Recurring concern

Failure to ensure essential clinical equipment and supplies are available and serviceable

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First reported 30 Aug 2013•Latest report 8 May 2026

Definition

What this concern includes

Includes availability, stock, checking, maintenance or servicing failures that leave essential clinical equipment or supplies unavailable or unfit for use.

Not included

  • Excludes non-clinical equipment and vehicle, environmental, or recreational-equipment checks.
  • Excludes failures concerning the operation or use of equipment during care when no equipment-readiness or serviceability check is implicated.
  • Excludes generic staffing, training, documentation, audit, or supervision deficiencies unless they are specifically tied to the reliability of daily clinical-equipment serviceability checks.
  • Excludes checks of patient condition, care processes, messages, or other non-equipment objects.
Reports
41

Distinct published reports

Individual concerns
46

A report can raise multiple concerns

Date range
2013–2026

First to latest report issue date

Stated actions
43

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

NHS England6
Department of Health and Social Care4
Care Quality Commission3
East Kent Hospitals University NHS Foundation Trust2
General Pharmaceutical Council2
Greater Manchester Health and Social Care Partnership2
Royal College of Physicians2
Association Of Anaesthetists (Great Britain & Ireland)1
Avenue House Nursing and Care Home1
Ayuntamiento de La Oliva1
Barking, Havering and Redbridge University Hospitals NHS Trust1
Barts Health NHS Trust1
Blackpool Teaching Hospitals NHS Foundation Trust1
Brunswick Ward at Lindridge1
Care UK1

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.

  1. Suffolk

    AI-generated summary

    Matthew Colin FITTEN · 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

    Matthew Fitten was found deceased at home on 17 April 2020, and toxicology identified a toxic quantity of methadone in his blood. During the COVID-19 pandemic, his methadone collection was changed from three times per week to fortnightly, but he received three large bottles without a measuring jug or instructions for accurately measuring his prescribed daily dose. The report identifies concerns that this increased access to methadone and the lack of suitable dosing arrangements contributed to his death.

    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 measuring equipment and instructions for accurate daily methadone dosing

    Wider context from the report

    “During the evidence it was heard that at the start of the Covid19 pandemic PHE guidance was issued to Turning Point (the Suffolk Recovery Network) that individuals on opiate replacement treatment (Methadone) should be moved off short term (daily or tri-weekly) prescription collections to longer term ones. In Matthew’s case his collection was changed from 3 times per week to fortnightly. The doctor who made the changes to the prescription stipulated that Matthew’s dose must be in single daily dosage bottles. Matthew had a secure store in his home and was used to taking his Methadone from single daily dosage bottles. In addition the Turning Point doctor had sent a letter to all of the pharmacy’s that supplied opiate replacement therapies to his patients, explaining that only daily usage bottles should be prescribed. On the 15th April 2020 Matthew collected his 14-day methadone supply from the Haverhill Pharmacy in Haverhill, Suffolk. Evidence produced by Matthews father during the inquest itself, clearly showed that Matthew had been issued three bottles of Methadone to cover the 14-day period. These bottles contained 100ml, 156ml and 500ml of Methadone respectively. In addition, because Matthew’s prescription had been for single dose bottles a separate ‘measuring jug’ had not been prescribed by the Turning Point doctor. Matthew’s prescribed dose of Methadone was 54ml daily. As such, when Matthew was given the 100ml, 156ml and 500ml Methadone bottles on the 15th April 2020, he was not given anything to accurately measure his daily dose from them. It is therefore probable, that due to a lack of a measuring jug, Matthew guessed his first dose from the larger Methadone bottles with tragic consequences. Had Matthew been given daily dose bottles of Methadone as prescribed, or a measuring jug and instructions on how to use it had been provided, on a balance of probability basis his death would not have occurred. ”

    Source location

    Matthew Colin FITTEN · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  2. Blackpool and the Fylde

    AI-generated summary

    James David FLETCHER · 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

    James David Fletcher died in hospital on 14 July 2018 following peritonitis caused by leakage of gastric contents after PEG tube insertion. The report identifies concerns including failure to consider or detect peritonitis, continued use of the PEG tube despite it being contraindicated, inadequate communication and record keeping, insufficient awareness of post-operative PEG risks, and difficulties ensuring essential medication was available.

    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 ensure essential medication is available in the correct location

    Wider context from the report

    “6) The evidence disclosed that certain essential medication had not been retained in close proximity to the Deceased, where it was required. I am concerned that, in such circumstances, essential medication may be required urgently to protect the life of a patient and that systems should be robust enough to ensure that it is available in the correct location. ”

    Source location

    James David FLETCHER · Prevention of Future Deaths report
    Page 2 · 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

    Existing admission medication reviews, clinical pharmacist assessments and in-Trust prescribing arrangements address essential medication availability.

