Recurring concern

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

First to latest report 30 Aug 2013 — 8 May 2026

Reports that mention this concern
41
Times this concern has been raised
46
Stated actions linked to this concern
43

What this concern includes

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

What is 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 and published responses 41 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Manchester South

    AI-generated summary

    Michael Guy Hutchence · 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

    Michael Guy Hutchence broke his lower leg after slipping on an icy pavement and died in hospital on 28 January 2016. The report raised concerns about repeated ward moves, staffing and record-keeping, weight-based anticoagulant dosing and inconsistent weight recording, inadequate equipment for leg elevation, and delays to surgery after two operation kits were found to be non-sterile. The stated medical cause of death included bronchopneumonia, deep vein thrombosis and pulmonary embolus, and fractured tibia and fibula.

    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

    Shortage of Braun’s Frames for safe leg elevation

    Wider context from the report

    “6. I was told that the ideal way of elevating a patient’s leg is by using a Braun’s Frame. There was (and apparently still is) a shortage of these within the hospital, such that his leg was at all times elevated by using pillows. This was a potential for causing or contributing to the formation of DVT’s. ”

    Source location

    Michael Guy Hutchence · Prevention of Future Deaths report
    Page 1 · 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

    Purchase and provide four additional Braun frames for Ward D1, increasing the hospital total to eight.

    Verbatim wording from the response

    “I can advise that four new Braun frames have since been purchased and were delivered to Ward D1 on 25 July 2016; we now have 8 in total. There is still a potential that outlying trauma patients, in the very busy winter period, may still have pillows utilised as an elevation method.”

    Source location

    2016-0228-Response-by-Stockport-NHS-Trust
    Page 2 · response
    Published 20 June 2016

    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

    There is no direct evidence that limb elevation reduces venous thromboembolism, and the elevation method does not affect that risk.

    Verbatim wording from the response

    “6) I was told the ideal way of elevating a patient’s leg is by using a Braun’s frame. There was (and apparently still is) a shortage of these within the hospital such that Mr Hutchence’s leg was at all times elevated by using pillows. This was a potential for causing or contributing to the formation of D.V.T’s”

    Source location

    2016-0228-Response-by-Stockport-NHS-Trust
    Page 2 · response
    Published 20 June 2016

    Open published response

  2. Cornwall and Isles of Scilly

    AI-generated summary

    Charlie Mark Jermyn · 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

    Charlie Jermyn was born at home on 9 May 2015 and developed sleepiness, feeding difficulty and possible respiratory distress. He stopped breathing during a routine visit the following day and died in hospital despite resuscitation attempts. The principal concerns were delayed recognition and referral for suspected sepsis, inadequate telephone triage and recording, insufficient observations, and wider shortcomings in midwifery guidance, equipment and training.

    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 and non-use of standard physiological observation equipment for mothers and babies

    Wider context from the report

    “4. All Community Midwives should be provided with standard equipment to include, ear thermometers, stethoscopes, blood sugar testing and SATS monitors and these should be used as routine practice to make routine observations on mother and baby. ”

    Source location

    Charlie Mark Jermyn · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. Warwickshire

    AI-generated summary

    Stanley SAMPEY · 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

    Stanley Sampey, an in-patient at George Eliot Hospital, choked on a food bolus while eating in bed on 5 March 2016. Staff found that both the wall-mounted suction device and a portable suction unit were not working, and concerns included the lack of working suction equipment and inadequate checking procedures.

    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 working suction equipment on wards

    Wider context from the report

    “1. There was no working available suction equipment on the Ward to manage the patient’s airway at the time of the cardiac arrest. ”

    Source location

    Stanley SAMPEY · Prevention of Future Deaths report
    Page 1 · 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 an effective procedure for checking suction equipment on wards

    Wider context from the report

    “2. There was a lack of any structured checking procedure in place to ensure working suction equipment on wards. 3. The battery on the portable suction unit was found to be flat and the checking procedure was incorrect. ”

    Source location

    Stanley SAMPEY · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  4. West Yorkshire (Western)

    AI-generated summary

    Carl Lee Thompson · 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

    Carl Lee Thompson died from drowning on 10 August 2015 after being overwhelmed by surf and waves while bathing in the sea in Fuerteventura. Concerns included inadequate or defective lifesaving and resuscitation equipment, lifeguards’ lack of training in its use, and delays in obtaining replacement equipment and emergency medical assistance.

