordination, shortcomings in bathroom and high-risk-area safety measures, confusion about bath-plug controls, unreliable investigation and learning processes, and inadequate record keeping and risk documentation.

Read the report on judiciary.uk
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 to promptly inform and coordinate with the site co-ordinator during emergencies
Wider context from the report
“(1) Essex Partnership NHS Foundation Trust staff immediate emergency response was not followed: a. pinpoint alarms were not activated immediately on finding Sharon Langley unresponsive b. there was a delay calling the ambulance and basic key information about the type of the emergency was not relayed: i. by qualified nurses who made the 999 calls, or ii. to paramedics on attendance c. there was a delay informing the site co-ordinator of the emergency even though she was based on the ward and there was a lack of co-ordination of the emergency resulting in the ambulance being called a second time by the site co-ordinator d. staff trained in basic life support did not assist the two nurses who were attempting to resuscitate Sharon Langley ”
Source location
Sharon Elizabeth Langley · Prevention of Future Deaths report
Page 2 · concerns
Open source report
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
Share emergency-response learning through basic-life-support and grab-bag training, including prompt notification of the Site Coordinator and Doctor.

Verbatim wording from the response
“- The importance of informing the Site Coordinator and Doctor, at the time of the medical emergency, will be shared and highlighted by our colleagues who currently deliver the basic life support and grab bag training. In addition, any learning (examples of good practice or areas for improvement) which derives from a medical emergency, can be shared as part of the training (1c).”

Source location
Response from Essex Partnership University NHS Foundation Trust
Page 2 · response
Published 7 March 2023
Open published response
18 Aug2022
South Yorkshire (Western)
Concerns raised1
1. Failure to provide clear CPR leadership and task structure
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Provide monthly unannounced resuscitation drills, assess response times, record responders and retrain staff where issues are identified.
  Stated by Cygnet Health Care LimitedStated completed
2. Action
  Provide nurse drop-in sessions with the ILS lead, including practical refresher training on emergency equipment.
  Stated by Cygnet Health Care LimitedStated completed
3. Action
  Complete ILS train-the-trainer qualification for the resuscitation lead.
  Stated by Cygnet Health Care LimitedStated planned
AI-generated summary

Chelsea Blue Louise Mooney · 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

Chelsea Blue Louise Mooney died two days after tying two non-fixed ligatures while in hospital, following inadequate observations and delays in the emergency response. Principal concerns included insufficient review of her diagnosis, inadequate exploration of allegations and information-sharing decisions, a failure to learn from previous ligature incidents, uncertainty among staff about responding to her, and delays and poor coordination during the final emergency response.

Read the report on judiciary.uk
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 to provide clear CPR leadership and task structure
Wider context from the report
“8. Whilst in evidence I have heard about the practice exercises using the 'Red Bag' it is clear that there was limited confidence and clarity around the CPR needed for Chelsea. There was not a clear structure of one person leading and others knowing exactly what and how to do tasks. ”
Source location
Chelsea Blue Louise Mooney · Prevention of Future Deaths report
Page 4 · concerns
Open source report
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
Provide monthly unannounced resuscitation drills, assess response times, record responders and retrain staff where issues are identified.

Verbatim wording from the response
“70. In addition the Hospital has a schedule of resuscitation drills that are carried out monthly at an unannounced time and part of the drill includes staff response times. The resuscitation drills are completed by the Resuscitation Lead for Cygnet Hospital Sheffield and the local Quality Manager. The resuscitation drills are assessed and a compliance percentage is generated. The Staff members’ names that respond are also logged. If there is an identified issue raised regarding a specific staff member or any practice then they are put on the next BLS or ILS course as a refresher. The resuscitation lead is also a BLS trainer which allows for quick turnaround of training and also allows for in depth discussion and analysis following the drills.”

Source location
Response from Cygnet Health Care
Page 17 · response
Published 3 October 2022
Open published response
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
Provide nurse drop-in sessions with the ILS lead, including practical refresher training on emergency equipment.

Verbatim wording from the response
“71. The resuscitation lead has also been nominated to complete the ILS train the trainer course which allows her to then teach the ILS course. This is currently completed by an external trainer.”

Source location
Response from Cygnet Health Care
Page 17 · response
Published 3 October 2022
Open published response
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
Complete ILS train-the-trainer qualification for the resuscitation lead.

Verbatim wording from the response
“71. The resuscitation lead has also been nominated to complete the ILS train the trainer course which allows her to then teach the ILS course. This is currently completed by an external trainer.”