    Verbatim wording from the response

    “6) Approximate availability of essential medication – The practice in the Trust is that all patients on admission have their medication reviewed by the admitting doctor and are then seen by a clinical pharmacist and drugs are prescribed for use within the Trust.”

    Source location

    2019-0146-Response-by-Blackpool-Teaching-Hospitals-NHS-Trust
    Page 2 · response
    Published 29 July 2019

    Open published response

  3. Northamptonshire

    AI-generated summary

    Gladys Kathleen Rich · 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

    Gladys Kathleen Rich suffered repeated falls after moving into Avenue House Nursing and Care Home, culminating in a fall on 28 December 2016 that caused traumatic subdural and subarachnoid haemorrhages and a skull fracture. She died on 3 March 2017; the medical cause of death included chest infection, intracranial haemorrhage and a fall, with rectal cancer and liver metastases also recorded. The principal concerns related to failures to identify and manage her falls risk, ineffective referral and follow-up by the care home and Falls Prevention Service, inadequate resources and equipment, and the absence of an effective system to ensure required falls-prevention input was delivered.

    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

    Unavailability of required falls prevention equipment

    Wider context from the report

    “d) The care home may not have some of the equipment that they require for patients such as Mrs Rich e.g. a bed sensor mat. ”

    Source location

    Gladys Kathleen Rich · 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

    Floor-based sensor mats and staff monitoring are considered sufficient; bed sensors offer no additional advantage and communal-area sensors are unsafe.

    Verbatim wording from the response

    “out of bed, she did have a sensor mat on the floor by her bed, which did alert staff if she was up and walking around her bedroom. A floor based sensor mat is the normal equipment used in care homes for residents at risk of falls. Bed sensor mats are extremely rare and we believe do not offer any advantages over floor based pressure mats. Mrs Rich also had falls in the communal areas of the home and unfortunately no sensor could safely be used to reduce the likelihood of these. However, staff were aware of her high falls risk, and did monitor her when mobilising independently with her frame.”

    Source location

    2018-0149_Redacted-Response-by-Avenue-House-Care-Home
    Page 2 · response
    Published 8 July 2018

    Open published response

  4. Manchester West

    AI-generated summary

    James Sheffield · 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

    James Sheffield suffered a cardio-respiratory arrest on 12 July 2016 after surgery following an accidental fall and died on 17 July 2016. The report identified concerns about the absence of an established system to ensure that patient-owned CPAP equipment remained with patients during internal hospital transfers and was immediately available and ready for use. The report stated that the missing CPAP machine did not have a bearing on the outcome.

    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 ensure immediate availability and readiness for use of patient-owned medical equipment after internal transfers

    Wider context from the report

    “3. However, the evidence that I heard revealed that there was no established system in place to ensure that such a piece of important medical equipment would remain with the patient in the event of transfer of that patient within the hospital from differing wards, units or departments; 4. Whilst I heard evidence that a comprehensive “Report following investigation” had been conducted by Salford Royal Hospital, facilitated by their Governance Manager, in which there was correctly identified the necessary potential root causes, conclusions and sharing of lessons, proposed monitoring mechanisms, ward to ward transfer documents and electronic record systems that had been put in place – nevertheless, the evidence that I received suggested that there were outstanding protocols and/or policies to be implemented to ensure that following an internal transfer, patient owned medical equipment such as the “CPAP” machine should not only be moved with that patient, but specific measures taken to ensure that it was both immediately available and ready for use to enable the patient to self-care upon completion of the transfer. ”

    Source location

    James Sheffield · 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

    Implement and operate enhanced ward-to-ward transfer documentation requiring equipment readiness confirmation and explanations for unavailable equipment.

    Verbatim wording from the response

    “Further to the assurances given by ████████ at the Inquest into the death of James Sheffield which concluded on Wednesday 31 January 2018, the Trust has already now implemented further changes to the ward to ward transfer document on its electronic patient record system in order to address the additional concern raised.”

    Source location

    2018-00214-Response-by-Salford-Care-Organisation-NHS-Trust
    Page 2 · response
    Published 14 April 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 ward-transfer documentation and process changes are considered sufficient to address the identified recurrence risk, so no further Regulation 28 action is needed.

    Verbatim wording from the response

    “In the circumstances, it is clear that the duty to make a Regulation 28 report is no longer engaged since the Trust has already taken steps to put in place measures to prevent the recurrence of the risk identified.”