    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 suction equipment for clearing airways

    Wider context from the report

    “• The emergency bag did not contain suction equipment to clear the airways • A hole in the ambubag used in the resuscitation attempts prevented the flow of oxygen • The defibrillator used during resuscitation was inoperable given it was found to have no batteries • Delay of 45 minutes to obtain a replacement defibrillator • Absence of equipment to dry the casualty • Substantial delay before the arrival of the ambulance and doctor for emergency treatment. ”

    Source location

    Carl Lee Thompson · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  5. Portsmouth and South East Hampshire

    AI-generated summary

    James Robertson · 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 Robertson died on 22 July 2015 while resident at Cams Ridge Care Home, after he was last checked at around 13.00 hours and found apparently deceased at around 15.30 hours. Concerns included inaccurate recording of care-check times, delayed recognition of his DNACPR status, and inadequate equipment in the emergency resuscitation pack, particularly the lack of a suction 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 useful equipment in nursing home emergency resuscitation packs

    Wider context from the report

    “3) I was also told that there are no national standards for what should be included in emergency resuscitation packs kept at nursing homes and in consequence, the pack brought to assist Mr Robertson was lacking useful equipment, particularly a suction unit. ”

    Source location

    James Robertson · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  6. Worcestershire

    AI-generated summary

    Bryan Arnold CATANACH · 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

    Bryan Arnold Catanach sustained a fractured odontoid peg and cervical injury after a fall, and died in hospital on 8 February 2015 after his condition deteriorated. The report identified concerns about communication and delays in transfer and senior review, inpatient falls prevention, and the availability and use of appropriate traction 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 and poor identification of required traction equipment

    Wider context from the report

    “(4) Traction equipment - Mr Catanach had a halo crown fitted in an attempt to reduce the fracture he had suffered. At the time this was undertaken Mr Newton-Ede did not have available to him the required Balkan beam traction equipment and a Swan neck device was used instead. This was plainly inferior and indeed a pulley wheel was found to have jammed the following morning rendering the traction ineffective and causing the fracture to slip back. It took 48 hours for the correct traction equipment to be found. It was likely that the equipment was available the whole time but that either staff did not know where it was kept, or those sent to find it did not know for what they were looking. It is a matter for the Trust to reflect on how to remedy this situation. It would seem that training of relevant staff would be a sensible first step. ”

    Source location

    Bryan Arnold CATANACH · 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

    Expand on-site spinal equipment and establish a central store for traction apparatus.

    Verbatim wording from the response

    “Traction Equipment Your own investigations correctly identified the challenges that had occurred in both identifying and securing the timely use of appropriate traction equipment. Since this incident, the Trust has expanded the range of spinal equipment held on site in the Trust and has created a central store for all traction apparatus. The Trust has also enhanced its internal register of equipment and in so doing, highlighted other sites around the hospital and beyond that hold similar equipment beyond that within our store. Finally, an enhanced pictorial training folder has been developed to allow staff, who may infrequently request spinal equipment, to recognise all of its contingent parts once delivered. The spinal services team have also responded to the issues around equipment training and orientation.”

    Source location

    Bryan-Catanach-Response
    Page 2 · response
    Published 1 December 2015

    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

    Enhance the internal equipment register to identify traction equipment held elsewhere.

    Verbatim wording from the response

    “Traction Equipment Your own investigations correctly identified the challenges that had occurred in both identifying and securing the timely use of appropriate traction equipment. Since this incident, the Trust has expanded the range of spinal equipment held on site in the Trust and has created a central store for all traction apparatus. The Trust has also enhanced its internal register of equipment and in so doing, highlighted other sites around the hospital and beyond that hold similar equipment beyond that within our store. Finally, an enhanced pictorial training folder has been developed to allow staff, who may infrequently request spinal equipment, to recognise all of its contingent parts once delivered. The spinal services team have also responded to the issues around equipment training and orientation.”

    Source location

    Bryan-Catanach-Response
    Page 2 · response
    Published 1 December 2015

    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 pictorial traction-equipment guidance and respond to related staff training and orientation needs.

    Verbatim wording from the response

    “Traction Equipment Your own investigations correctly identified the challenges that had occurred in both identifying and securing the timely use of appropriate traction equipment. Since this incident, the Trust has expanded the range of spinal equipment held on site in the Trust and has created a central store for all traction apparatus. The Trust has also enhanced its internal register of equipment and in so doing, highlighted other sites around the hospital and beyond that hold similar equipment beyond that within our store. Finally, an enhanced pictorial training folder has been developed to allow staff, who may infrequently request spinal equipment, to recognise all of its contingent parts once delivered. The spinal services team have also responded to the issues around equipment training and orientation.”

    Source location

    Bryan-Catanach-Response
    Page 2 · response
    Published 1 December 2015

    Open published response

  7. Manchester West

    AI-generated summary

    Davina Tavener · 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

    Davina Tavener died on 1 November 2014 after collapsing during a Ryanair flight from Manchester to Lanzarote. Cardiopulmonary resuscitation continued until the aircraft landed, but the aircraft did not carry airway adjuncts, suction equipment, a bag-valve-mask or a defibrillator. The report raised concerns that the absence of this equipment could contribute to future deaths and called for review of the requirements for medical equipment on aircraft.

