Recurring concern

Unreliable assessment of whether a person is breathing

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First reported 6 Dec 2016•Latest report 8 Jan 2026

Definition

What this concern includes

Includes failures of dedicated processes, methods, environmental arrangements or staff practices intended to determine whether a person is breathing, including inadequate listen-and-feel assessment, unreliable visual observation from a cell hatch, impaired ability to hear breathing in a vehicle or scan room, and other barriers to promptly confirming absent or abnormal breathing.

Not included

Excludes recognition and management of agonal breathing where the assertion does not concern determining whether breathing is present or absent; that narrower hazard is covered separately.
Excludes failures in CPR, resuscitation delivery or emergency treatment after breathing status has been reliably established.
Excludes general clinical observation or monitoring deficiencies where assessment of breathing status is not the material unsafe condition.
Excludes unrelated respiratory diagnosis or chronic respiratory-care failures without a deficient breathing-status assessment.

Reports: 7
Individual concerns: 7
Date range: 2016–2026
Stated actions: 9

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.

Care UK2

Pentonville Prison2

Care UK Limited1

Coventry and Warwickshire Partnership NHS Trust1

HM Prison and Probation Service1

Metropolitan Police Service1

Ministry of Justice1

NHS England1

Office of the Chief Coroner1

Security Industry Authority1

Tesco PLC1

T.S.S. (Total Security Services) Limited1

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.

8 Jan2026
Sefton, St Helens and Knowsley
Concerns raised1
1. Lack of national pathway guidance for call handlers on assessing whether someone is breathing and whether CPR is required
This report raised 1 other concern. 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
  Provide CPR Toolkit Training to NHS Pathways health advisors, including the ‘No, No, Go’ approach and telephone-guided CPR initiation.
  Stated by NHS EnglandStated completed
AI-generated summary

Drew John GREAVES-PIMBLETT · 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

Drew John Graves-Pimblett, aged 26 and with a history of epilepsy, was found unresponsive and not breathing at home on 22 March 2025. An ambulance was initially stood down after telephone triage, but police later commenced CPR and Drew was pronounced deceased. The inquest concluded that he died from Sudden Unexpected Death in Epilepsy (SUDEP), related to epilepsy and natural causes. The principal concern was that call handlers lacked sufficient guidance and did not ask probing questions about breathing, body temperature, turning Drew over, or stiffness before deciding that resuscitation would not be effective.

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 national pathway guidance for call handlers on assessing whether someone is breathing and whether CPR is required
Wider context from the report
“Though a telephone triage is always challenging and subjective, there appears to be a gap in the national pathways for call handlers. Consideration as to further guidance and assistance to call handlers on probing questioning for fundamental aspects such as breathing and where and how to best show how cold the body is. If someone is not breathing to ask how they know and/or techniques such as head to the chest, where to take a pulse etc. for the call handler to make a more informed decision as to whether someone is breathing and if CPR is required. When a call is made to NWAS, often it is by someone not thinking straight and so specific questions on breathing and general presentation may be of assistance in assessing the call. ”
Source location
Drew John GREAVES-PIMBLETT · 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
Provide CPR Toolkit Training to NHS Pathways health advisors, including the ‘No, No, Go’ approach and telephone-guided CPR initiation.

Verbatim wording from the response
“Also, of relevance to this particular case, in terms of additional training regarding the assessment of consciousness and breathing, health advisors utilising NHS Pathways who have completed the core training are provided with ‘CPR Toolkit Training’. This encompasses what is called the ‘No, No, Go’ approach where, if the patient is not conscious or not breathing (either normally or at all), health advisors are trained to proceed immediately to the initiation of cardiopulmonary resuscitation (CPR) as presented by the system. This additional training seeks to ensure that health advisors are supported to proceed quickly to the required life supporting advice.”