    Source location

    2018-00214-Response-by-Salford-Care-Organisation-NHS-Trust
    Page 2 · response
    Published 14 April 2018

    Open published response

  5. Stoke-on-Trent and North Staffordshire

    AI-generated summary

    Donald John TILL · 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

    Donald John TILL, a 68-year-old man with a history of small bowel adenocarcinoma, presented with abdominal pain and vomiting caused by a large bowel obstruction. After emergency surgery on 4 January 2017, he aspirated faeculent material during anaesthesia, developed aspiration pneumonia, deteriorated in intensive care, and died on 5 January 2017. Concerns included unavailable previous medical records, anaesthesia on a ward bed without rapid tilt, problems sourcing suitable bronchoscopy equipment, and the non-use of cricoid pressure and a nasogastric tube before anaesthesia.

    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 a bronchoscope on the standard anaesthetic equipment trolley

    Wider context from the report

    “3. A bronchoscope was not part of the standard anaesthetic equipment trolley and when one was sourced it had a suction button missing. ”

    Source location

    Donald John TILL · 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

    Unavailability of a functional bronchoscope suction button

    Wider context from the report

    “3. A bronchoscope was not part of the standard anaesthetic equipment trolley and when one was sourced it had a suction button missing. ”

    Source location

    Donald John TILL · 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 a rapid-tilt trolley for anaesthesia

    Wider context from the report

    “2. The deceased was anaesthetised on a ward bed and it would have helped if he had been on a trolley with rapid tilt. ”

    Source location

    Donald John TILL · 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 disposable bronchoscopy equipment and assess its efficacy for possible wider use in theatres.

    Verbatim wording from the response

    “3. In the initial stages of aspiration, ‘blind’ endotracheal suction can often suffice to treat the presenting problem. It is only once the majority of the aspirate has been removed by this technique, that it is possible to perform bronchoscopy to attempt to remove further debris and wash out the lungs. Throughout the UK, bronchoscopes are not a standard piece of equipment on the ‘difficult airways trolley’. However, currently, our Critical Care areas are reviewing the use of disposable bronchoscopy equipment and once the efficacy of this relatively newly available equipment has been assessed as beneficial, we will further assess whether their use should be extended to being a standard piece of equipment in theatres.”

    Source location

    2018-0013-Response-by-University-Hospitals-of-North-Midlands
    Page 3 · response
    Published 7 March 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

    Ensure beds and trolleys have rapid-tilt facilities and keep a rapid-tilt trolley available for high-risk patients.

    Verbatim wording from the response

    “2. Following the investigation into the care provided to Mr Till (Root Cause Analysis), it was identified that a rapid tilting trolley may have assisted in treating Mr Till. Measures were taken at the time to ensure that rapid tilt trolley was on standby for those high risk patients. It is my understanding that all beds and trolleys have a rapid tilt facility for emergency situations. This information has been fed back to the Corporate Governance Team in order to take forward any training needs.”

    Source location

    2018-0013-Response-by-University-Hospitals-of-North-Midlands
    Page 3 · response
    Published 7 March 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

    Bronchoscopes are not generally standard difficult-airway-trolley equipment, and initial aspiration treatment can often use blind endotracheal suction.

    Verbatim wording from the response

    “3. In the initial stages of aspiration, ‘blind’ endotracheal suction can often suffice to treat the presenting problem. It is only once the majority of the aspirate has been removed by this technique, that it is possible to perform bronchoscopy to attempt to remove further debris and wash out the lungs. Throughout the UK, bronchoscopes are not a standard piece of equipment on the ‘difficult airways trolley’. However, currently, our Critical Care areas are reviewing the use of disposable bronchoscopy equipment and once the efficacy of this relatively newly available equipment has been assessed as beneficial, we will further assess whether their use should be extended to being a standard piece of equipment in theatres.”

    Source location

    2018-0013-Response-by-University-Hospitals-of-North-Midlands
    Page 3 · response
    Published 7 March 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 rapid-tilt facilities on beds and trolleys are considered sufficient for emergency situations involving high-risk patients.

    Verbatim wording from the response

    “2. Following the investigation into the care provided to Mr Till (Root Cause Analysis), it was identified that a rapid tilting trolley may have assisted in treating Mr Till. Measures were taken at the time to ensure that rapid tilt trolley was on standby for those high risk patients. It is my understanding that all beds and trolleys have a rapid tilt facility for emergency situations. This information has been fed back to the Corporate Governance Team in order to take forward any training needs.”

    Source location

    2018-0013-Response-by-University-Hospitals-of-North-Midlands
    Page 3 · response
    Published 7 March 2018

    Open published response

  6. Portsmouth and South East Hampshire

    AI-generated summary

    Rafe Robbie Angelo · 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

    Rafe Robbie Angelo was born at 17:30 on 23 September 2014 after his mother was transferred from the Blake Birthing Centre to hospital during labour. He was born pale and floppy, without breathing or a heart rate, and died after 37 minutes of resuscitation. The principal concerns included delays in recognising the need for urgent delivery and communication failures between the birthing centre, ambulance service and hospital, including failure to request a time-critical transfer and a non-urgent ambulance stop.