    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 mandatory carriage of airway adjuncts, suction equipment, bag-valve-mask equipment and defibrillators on all aircraft

    Wider context from the report

    “The Regulations do not require Aircraft to carry the equipment requested by ████████ and the minimum requirement is to carry the equipment carried by Ryanair on Flight FR2131. It was accepted that Ryanair was operating within the Regulations in relation to medical equipment on Flight FR2131. iii. The evidence at the Inquest confirmed that some Airlines do carry the equipment requested by ████████, even though there is no Regulation for such equipment to be carried. Evidence was given that the equipment is carried on some long haul flights as opposed to short haul flights but it was accepted that the differential is not relevant in view of the fact that a cardiac arrest can occur at any time whether the Aircraft is ten minutes into a flight or ten hours into a flight. iv. ████████ gave evidence, supported by the Pathologist, that when someone has suffered a cardiac arrest, time is of the essence and the equipment requested by her could be critical in an attempt to save life. ████████ confirmed that a defibrillator would be critical to survival in cardiac events and a defibrillator would give someone the best chance of survival in a situation where there is a cardiac arrest. The evidence confirmed that for every one minute when activity in the heart has stopped the chance of survival reduces by ten percent and the availability of a defibrillator at the earliest time would increase the chance of survival. Both ████████ and the Pathologist gave evidence that an airway adjunct, suction equipment, bag-valve-mask and a defibrillator should be carried on all Aircraft as a mandatory provision of medical equipment to assist in the treatment and resuscitation of a passenger on an Aircraft and to give a passenger the best chance of survival until the Aircraft can reach the nearest destination. The provision of the aforementioned equipment would be used for the reasons explained in ████████ evidence and detailed in paragraph 4.4 of this report. v. Evidence was given that all the above equipment is now available as relatively inexpensive portable equipment and, in particular, a defibrillator is very simple to operate in that the defibrillator will announce instructions in relation to use by the operator. vi. It may be felt that cases of sudden cardiac arrest on Aircraft are very rare but Airlines carrying defibrillators have led to lives being saved and the saving of a single life would justify the availability of equipment on all Aircraft for use as and when a medical emergency arises. The Federal Aviation Authority has required US Airlines to carry a defibrillator on flights since 1994. vii. The evidence raised concerns that there is a risk that future deaths will occur unless action is taken to review the above issues. ”

    Source location

    Davina Tavener · 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

    Engage Member States to reconsider defibrillator carriage through available-data analysis and an initial discussion at the scheduled advisory-group meeting.

    Verbatim wording from the response

    “We will therefore engage with our Member States to reconsider the situation through analysis of available data. We will launch a first discussion on this matter at our next meeting with Member”

    Source location

    2015-0252-Response-by-EASA
    Page 1 · response
    Published 3 July 2015

    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

    Write to Ryanair about carrying AEDs on its fleet.

    Verbatim wording from the response

    “Regarding the carriage of AED’s on short-haul aircraft, there may be very little impact on the actual overall statistics. Notwithstanding that, I can confirm that the Chief Executive of the IAA has written to the Chief Executive of Ryanair on the matter. Further to that correspondence, it is our understanding that Ryanair are now positively reviewing the”

    Source location

    2015-0252-Response-by-IAA
    Page 2 · response
    Published 3 July 2015

    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

    Passengers are not at increased risk of sudden cardiac arrest, which is exceptionally rare on short-haul flights, and defibrillators often do not succeed.

    Verbatim wording from the response

    “In terms of possible changes to the current regulations on compulsory carriage of defibrillators, the CAA’s current view as set out on its Aviation Health Unit website, is that cases of sudden cardiac arrest are very rare when compared to the number of passengers carried. The evidence from those airlines that have been carrying them on a voluntary basis is that although a few lives are saved, in most cases the use of a defibrillator is not successful. This is partly because some of the cases are not due to ventricular fibrillation (the most common cause of cardiac arrest) and therefore a defibrillator will not be able to restore a normal rhythm. Also even if a normal heart rhythm can be restored, the cause of the abnormal rhythm – such as a heart attack – cannot be treated until the person gets to hospital and this can take several hours.”

    Source location

    2015-0252-Response-by-CAA
    Page 2 · response
    Published 3 July 2015

    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 voluntary carriage, regulatory consideration requirements and evidence review make mandating general carriage of this equipment currently difficult to justify.