Source location
Response from NHS England
Page 4 · response
Published 9 January 2026
Open published response
26 Aug2025
Inner North London
Concerns raised1
1. Failure to recognise breathing difficulty and place an unresponsive person in the recovery position
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.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
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 recognise breathing difficulty and place an unresponsive person in the recovery position
Wider context from the report
“When Ms Jaiyesimi was on the floor having suffered several fits, no person put her in the recovery position. They were apparently unaware that her present position could be causing an airway obstruction preventing her breathing. Then when Ms Jaiyesimi stopped breathing, nobody recognised this, though they were looking at her and made one inadequate attempt to feel for breathing (by placing a single finger somewhere near her nose). No person ever attempted to check Ms Jaiyesimi’s pulse to see if her heart was still beating. Even if they had identified her cardiac arrest, there was nobody present who would have started CPR. Nobody thought of fetching one of the store defibrillators. Lack of CPR notwithstanding, the failure to understand the situation properly meant that nobody relayed the crucial information of the arrest to the ambulance service. ”
Source location
Gabriella Omolabake Torisheju JAYIESIMI · Prevention of Future Deaths report
Page 2 · concerns
Open source report
22 Jun2021
Surrey
Concerns raised1
1. Use of an unreliable chest/abdomen movement observation method for checking breathing through cell door hatches
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

Serena Nicolle · 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

Serena Nicolle died in her cell at HMP Bronzefield on 3 September 2018 from ventricular arrhythmia in the context of hypertensive heart disease, with diabetes, sleep apnoea, obesity and stress also recorded. Two prison staff members incorrectly assessed her as breathing after observing movement through the cell hatch, and the Coroner was concerned that this standard procedure may be an unreliable way to check breathing and could create a risk of future deaths.

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
Use of an unreliable chest/abdomen movement observation method for checking breathing through cell door hatches
Wider context from the report
“During the course of the inquest the court heard evidence that observing the movement of an individual’s chest and abdomen through a cell hatch is a standard procedure for checking whether they are breathing, in circumstances where they are not otherwise moving or responding to prison staff. The court heard that this is the position across the prison estate and is not limited to HMP Bronzefield. The court also heard evidence from expert witness Dr ████████, a Consultant Cardiologist, who stated that in his opinion it is very difficult to assess whether somebody is breathing or not by looking for movement in the chest/abdomen from a distance. The Coroner is concerned that on 3 September 2018 two members of prison staff assessed that Mrs Nicolle was breathing when she was in fact deceased, and that in doing so they followed standard procedures which are in place across the prison estate. Whilst these errors did not contribute to Mrs Nicolle’s death, the Coroner is concerned that were similar errors to occur in the future, it would present a risk of future deaths, particularly given Dr ████████ evidence that it is difficult to assess whether somebody is breathing or not by looking for movement in the chest/abdomen from a distance. 1. The observation of an individual’s chest/abdomen through a cell door hatch may be an unreliable method of checking whether they are breathing, in circumstances in which they are not otherwise moving or responding to prison staff, and therefore gives rise to the risk of future deaths. ”
Source location
Serena Nicolle · Prevention of Future Deaths report
Page 3 · concerns
Open source report
30 Oct2019
Inner North London
Concerns raised1
1. Failure to confirm absent breathing using an adequate assessment
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 4
1. Action
  Require annual Immediate Life Support training for employed resuscitation staff and monitor compliance through monthly dashboards and the Resuscitation Committee.
  Stated by Care UKStated completed
2. Action
  Contract for additional prison-scenario Immediate Life Support training sessions beyond annual recertification across Care UK sites.
  Stated by Care UKStated planned
3. Action
  Film selected scenario-based resuscitation exercises for use in in-house training and induction.
  Stated by Care UKStated planned
1. Action
  Request CCTV or body-worn-camera footage after on-site custody deaths involving resuscitation and review it through immediate and internal learning reviews.
  Stated by Care UKStated completed
AI-generated summary

Robert Thomas GINN · 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

Robert Thomas Ginn hanged himself in his cell at HM Prison Pentonville and was discovered at around 1.05am on 29 November 2018. Concerns were raised about the quality of the nurse-led resuscitation attempt, including failure to check breathing, inadequate oxygenation, variable chest compressions, lack of coaching, and incorrectly applied defibrillator pads.

