Recurring concern

Unreliable emergency response to patient collapse

Get email alerts

Request correction

First reported 16 Dec 2013•Latest report 26 May 2026

Definition

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.

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: 33
Individual concerns: 47
Date range: 2013–2026
Stated actions: 77

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.

East London NHS Foundation Trust3

Ministry of Justice3

NHS England3

Central and North West London NHS Foundation Trust2

Department of Health and Social Care2

Essex Partnership University NHS Foundation Trust2

HM Prison and Probation Service2

Metropolitan Police Service2

Aspray House1

Barts Health NHS Trust1

Broadmoor Hospital1

Bupa Care Homes (GL) Limited1

Caremark (Chiltern & Three Rivers)1

Care Quality Commission1

Greater Manchester Mental Health NHS Foundation Trust1

Concerns and responses across reports

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

12 Aug2024
Inner North London
Concerns raised1
1. Failure of nursing staff to call ambulances without prior senior clinician approval
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.
Actions described in response 2
1. Action
  Complete refresher Intermediate Life Support training for the nurse involved.
  Stated by East London NHS Foundation TrustStated planned
2. Action
  Disseminate to nursing staff that emergency services may be called without senior permission and physical health may contribute to behaviour.
  Stated by East London NHS Foundation TrustStated completed
Respondent positions 1
1. Position
  Nursing staff do not require senior permission to call emergency services; this is not agreed Trust practice.
  Stated by East London NHS Foundation TrustDisputes the concern
AI-generated summary

Nimo OSMAN · 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

Nimo Osman was in state detention under a Hospital Order and receiving psychiatric inpatient care when she collapsed on the ward on 21 April 2022. She was unresponsive for over half an hour before an ambulance was called and died in hospital on 23 April 2022 from hypoxic ischaemic brain injury. The principal concerns were delays in recognising the emergency and calling an ambulance, whether learning had been embedded among staff, completion of venous thromboembolism assessments, and ambiguity in the Trust’s venous thromboembolism policy.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure of nursing staff to call ambulances without prior senior clinician approval
Wider context from the report
“Following the discovery of Ms Osman’s collapse on Rosebank Ward on 21 April 2022, it took staff a significant number of minutes to recognise that instead of just lying on the floor, Ms Osman was actually unrousable. A few minutes later a nurse arrived on the scene, who decided to summon the duty senior nurse (DSN) by radio, rather than activating the alarm system, which would have summoned the rapid response team sooner. The DSN contacted the duty doctor to inform them that there was a medical emergency, prior to calling an ambulance. In total, Ms Osman had been on the floor and unresponsive for over half an hour before an ambulance was called. I also viewed the CCTV evidence covering this course of events. I heard evidence from a consultant neurosurgeon and a consultant neuroradiologist. Their evidence was such that, in Ms Osman’s case this delay would not have made a difference because she had suffered a catastrophic brain injury and her condition was likely to have been unsalvageable from the moment she was found unresponsive on the floor. However, I consider that a delay of circa 30 minutes in calling an emergency ambulance raises a considerable risk, if repeated in the case of another patient requiring emergency treatment at hospital. I was initially reassured by the evidence of a very senior member of nursing staff (Nurse A) about the work that has been done to educate all staff that anyone can call 999 for an ambulance if they consider it necessary, without seeking the advice of colleagues or the specific approval of a doctor. I was told by Nurse A that they were confident that the education and training undertaken with staff had had a positive impact and that a delay of this kind was unlikely to be repeated in the future. However, a senior nurse (Nurse B) who was on duty at the time of Ms Osman’s collapse told me in their evidence (over two years after Ms Osman’s death) that nursing staff cannot and would not call an ambulance of their own volition. Nurse B told me that she would only ever call an ambulance if told to do so by a more senior clinician. Nurse B went on to tell me that it was often the case that by the time an ambulance had been called and arrived, a patient would die; the manner in which this evidence was given led me to form the view that the Nurse B seemed to think that this was ‘just one of those things that happens’. While I was told by Nurse A (who seemed genuinely concerned) that this matter would be escalated and addressed, I was concerned that over two years since Ms Osman’s death this view was still held by a senior and experienced member of the nursing team who led a team of more junior nurses. My concern was such that I am not reassured that sufficient steps have been taken to prevent the recurrence of such a risk in the future. ”
Source location
Nimo OSMAN · 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
Complete refresher Intermediate Life Support training for the nurse involved.