Source location
Response from Cygnet Health Care
Page 17 · response
Published 3 October 2022
Open published response
6 Sep2021
Milton Keynes
Concerns raised3
1. Inhibitory hierarchical structure preventing staff from speaking up during emergencies
2. Inappropriate delegation of irrelevant tasks during anaesthetic emergencies
3. Failure of emergency team leadership, role clarity and coordination
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 5
1. Action
  Develop multidisciplinary training resources and short scenarios on unrecognised oesophageal intubation.
  Stated by Association Of Anaesthetists (Great Britain & Ireland) and Difficult Airway Society and Royal College of AnaesthetistsStated planned
2. Action
  Work with stakeholders to highlight the need for sufficient theatre-team time for essential emergency-drill training.
  Stated by Association Of Anaesthetists (Great Britain & Ireland) and Difficult Airway Society and Royal College of AnaesthetistsStated planned
3. Action
  Promote and embed the Human Factors guidance for Anaesthesia recommendations in practice.
  Stated by Association Of Anaesthetists (Great Britain & Ireland) and Difficult Airway Society and Royal College of AnaesthetistsStated planned
1. Action
  Develop and disseminate multidisciplinary team training resources on oesophageal intubation, including flashcards and short scenarios.
  Stated by Association Of Anaesthetists (Great Britain & Ireland) and Difficult Airway Society and Royal College of AnaesthetistsStated completed
2. Action
  Develop additional multidisciplinary team training resources through the simulation workstream.
  Stated by Association Of Anaesthetists (Great Britain & Ireland) and Difficult Airway Society and Royal College of AnaesthetistsStated planned
Respondent positions 1
1. Position
  Individual NHS trusts are responsible for delivering emergency simulation and team-based training, subject to available resources and clinical trainer time.
  Stated by Department of Health and Social CareRedirects responsibility
AI-generated summary

Glenda May Logsdail · 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

Glenda May Logsdail was admitted with acute appendicitis and underwent emergency surgery. During induction of anaesthesia, an endotracheal tube was misplaced in the oesophagus and this was not recognised for a prolonged period, resulting in hypoxia, cardiac arrest, irreversible brain damage and her death. Concerns included failures to confirm tube placement, fixation on an incorrect diagnosis, inadequate team leadership and communication during the emergency, and inconsistent ventilator display configurations.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Inhibitory hierarchical structure preventing staff from speaking up during emergencies
Wider context from the report
“(5) There was evidence of an inhibitory hierarchical structure which prevented others shouting out. This is despite the fact that I found Dr ████████ to be a mild mannered, gentle and reflective witness. ”
Source location
Glenda May Logsdail · Prevention of Future Deaths report
Page 4 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Inappropriate delegation of irrelevant tasks during anaesthetic emergencies
Wider context from the report
“(7) The panic and chaos led to an inappropriate delegation of an irrelevant task to a Consultant Anaesthetist who attended to assist who eventually was the one to realise the ET tube was misplaced. This distracted her for a minute or two adding to the time when Mrs Logsdail was not ventilated. ”
Source location
Glenda May Logsdail · Prevention of Future Deaths report
Page 4 · concerns
Open source report
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 emergency team leadership, role clarity and coordination
Wider context from the report
“(6) There was panic and chaos in the anaesthetic room. There was considerable confusion as to roles and there was an absence of a leader dealing with the emergency. Dr ████████ was the natural leader but I found that he was effectively blind to what needed to be done – to check the capnograph and to reintubate. Individual staff members took on roles independently in the cardiac arrest. That is to be commended on an individual level but it betrays a fundamental lack of direction and control of the situation and bodes poorly for management of future life threatening emergencies. The team malfunctioned and did not operate as a team. ”
Source location
Glenda May Logsdail · Prevention of Future Deaths report
Page 4 · concerns
Open source report
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
Develop multidisciplinary training resources and short scenarios on unrecognised oesophageal intubation.

Verbatim wording from the response
“Your report highlights the critical importance of human factors in safe anaesthetic practice. Multidisciplinary team training has an important role to play in rehearsing emergency drills, embedding non-technical skills in practice and allowing teams to learn how to function well as a whole within a flattened hierarchy. Regular, multidisciplinary team training is one of the standards for our Anaesthesia Clinical Services Accreditation (ACSA) scheme. However, in practice, it is a standard that many departments find difficult to meet to an adequate level due to the pressure on theatre time. To support this, we will:”

Source location
2021-0295-Response-from-Royal-College-of-Anaesthetists_Published
Page 1 · response
Published 9 September 2021
Open published response
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 stakeholders to highlight the need for sufficient theatre-team time for essential emergency-drill training.