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 confirm absent breathing using an adequate assessment
Wider context from the report
“3. At inquest, one of the nurses said that she looked at Mr Ginn’s chest at the outset, but she did not put her cheek to his mouth to listen and feel for breath in order to confirm he was not breathing. ”
Source location
Robert Thomas GINN · 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
Require annual Immediate Life Support training for employed resuscitation staff and monitor compliance through monthly dashboards and the Resuscitation Committee.

Verbatim wording from the response
“Our policy for the standards of training for employed staff within our Health in Justice service who respond to resuscitation is Immediate Life Support (ILS) training, provided by Resuscitation Council accredited trainers. Although the requirement from the Resuscitation Council is that attendee’s repeat this on a 3 yearly cycle, we mandate that all Care UK employed staff complete this annually. Assurance around the compliance of this training is monitored via monthly performance dashboards and reported to Care UK’s Resuscitation Committee.”

Source location
Response from Care UK
Page 2 · response
Published 13 December 2019
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
Contract for additional prison-scenario Immediate Life Support training sessions beyond annual recertification across Care UK sites.

Verbatim wording from the response
“Going forwards, we will contract with our ILS training provider to deliver additional training sessions, including some prison scenario based training. These will be in addition to the annual re-certification sessions. We anticipate that this will be rolled out across our sites nationally over 2020. In addition our intention is to film some of these scenario-based training exercises for use at in-house training events and induction.”

Source location
Response from Care UK
Page 2 · response
Published 13 December 2019
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
Film selected scenario-based resuscitation exercises for use in in-house training and induction.

Verbatim wording from the response
“Going forwards, we will contract with our ILS training provider to deliver additional training sessions, including some prison scenario based training. These will be in addition to the annual re-certification sessions. We anticipate that this will be rolled out across our sites nationally over 2020. In addition our intention is to film some of these scenario-based training exercises for use at in-house training events and induction.”

Source location
Response from Care UK
Page 2 · response
Published 13 December 2019
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
Request CCTV or body-worn-camera footage after on-site custody deaths involving resuscitation and review it through immediate and internal learning reviews.

Verbatim wording from the response
“Following a death in custody where resuscitation has taken place on site, a request is made to the prison for the opportunity to view or receive a copy of any CCTV or body worn camera footage so that this can be reviewed as part of Care UK’s 72hr immediate review process and Internal Learning Review. This is to enable us to identify issues or concerns and to assist in improving clinical care and identifying training needs.”

Source location
Response from Care UK
Page 2 · response
Published 13 December 2019
Open published response
29 Jun2018
Inner North London
Concerns raised1
1. Difficulty assessing whether breathing is present and normal
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 2
1. Action
  Deliver ELS training scenarios requiring officers to assess breathing, reposition subjects, recognise noisy breathing and provide CPR.
  Stated by Metropolitan Police ServiceStated completed
2. Action
  Train officers to conduct thorough breathing checks, monitor breathing, open airways and commence CPR when breathing is abnormal or uncertain.
  Stated by Metropolitan Police ServiceStated completed
Respondent positions 1
1. Position
  Existing MPS Emergency Life Support training addresses recognition of concealed medical emergencies, choking, abnormal breathing and appropriate first-aid responses.
  Stated by Metropolitan Police ServiceExisting arrangements considered sufficient
AI-generated summary

Rashan Jermaine CHARLES · 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

Rashan Jermaine Charles entered a convenience store after a foot chase, put a package in his mouth, and was restrained and handcuffed during a struggle. He lost consciousness and suffered cardiac arrest; the recorded medical cause of death was cardiac arrest due to upper airway obstruction by a foreign body during restraint. Concerns included recognising choking when it resembles resistance, assessing breathing in stressful conditions, and managing assistance from members of the public.