Verbatim wording from the response
“5. I can confirm, that at the time of Ms Osman’s death and at the inquest, Nurse B’s Intermediate Life Support (ILS) training was up to date. This training is clear in highlighting the expectations of a staff member attending a medical emergency. These expectations include that the staff member will undertake an initial check of the service user, summons help internally, and ensure an ambulance is called. No permission is required from a senior staff member. Following the inquest, the BLN spoke to Nurse B and Nurse B confirmed that she recognised the need for escalation immediately in medical emergencies as opposed to waiting for senior input. The BLN and Nurse B agreed that Nurse B will complete refresher ILS training. In the meantime, Nurse B has also completed a reflective piece in relation to this matter.”

Source location
Response from East London Foundation Trust
Page 3 · response
Published 13 August 2024
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
Disseminate to nursing staff that emergency services may be called without senior permission and physical health may contribute to behaviour.

Verbatim wording from the response
“6. This matter was also brought up with all the Lead Nurses at the Trust shortly after the inquest to ensure that the message that ‘permission from senior staff is NOT required to call emergency services’ was disseminated to all nursing staff. As a reminder, this was followed up at the Lead Nurses meeting on 28 August 2024.”

Source location
Response from East London Foundation Trust
Page 3 · response
Published 13 August 2024
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
Nursing staff do not require senior permission to call emergency services; this is not agreed Trust practice.

Verbatim wording from the response
“4. I share your concerns that one of the Trust’s nurses was under the impression that an ambulance could only be called if under the instruction of a more senior nurse. This is”

Source location
Response from East London Foundation Trust
Page 2 · response
Published 13 August 2024
Open published response
25 Jun2024
Cumbria
Concerns raised1
1. Failure to perform and respond appropriately to basic checks and signs of life during resuscitation
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 6
1. Action
  Provide basic life-support training for all senior staff and registered nurses.
  Stated by WESTMORLAND HEALTHCARE LIMITEDStated completed
2. Action
  Conduct daily walk-round audits that test staff knowledge of ABCDE assessment and recognition of cardiac arrest.
  Stated by WESTMORLAND HEALTHCARE LIMITEDStated completed
3. Action
  Followed up the provider’s actions addressing the CPR incident, including staff refresher training and action concerning the involved nurse.
  Stated by Care Quality CommissionStated completed
1. Action
  Continue the fitness-to-practise investigation into the registered nurse and decide whether to progress or close the case for public-protection reasons.
  Stated by Nursing and Midwifery CouncilStated in progress
2. Action
  Complete a risk assessment to determine whether urgent interim restrictions or suspension are required to protect the public.
  Stated by Nursing and Midwifery CouncilStated completed
3. Action
  Keep the decision not to impose an interim order under review pending new information.
  Stated by Nursing and Midwifery CouncilStated in progress
Respondent positions 1
1. Position
  An interim order restricting or suspending the nurse’s practice was not considered necessary for public protection or otherwise in the public interest.
  Stated by Nursing and Midwifery CouncilNo action considered necessary
AI-generated summary

James Reginald Capstick · 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 Reginald Capstick died in hospital on 1 October 2022 after sustaining multiple rib fractures during more than 20 minutes of chest compressions when he was not in cardiac arrest, followed by respiratory insufficiency and pneumonia. The report raised concerns about the quality of care at Westmorland Court, the reliability of care records, the absence of a defibrillator at the time, and the failure to recognise signs of life during the resuscitation attempt.

