Recurring concern

Unreliable emergency response to patient collapse

First to latest report 16 Dec 2013 — 26 May 2026

Reports that mention this concern
33
Times this concern has been raised
47
Stated actions linked to this concern
77

What this concern includes

Includes failures in the dedicated emergency-response process for a collapsed patient, including response guidance and policies, staff training and familiarity with emergency systems, recognition and escalation, emergency equipment use, attendance, positioning and resuscitation actions.

What is not included
  • Excludes generic emergency-response or resuscitation deficiencies where patient collapse is not the identified operational context.
  • Excludes failures limited to later hospital treatment, admission or post-resuscitation care after the immediate collapse response was adequate.
  • Excludes generic staffing, communication or documentation deficiencies unless they directly impair the emergency response to patient collapse.
  • Excludes condition-specific emergency systems, such as Code Blue or agonal-breathing recognition, when that named system provides the more specific supported parent boundary.
  • Excludes the occurrence or outcome of a collapse where no deficiency in the dedicated response process is identified.

Reports and published responses 33 reports

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

  1. Manchester West

    AI-generated summary

    Margaret Walker · 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

    Margaret Walker, a detained patient at the Sephton Unit, was found unresponsive on 7 August 2012 and later diagnosed as having died from coronary artery disease. Concerns included inconsistent diabetes care, delays and omissions in obtaining and communicating medication and blood-test information, inadequate clinical-record documentation, and the defibrillator not being applied before ambulance personnel arrived.

    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 apply an available defibrillator promptly during resuscitation

    Wider context from the report

    “(3) When Mrs Walker was found unresponsive at approximately 6.00am on the morning of the 7th August 2012, cardio-pulmonary resuscitation was appropriately commenced and continued and a defibrillator was obtained. However the defibrillator was not applied prior to the arrival of ambulance personnel who then applied their own defibrillator, which did not reveal a heart rhythm suitable for a shock to be given. ”

    Source location

    Margaret Walker · 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

    Address resuscitation competency of staff involved in the incident through specific Trust competency processes.

    Verbatim wording from the response

    “In this case, while the staff involved in the incident were compliant with their mandatory training requirements they had not appropriately followed the Trust approved Resuscitation policy and procedures in relation to the use of the automated external defibrillator. I would like to reassure you that this has been addressed with the staff in question who has undergone specific Trust processes in relation to their competency.”

    Source location

    2014-0134-Response-by-5-Boroughs-Partnership-NHS-Foundation-Trust
    Page 3 · response
    Published 25 March 2014

    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

    Conduct annual resuscitation practice drills including automated external defibrillator use and document competency outcomes.

    Verbatim wording from the response

    “In line with NPSA and RCUK guidelines, it is recommended that services undertake practice drills to support further learning within the clinical environment. The Trust operates an annual practice drill schedule that includes use of an automated external defibrillator. Practice drills are undertaken by the Trust resuscitation trainers to ensure correct standards of practice are demonstrated. Staff are assessed against the RCUK competency framework during practice drills; the outcomes of practice drills are documented to identify areas of good practice and areas requiring improvement. Local actions plans are agreed to address any areas of concern. Records are available which evidence that Sephton Ward have had 4 practice drills completed between November 2012 and January 2014.”

    Source location

    2014-0134-Response-by-5-Boroughs-Partnership-NHS-Foundation-Trust
    Page 3 · response
    Published 25 March 2014

    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

    Staff involved in the resuscitation incident complied with mandatory training requirements; the failure concerned following approved procedures instead.

    Verbatim wording from the response

    “In line with National Patient Safety Agency (NPSA) RRO10 “Resuscitation in Mental Health and Learning Disability inpatient settings” (November 2008) and Resuscitation Council UK (RCUK) requirements, all medical staff and registered nurses working within inpatient settings are expected to be competent to the standard of Immediate Life Support (ILS). All support workers are expected to be competent to the standard of Basic Life Support (BLS).”

    Source location

    2014-0134-Response-by-5-Boroughs-Partnership-NHS-Foundation-Trust
    Page 3 · response
    Published 25 March 2014

    Open published response

  2. North London

    AI-generated summary

    Adrian Anthony Cowan · 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

    Adrian Anthony Cowan, who was detained under the Mental Health Act 1983, had a seizure on 14 June 2012 and was later found unresponsive in his room after being observed breathing normally. The inquest recorded natural causes, with pulmonary thromboembolism and deep vein thrombosis as the medical cause of death, alongside epilepsy and diabetes. Concerns related to unclear emergency-response guidance, including the failure to require the duty doctor to attend, and staff difficulties in responding calmly and applying basic life-support 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

    Failure of emergency-response policy to require requesting duty doctor attendance

    Wider context from the report

    “(1) That the trust policy dealing with the staff response did not include a clear set of guidance to those staff members responding to Mr Cowan’s collapse nor did the policy include the need, as part of the emergency response, to request the duty doctor to attend. ”

    Source location

    Adrian Anthony Cowan · 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 of nursing staff to respond to collapses in a calm coordinated manner

    Wider context from the report

    “(2) Some of the nursing staff were not able, when responding to Mr Cowan being found collapsed, act in a calm coordinated manner and were not able to apply the training they had received in basic life support. ”

    Source location

    Adrian Anthony Cowan · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of clear staff-response guidance for collapses

    Wider context from the report

    “(1) That the trust policy dealing with the staff response did not include a clear set of guidance to those staff members responding to Mr Cowan’s collapse nor did the policy include the need, as part of the emergency response, to request the duty doctor to attend. ”

    Source location

    Adrian Anthony Cowan · 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 the Trust resuscitation policy to address emergency response guidance.