    Verbatim wording from the response

    “Some airlines do carry defibrillators on a voluntary basis – particularly those operating on long haul sectors or mixed long haul and short sectors. The EASA regulations require operators to consider carrying them, depending on the type of their operations and other factors, such as passenger demographics (age etc). In the case of an airline operating only short haul routes, with flight durations of typically up to 3-4 hours (but often much shorter), the likelihood of a passenger who was well at the time of boarding having a significant medical event during the flight, let alone a cardiac arrest, is exceptionally small.”

    Source location

    2015-0252-Response-by-CAA
    Page 2 · response
    Published 3 July 2015

    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 UK cannot act alone to introduce legal changes because mandating the equipment would require significant international agreement.

    Verbatim wording from the response

    “It would be for EASA to consider the need for any change in the Regulations which apply to EU operators and for ICAO to consider this in relation to non-European operators. In either case, this”

    Source location

    2015-0252-Response-by-CAA
    Page 2 · response
    Published 3 July 2015

    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

    EASA must consider regulatory changes for EU operators, while ICAO must consider them for non-European operators.

    Verbatim wording from the response

    “It would be for EASA to consider the need for any change in the Regulations which apply to EU operators and for ICAO to consider this in relation to non-European operators. In either case, this”

    Source location

    2015-0252-Response-by-CAA
    Page 2 · response
    Published 3 July 2015

    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 EASA and ICAO arrangements, including operator risk assessments, are considered sufficient; AED carriage is not strictly required.

    Verbatim wording from the response

    “All AOC holders are in full compliance with the recommendations of European Aviation Safety Agency (EASA) and International Civil Aviation Organisation (ICAO).”

    Source location

    2015-0252-Response-by-IAA
    Page 2 · response
    Published 3 July 2015

    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

    Operators are responsible for deciding whether to carry AEDs based on the particular needs and risk assessment of each operation.

    Verbatim wording from the response

    “Namely the acceptable means of compliance to the rule concerned (CAT.IDE.A.225), listing the content of the Emergency Medical Kit, recommend operators to determine through risk assessment the need to carry the defibrillator. So there is no strict requirement for operators, but only a recommendation based on the result of a risk assessment.”

    Source location

    2015-0252-Response-by-IAA
    Page 2 · response
    Published 3 July 2015

    Open published response

  8. London (East)

    AI-generated summary

    Ronald Alfred Smith · 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

    Ronald Alfred Smith was admitted to Queen’s Hospital with a sigmoid volvulus causing bowel obstruction and bowel ischaemia, and died on 2 February 2014 before a flexible sigmoidoscopy could be performed. The principal concern was that staff could not access the equipment out of hours, and that no clear protocol for doing so had been established despite the identified need.

    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 make flexible sigmoidoscopy equipment available out of hours

    Wider context from the report

    “there was a failure in this case to access a flexible sigmoidoscope out of hours. This item of surgical equipment was not available to the surgical registrar who considered that this was the only intervention that may have benefitted the patient. Mr Smith’s death occurred in February 2014. The Trust’s root cause analysis report identified the need for a clearly communicated and accessible protocol for access to flexible sigmoidoscopies out of hours. Notwithstanding the period of 16 months which has elapsed since Mr Smith’s death there is still no protocol in place at the Trust. I consider that action should be taken to expedite a clear procedure for such equipment to be available to staff out of hours. ”

    Source location

    Ronald Alfred Smith · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  9. Cheshire

    AI-generated summary

    CHRISTOPHER RICARDO WILLIAMS · 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 Ricardo Williams was detained under the Mental Health Act and resident in a medium secure unit when he became unresponsive and was pronounced dead at the scene on 6 November 2013. The inquest concluded that the death was from natural causes, with the medical cause recorded as massive pulmonary embolism. Concerns included a defibrillator not working, failure to check it daily, absence of a cross-check system, and no hospital policy for managing sudden or unexpected 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

    Failure to check defibrillator equipment daily for serviceability

    Wider context from the report

    “(2) The defibrillator had not been checked on 5 November, although there was a requirement for the equipment to be checked daily for serviceability by the nursing staff. ”

    Source location

    CHRISTOPHER RICARDO WILLIAMS · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  10. Manchester South

    AI-generated summary

    Afifa Qaisar · 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

    Afifa Qaisar was admitted to Tameside General Hospital on 23 June 2013 with collapse and confusion, initially diagnosed as meningitis with sepsis, and died at 20.30 hours the same day. Concerns included uncertainty about whether drugs recorded as given had actually been administered, unavailability of required resuscitation equipment, failure to notify the RMO, delays in platelet and Hb support, an inappropriate response to an apparently non-running saline infusion, and failure to commence fluid balance monitoring or catheterisation.

    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 Gum-elastic Bougie Airway on the crash trolley

    Wider context from the report

    “2. During resuscitation the staff wished to use a “Gum –elastic Bougie Airway” but when they looked they found it was not available on the ‘crash trolley’. ”

    Source location

    Afifa Qaisar · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026