Verbatim wording from the response
“Your report highlights the critical importance of human factors in safe anaesthetic practice. Multidisciplinary team training has an important role to play in rehearsing emergency drills, embedding non-technical skills in practice and allowing teams to learn how to function well as a whole within a flattened hierarchy. Regular, multidisciplinary team training is one of the standards for our Anaesthesia Clinical Services Accreditation (ACSA) scheme. However, in practice, it is a standard that many departments find difficult to meet to an adequate level due to the pressure on theatre time. To support this, we will:”

Source location
2021-0295-Response-from-Royal-College-of-Anaesthetists_Published
Page 1 · response
Published 9 September 2021
Open published response
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
Promote and embed the Human Factors guidance for Anaesthesia recommendations in practice.

Verbatim wording from the response
“• In January 2022, the Association and the Difficult Airway Society launched their Human Factors guidance for Anaesthesia. We will work together to promote and embed the recommendations from this guidance in practice.”

Source location
2021-0295 - Response from Royal College of Anaesthetists
Page 2 · response
Published 9 September 2021
Open published response
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
Develop and disseminate multidisciplinary team training resources on oesophageal intubation, including flashcards and short scenarios.

Verbatim wording from the response
“To help embed the key messages of the campaign into practice, and recognising the critical importance of human factors in safe anaesthetic practice, we developed resources for multidisciplinary team training on the subject of oesophageal intubation. One of these resources were a set of flashcards, short scenarios that could be delivered with no need for theatre downtime. The flashcards have been downloaded over 2,000 times. Colleagues at the Royal United Hospital Bath developed a packaged of “tea trolley” training on the subject of oesophageal intubation, which has also been made freely available on our webpage.”

Source location
2021-0295 - Response from Royal College of Anaesthetists
Page 1 · response
Published 9 September 2021
Open published response
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
Develop additional multidisciplinary team training resources through the simulation workstream.

Verbatim wording from the response
“• We will develop more resources for multidisciplinary team training through the RCoA’s simulation workstream.”

Source location
2021-0295 - Response from Royal College of Anaesthetists
Page 2 · response
Published 9 September 2021
Open published response
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
Individual NHS trusts are responsible for delivering emergency simulation and team-based training, subject to available resources and clinical trainer time.

Verbatim wording from the response
“In relation to your concerns about multi-disciplinary team working in an emergency situation, you may wish to note that specific simulation-based training for emergency skills and team-based drills in specialised areas of clinical practice, such as the operating theatre, is the responsibility of, and delivered by, individual NHS trusts, based on the”

Source location
2021-0295-Response-from-Department-of-Health-Social-Care_Published
Page 1 · response
Published 9 September 2021
Open published response
14 Oct2019
Inner North London
Concerns raised1
1. Lack of incident command during emergency response
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

César Cuauhtémoc González Barrón · 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

César Cuauhtémoc González Barrón died while performing as a Mexican wrestler at a Lucha Libre event. After he lost consciousness and suffered cardiac arrest, there were delays in recognising the emergency, summoning assistance, starting CPR and providing effective resuscitation. The report also identified inadequate event briefing, unclear emergency roles and procedures, communication difficulties, delayed ambulance access, and a confused handover to ambulance staff.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of incident command during emergency response
Wider context from the report
“6. When Mr González Barrón collapsed, the scene was chaotic. No person took charge. There were lots of people in the ring, but the first aider was unable to identify which, if any, were staff, so that she could ask them for assistance, for example, in retrieving her equipment. She was distracted by the noise and comment of those around. ”
Source location
César Cuauhtémoc González Barrón · Prevention of Future Deaths report
Page 2 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to identify and deploy the available trained first aider

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Confusion over which public body has primary responsibility for acute medical emergencies in custodial settings

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3

Concerns raised2

Failure to establish clear command and control arrangements during critical medical emergencies in custodial settings

Failure to establish a communication strategy during critical medical emergencies in custodial settings

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Concerns raised2

Delayed and disorganised staff responses to developing emergencies

Failure to provide effective leadership of emergency responses

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3

Concerns raised1

Failure of emergency-service first-responder allocation to provide appropriate care for concern-for-welfare emergencies

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.6

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.5

Respondent positions 1

Actions described in response 5

Respondent positions 3

Respondent positions 2

Actions described in response 3

Actions described in response 6

Respondent positions 5