    Verbatim wording from the response

    “I would like to assure you that we have taken immediate action to review the Trust’s resuscitation policy, which at the time of Mr Cowan’s Death was up to date and was not due to be reviewed until 2015.”

    Source location

    2014-0111-Response
    Page 1 · response
    Published 7 February 2014

    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

    Update the resuscitation policy with deteriorating-patient actions, an expanded NEWS Score, and a requirement to contact the duty doctor during medical emergencies.

    Verbatim wording from the response

    “The update to the policy will incorporate additional action to be taken in the future in response to the “deteriorating patient”, and we will update and expand the “NEWS” Score, which is a nationally recognised tool for assessing patients whose physical health may be deteriorating. The revised policy will make clear the need to contact the duty doctor in the event of a medical emergency.”

    Source location

    2014-0111-Response
    Page 2 · response
    Published 7 February 2014

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Display step-by-step breathing-assessment and emergency-response guidance across all Forensic Service ward areas.

    Verbatim wording from the response

    “I would like to clarify that the Trust’s resuscitation policy in place at the time of Mr Cowan’s death did list the actions to be taken to determine whether a patient was breathing or not, and explained what action was to be taken in such events. We have now displayed this step by step guide within all ward areas within the Forensic Service, and we will be introducing this in all our other inpatient areas. I would further wish to reassure you that the training provided to frontline staff will reiterate the changes in our policy once it has been ratified which I anticipate will have been completed by 30th April 2014.”

    Source location

    2014-0111-Response
    Page 2 · response
    Published 7 February 2014

    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

    Introduce the step-by-step emergency-response guide in all other inpatient areas.

    Verbatim wording from the response

    “I would like to clarify that the Trust’s resuscitation policy in place at the time of Mr Cowan’s death did list the actions to be taken to determine whether a patient was breathing or not, and explained what action was to be taken in such events. We have now displayed this step by step guide within all ward areas within the Forensic Service, and we will be introducing this in all our other inpatient areas. I would further wish to reassure you that the training provided to frontline staff will reiterate the changes in our policy once it has been ratified which I anticipate will have been completed by 30th April 2014.”

    Source location

    2014-0111-Response
    Page 2 · response
    Published 7 February 2014

    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

    Revise and regularly run lifelike-manikin resuscitation assessments and practical sessions across Forensic Service and Trust wards.

    Verbatim wording from the response

    “In order to improve the confidence and competence of staff’s application of resuscitation techniques, regular assessments and practical sessions have been implemented using a lifelike manikin, designed to offer a highly realistic platform for the teaching of resuscitation. This approach is being revised and will in future be run regularly across all wards within the Forensic Service and the Trust. I have asked our Resuscitation Officer to conduct unannounced resuscitation scenarios across the Forensic wards so that we may further strengthen staffs ability to respond in an emergency situation.”

    Source location

    2014-0111-Response
    Page 2 · response
    Published 7 February 2014

    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

    Conduct unannounced resuscitation scenarios across Forensic wards to strengthen emergency response.

    Verbatim wording from the response

    “In order to improve the confidence and competence of staff’s application of resuscitation techniques, regular assessments and practical sessions have been implemented using a lifelike manikin, designed to offer a highly realistic platform for the teaching of resuscitation. This approach is being revised and will in future be run regularly across all wards within the Forensic Service and the Trust. I have asked our Resuscitation Officer to conduct unannounced resuscitation scenarios across the Forensic wards so that we may further strengthen staffs ability to respond in an emergency situation.”

    Source location

    2014-0111-Response
    Page 2 · response
    Published 7 February 2014

    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 resuscitation policy already listed actions for determining whether a collapsed patient was breathing and responding to such events.

    Verbatim wording from the response

    “I would like to clarify that the Trust’s resuscitation policy in place at the time of Mr Cowan’s death did list the actions to be taken to determine whether a patient was breathing or not, and explained what action was to be taken in such events. We have now displayed this step by step guide within all ward areas within the Forensic Service, and we will be introducing this in all our other inpatient areas. I would further wish to reassure you that the training provided to frontline staff will reiterate the changes in our policy once it has been ratified which I anticipate will have been completed by 30th April 2014.”

    Source location

    2014-0111-Response
    Page 2 · response
    Published 7 February 2014

    Open published response

  3. Surrey

    AI-generated summary

    Sarah Anne Shepherd · 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

    Sarah Anne Shepherd, a patient detained under the Mental Health Act, was found in her room with a plastic bin liner over her head on 12 September 2011 and died in hospital the following day. The report identified concerns about unclear referral processes to the Psychiatric Intensive Care Unit, failures to attempt resuscitation in accordance with guidance, and uncertainty and misleading materials concerning resuscitation 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

    Unclear alignment of resuscitation training with current guidance

    Wider context from the report

    “(2) It was apparent from the evidence that the nursing staff who found the Deceased in an unresponsive state on the 12th September 2011 did not attempt to resuscitate her in accordance with the guidelines of the Resuscitation Council. They understood that resuscitation should be started if the patient was not “breathing” whereas the Council states that it should be started if the patient is not “breathing normally”. The evidence heard as to what training the nursing staff had been given concerning when resuscitation should be started was unclear and confusing. It remains unclear whether the resuscitation training now being given to clinical staff (a) is fully and clearly in accordance with the current guidance of the Resuscitation Council and (b) includes training as to what observations should be taken and recorded. Further, it was apparent from the evidence that the resuscitation bags used by staff contain a laminated aide memoire which is itself misleading as it refers to the use of resuscitation when the patient is not “breathing” rather than “breathing normally”. ”

    Source location

    Sarah Anne Shepherd · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

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

Back to top

Data last updated 7 September 2026