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
Difficulty assessing whether breathing is present and normal
Wider context from the report
“When updating police officer training, it would seem helpful for those developing policies and protocols to bear the following factors in mind, factors that might not otherwise be evident to police officers. 1. An apparent struggle to resist search or arrest, might in fact be a struggle to breathe, or might become that. 2. Choking is not always accompanied by classic signs such as clutching the throat, coughing, red face or bulging eyes, but can be silent and very quick. 3. It can be extremely difficult to assess whether breathing is present and normal, particularly in a stressful and/or noisy situation. (I heard evidence that, for training purposes, abnormal breathing could possibly in future be simulated by a virtual reality programme.) 4. Members of the public can sometimes give vital assistance, but this assistance might need to be managed. Analysis of a situation by a member of the public might give helpful insight, but on the other hand might not be accurate. Even a single member of the public might unwittingly distract an officer, especially in a fast paced environment. I heard evidence that, at present, MPS training does not include specific advice about how best to utilise members of the public who are willing and able to assist police officers. ”
Source location
Rashan Jermaine CHARLES · 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 ELS training scenarios requiring officers to assess breathing, reposition subjects, recognise noisy breathing and provide CPR.

Verbatim wording from the response
“The careful assessment of a subject’s breathing features in one of the training scenarios within the 2018 / 2019 ELS training package. The scenario requires an assessment of a subject’s breathing, and them being re-positioned to assist breathing. The scenario then develops to noisy breathing and onto the delivery of cardiopulmonary resuscitation (CPR).”

Source location
2018-0210-Response-by-Metropolitan-Police
Page 2 · response
Published 14 August 2018
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
Train officers to conduct thorough breathing checks, monitor breathing, open airways and commence CPR when breathing is abnormal or uncertain.

Verbatim wording from the response
“The importance of completing a thorough breathing check and regularly monitoring a subject’s breathing is central to ELS training. The training states that if breathing cannot be established because a subject is in the recovery position, they should be turned onto their back to facilitate a full breathing check. It further states that CPR should be commenced if there is any doubt.”

Source location
2018-0210-Response-by-Metropolitan-Police
Page 3 · response
Published 14 August 2018
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 MPS Emergency Life Support training addresses recognition of concealed medical emergencies, choking, abnormal breathing and appropriate first-aid responses.

Verbatim wording from the response
“The possibility that an apparent struggle or resistance might mask a medical emergency is firmly established within the MPS’ Emergency Life Support (ELS) training. It is central to training concerning positional asphyxia and Acute Behavioural Disturbance. It has also informed the MPS’ review of guidelines associated with restraint positions. Current work is focusing upon tilting the subject’s head forward to help reduce the risk of concealed objects falling into the airway and causing choking. The revised guidance is currently being peer-reviewed prior to adoption by the MPS. The findings will be shared with the College of Policing to help ensure best practice across England and Wales.”

Source location
2018-0210-Response-by-Metropolitan-Police
Page 2 · response
Published 14 August 2018
Open published response
25 Apr2017
Coventry
Concerns raised1
1. Failure to reliably assess patients' breathing through the door window
This report raised 5 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

Joleen Linton · 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

Joleen Linton died on 3 August 2016 in her room on Spencer Ward, Caludon Centre, after being admitted as an informal patient following an overdose of prescribed drugs. She was discovered deceased at 0800 hours after hourly observations, with concerns about the practicality and reliability of observations, inaccurate recording of her position, reluctance to enter patients’ rooms, and a lack of clarity in the relevant 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 to reliably assess patients' breathing through the door window
Wider context from the report
“(2) Evidence indicated that in consequence of lighting, distance and obstructions it was not practical to reliably assess, through the door window, whether a patient was breathing; ”
Source location
Joleen Linton · Prevention of Future Deaths report
Page 2 · concerns
Open source report
6 Dec2016
Inner North London
Concerns raised1
1. Failure to assess breathing and perform airway manoeuvres during resuscitation
This report raised 14 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 2
1. Action
  Check that all Care UK clinical staff receive mandatory intermediate life-support training.
  Stated by Care UKStated completed
2. Action
  Develop and circulate a standard operating procedure for emergency response.
  Stated by Care UKStated in progress
AI-generated summary