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 perform and respond appropriately to basic checks and signs of life during resuscitation
Wider context from the report
“(3) To Nursing and Midwifery Council. A Registered nurse was in charge of the home on the night of Reg's injury. Her statement told us that she forgot her basic training and had never had to attempt CPR before. Despite clear signs of breathing and resistance to her efforts she continued to be guided by the call handler at NWAS who had been confused by her inconsistent responses to his questions. Basic checks and signs of life were ignored. I was told at inquest that after being stepped down from nursing duty for a while she had had further training and was back in position. I was told that a referral to yourselves had been made and acknowledged but nothing further had been heard, has the referral been closed? ”
Source location
James Reginald Capstick · 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
Provide basic life-support training for all senior staff and registered nurses.

Verbatim wording from the response
“As a Home, we are keen to drive “lessons learned” improvements across our care quality and practice. Ongoing discussions have been taking place and have been had with all staff about the case and understandably the concerns outlined by the Coroner in relation to basic life support and accuracy of record keeping. All senior staff and registered nurses now have the appropriate training in place for basic life support.”

Source location
Response from Westmorland Court Care Home
Page 4 · response
Published 9 August 2024
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 daily walk-round audits that test staff knowledge of ABCDE assessment and recognition of cardiac arrest.

Verbatim wording from the response
“Daily walk round audits are conducted which include testing staffs’ knowledge of the ABCDE assessment process to competently assess a resident and identify whether a person is in cardiac arrest.”

Source location
Response from Westmorland Court Care Home
Page 4 · response
Published 9 August 2024
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
Followed up the provider’s actions addressing the CPR incident, including staff refresher training and action concerning the involved nurse.

Verbatim wording from the response
“CQC were informed of the outcome of the local authority safeguarding investigation into the use of CPR on 1 December 2021 including actions to be taken to prevent further incidents. Actions included internal investigation by the provider, audit of the incident, a refresher of basic life support training for all staff, and a referral to the NMC regarding the individual nurse’s conduct. CQC followed up these actions and were reassured that staff had received refresher training in basic life support and that the provider had taken appropriate actions in relation to the registered nurse involved in the incident.”

Source location
Response from CQC
Page 1 · response
Published 9 August 2024
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
Continue the fitness-to-practise investigation into the registered nurse and decide whether to progress or close the case for public-protection reasons.

Verbatim wording from the response
“We can confirm that our investigations in relation to the concerns raised about the registered nurse in charge of the home on the night of Mr Capstick’s injury are ongoing. We have shared your concerns as set out in the PFD with the investigating team. We have also contacted Westmorland Court for further information and obtained details about the registered nurse’s current practice. We have contacted the registered nurse to give them the ability to comment on the concerns and are waiting for their response. We expect to make a decision in the next two to three weeks on whether to progress our investigations on the basis that we need to take action to protect the public or whether we can close the case on the basis that there are no public protection issues.”

Source location
Response from NMC
Page 3 · response
Published 9 August 2024
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Complete a risk assessment to determine whether urgent interim restrictions or suspension are required to protect the public.

Verbatim wording from the response
“We also carried out a risk assessment upon receipt of the referral to establish whether urgent interim action needed to be taken to suspend or restrict the individual’s practice. We concluded an interim order was not necessary for public protection and was not otherwise in the public interest. We continue to keep this under review pending receipt of new information.”

Source location
Response from NMC
Page 3 · response
Published 9 August 2024
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
Keep the decision not to impose an interim order under review pending new information.

Verbatim wording from the response
“We also carried out a risk assessment upon receipt of the referral to establish whether urgent interim action needed to be taken to suspend or restrict the individual’s practice. We concluded an interim order was not necessary for public protection and was not otherwise in the public interest. We continue to keep this under review pending receipt of new information.”

Source location
Response from NMC
Page 3 · response
Published 9 August 2024
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
An interim order restricting or suspending the nurse’s practice was not considered necessary for public protection or otherwise in the public interest.

Verbatim wording from the response
“We also carried out a risk assessment upon receipt of the referral to establish whether urgent interim action needed to be taken to suspend or restrict the individual’s practice. We concluded an interim order was not necessary for public protection and was not otherwise in the public interest. We continue to keep this under review pending receipt of new information.”