    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

    Unavailability of CTG equipment in birthing centres

    Wider context from the report

    “CTG is not currently available in birthing centres and should be considered in emergency situations such as this case especially if it is not possible to transport the mother to hospital. ”

    Source location

    Rafe Robbie Angelo · 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

    CTG should not be provided in low-risk birth centres because evidence shows no improved outcomes and increased unnecessary interventions.

    Verbatim wording from the response

    “Birth centres are accessed by women assessed to be low risk for complications. CTG is not made available in birth centres because NICE guidance clearly states that CTG must not be offered to women at low risk of complications in established labour (Intrapartum care for healthy women and babies NICE guidance, CG190, section 1.10.1). There is no evidence that the use of CTG in low-risk women improves the fetal/neonatal outcome. I am further advised that the evidence base shows that CTGs are not recommended in a low-risk population because they have a high false positive rate, generating much unnecessary interventions such as an instrumental delivery or a caesarean section. The evidence suggests that intermittent auscultation in a low-risk population appears to be equally effective at identifying problems but does not cause as much intervention.”

    Source location

    2017-0421-Response-by-Department-of-Health
    Page 4 · response
    Published 27 February 2018

    Open published response

  7. North East Kent

    AI-generated summary

    Andrew Jonathan WILSON · 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

    Andrew Jonathan Wilson had end-stage renal failure managed with home peritoneal dialysis and was admitted to Maidstone Hospital with sepsis on 20 July 2015. Peritoneal dialysis was unavailable at Maidstone Hospital and its satellite renal unit for three nights before he was transferred to the Kent and Canterbury Hospital, where dialysis was recommenced. He later deteriorated and died of natural causes; concerns were raised about the lack of arrangements, trained staff, equipment, and clinician awareness needed to provide peritoneal dialysis outside the Canterbury renal unit.

    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

    Unavailability of equipment for peritoneal dialysis

    Wider context from the report

    “(1) Although it was established on the balance of probability (after hearing the clinicians and an independent expert Consultant Nephrologist) that the absence of peritoneal dialysis on THIS occasion did not contribute to the death, the absence of any arrangements to provide peritoneal dialysis at hospitals other than the renal unit at Canterbury raised a concern. (2) There was an apparent absence of knowledge on the part of the treating clinicians at Maidstone Hospital that peritoneal dialysis could not be arranged either during the day or over-night at that hospital as there were no trained staff available nor was the equipment available. There were no arrangements in place to transport the equipment from the home of a patient to the hospital. ”

    Source location

    Andrew Jonathan WILSON · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  8. Brighton and Hove

    AI-generated summary

    Derek LEE · 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

    Derek LEE died on 5 June 2016 following an admission to Brunswick Ward. The report identified numerous concerns about his care, including medication management, incomplete assessments and documentation, falls and pressure-sore prevention, delayed referrals and treatment, nutrition, mobility, and the absence of a care co-ordinator. The inquest concluded that the death was from natural causes, and the report stated that the identified failings did not change the outcome.

    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 ensure timely provision and use of pressure-relieving equipment

    Wider context from the report

    “(4) No Waterloo score was done until the 4th May. Too late. No appropriate pressure relieving equipment was ordered until the 12th May. There was no evidence before me that the equipment was ever received or used for Mr Lee. When Mr Lee was admitted to the Acute Hospital he had a Grade 2 pressure sore on his Sacrum. ”

    Source location

    Derek LEE · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  9. Inner North London

    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

    Unavailability of a serviceable oxygen cylinder 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 4 · concerns

    Open source report

  10. South London

    AI-generated summary

    Christopher Brennan · 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

    Christopher Brennan, aged 15, was a patient at an adolescent psychiatric unit and died on 31 August 2014 after swallowing the lid of a roll-on deodorant, causing acute upper airway obstruction and cardiac arrest. The report identified concerns about the lack of clear and consistent guidance for managing items that could be used for self-harm and the absence of a laryngoscope from the unit’s emergency equipment.

    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

    Unavailability of laryngoscopes in emergency equipment on the unit

    Wider context from the report

    “(2) With regard to resuscitation: the emergency equipment on the unit did not include a laryngoscope. The item obstructing Christopher’s airway was subsequently used by ambulance personnel using Magill forceps with a laryngoscope, and this combination had been successfully used on a previous occasion when Christopher had swallowed a bottle top. Laryngoscopes are not part of the standardised items on the unit, and are not included in the Resuscitation Council guidance for mental healthcare settings. It has been suggested that this is because they are complex devices that require intense training and competency assessments before staff can use them, and that it may be counterproductive to make them available. However, in view of the circumstances of Christopher’s death, and the apparent prevalence of self harm in adolescent units, the matter is reported for consideration, both in relation to the laryngoscope itself and the access to staff trained in its use. ”

    Source location

    Christopher Brennan · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026