Tedros Habtom KAHSSAY · 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

Tedros Kahssay killed himself by hanging in HM Prison Pentonville about a month after being admitted on a charge of murdering his pregnant partner. Concerns included incomplete transfer and recording of information, shortcomings in reception screening, and significantly deficient and chaotic resuscitation procedures. The report states that he was already dead when resuscitation commenced, while expressing concern for other prisoners requiring 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
Failure to assess breathing and perform airway manoeuvres during resuscitation
Wider context from the report
“7. The resuscitation led by the two nurses occupying the positions of primary (Hotel 7) and secondary (Hotel 12) leads for emergency healthcare in the prison that night, was significantly lacking in the following ways. • The nurse with primary responsibility for emergency care in the prison did not have a proper understanding of the nature of a code red and a code blue prison medical emergency. (I have raised this issue in the past.) • One minute and twelve seconds elapsed after nurse arrival before any substantive care was given. The action during that one minute and twelve seconds did not appear to progress the resuscitation attempt. • There seemed no clear demarcation of roles and responsibilities during the resuscitation. Of course these may change as those giving resuscitation tire, but the changes seemed haphazard. • There was no checking for breath or airway manoeuvre at the outset or at any time during the resuscitation. • There was no checking for pulse at the outset, before commencing chest compressions, or at any time during the resuscitation. The lead nurse attempted to justify this by saying that she had not wanted to waste time. This was despite the first action upon finding the casualty being to apply a blood pressure cuff, on the basis that this was part of the nurse assessment. • When giving evidence, the lead nurse appeared to conflate the casualty who is in cardiorespiratory arrest with the casualty who is merely unconscious. She repeatedly talked about the need to give cardiopulmonary resuscitation (CPR) to an unconscious casualty. She said that, at the time she started chest compressions, she did not know whether Mr Kahssay was breathing or not breathing. • When CPR was given, chest compressions were ineffective, being too quick and too shallow. • There was only one brief attempt to use an ambubag, the majority of the resuscitation taking place without airway assistance or with a non rebreathe oxygen mask. • It appeared that one oxygen cylinder was empty, as it had to be changed for another. The nurse leading the resuscitation described it as chaotic. That is indeed how it appeared to me from her description and from viewing the bodycam footage. I was and remain very gravely concerned, not in this respect for Mr Kahssay who was in fact already dead when resuscitation commenced, but for anyone else in the prison in need of first aid. ”
Source location
Tedros Habtom KAHSSAY · 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
Check that all Care UK clinical staff receive mandatory intermediate life-support training.

Verbatim wording from the response
“All clinical staff that are employed by Care UK have ILS as a mandatory training requirement. A check has been undertaken to ensure that all Care UK clinical staff are receiving the ILS training. This has been confirmed to be the case.”

Source location
2016-0437-Response-by-Care-UK.pdf
Page 3 · response
Published 6 December 2016
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 circulate a standard operating procedure for emergency response.

Verbatim wording from the response
“In addition to this, the healthcare team plan to discuss issues relating to resuscitation and use of emergency bags regularly in their Friday afternoon training sessions. A SOP for emergency response is in development by the national team and is due for circulation shortly.”

Source location
2016-0437-Response-by-Care-UK.pdf
Page 3 · response
Published 6 December 2016
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Lack of national pathway guidance for call handlers on assessing whether someone is breathing and whether CPR is required

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.1

Concerns raised1

Failure to recognise breathing difficulty and place an unresponsive person in the recovery position

Concerns raised1

Use of an unreliable chest/abdomen movement observation method for checking breathing through cell door hatches

Concerns raised1

Failure to confirm absent breathing using an adequate assessment

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.4

Concerns raised1

Difficulty assessing whether breathing is present and normal

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.2

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

Concerns raised1

Failure to reliably assess patients' breathing through the door window

Concerns raised1

Failure to assess breathing and perform airway manoeuvres during resuscitation

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.2

Actions described in response 1

Actions described in response 4

Actions described in response 2

Respondent positions 1

Actions described in response 2