Source location
Response from NMC
Page 3 · response
Published 9 August 2024
Open published response
27 Feb2023
Essex
Concerns raised2
1. Failure to activate emergency alarms immediately
2. Failure to promptly inform and coordinate with the site co-ordinator during emergencies
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 3
1. Action
  Deliver drop-in refresher life-support training for clinical and administrative staff, emphasizing immediate help-seeking and pinpoint-alarm use.
  Stated by Essex Partnership University NHS Foundation TrustStated in progress
2. Action
  Conduct a medical-emergency simulation with Derwent Centre staff and share incident learning for incorporation into current training.
  Stated by Essex Partnership University NHS Foundation TrustStated in progress
3. Action
  Share emergency-response learning through basic-life-support and grab-bag training, including prompt notification of the Site Coordinator and Doctor.
  Stated by Essex Partnership University NHS Foundation TrustStated in progress
AI-generated summary

Sharon Elizabeth Langley · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

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

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to activate emergency alarms immediately
Wider context from the report
“(1) Essex Partnership NHS Foundation Trust staff immediate emergency response was not followed: a. pinpoint alarms were not activated immediately on finding Sharon Langley unresponsive b. there was a delay calling the ambulance and basic key information about the type of the emergency was not relayed: i. by qualified nurses who made the 999 calls, or ii. to paramedics on attendance c. there was a delay informing the site co-ordinator of the emergency even though she was based on the ward and there was a lack of co-ordination of the emergency resulting in the ambulance being called a second time by the site co-ordinator d. staff trained in basic life support did not assist the two nurses who were attempting to resuscitate Sharon Langley ”
Source location
Sharon Elizabeth Langley · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to promptly inform and coordinate with the site co-ordinator during emergencies
Wider context from the report
“(1) Essex Partnership NHS Foundation Trust staff immediate emergency response was not followed: a. pinpoint alarms were not activated immediately on finding Sharon Langley unresponsive b. there was a delay calling the ambulance and basic key information about the type of the emergency was not relayed: i. by qualified nurses who made the 999 calls, or ii. to paramedics on attendance c. there was a delay informing the site co-ordinator of the emergency even though she was based on the ward and there was a lack of co-ordination of the emergency resulting in the ambulance being called a second time by the site co-ordinator d. staff trained in basic life support did not assist the two nurses who were attempting to resuscitate Sharon Langley ”
Source location
Sharon Elizabeth Langley · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Deliver drop-in refresher life-support training for clinical and administrative staff, emphasizing immediate help-seeking and pinpoint-alarm use.

Verbatim wording from the response
“- EPUT’s Head of Deteriorating Patient Pathways and Resuscitation Training Officer is working closely with mental health wards to facilitate drop-in ‘refresher’ life support training for clinical and administrative staff dealing with emergency situations. During”

Source location
Response from Essex Partnership University NHS Foundation Trust
Page 1 · response
Published 7 March 2023
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 a medical-emergency simulation with Derwent Centre staff and share incident learning for incorporation into current training.

Verbatim wording from the response
“- The issue of calling for help as soon as possible is also shared during the weekly ‘virtual’ drop-in sessions which focus on the deteriorating patient. Head of Deteriorating Patient Pathways and Resuscitation Training Officer will continue to work with staff at the Derwent Centre to conduct a medical emergency simulation with the team and the importance of calling for help at the earliest possible opportunity is relayed during the post simulation feedback. In addition, the Trust’s training team have shared details of the learning from this incident and request for incorporation and sharing within the current training programme (1b, 1c).”

Source location
Response from Essex Partnership University NHS Foundation Trust
Page 2 · response
Published 7 March 2023
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
Share emergency-response learning through basic-life-support and grab-bag training, including prompt notification of the Site Coordinator and Doctor.

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

Source location
Response from Essex Partnership University NHS Foundation Trust
Page 2 · response
Published 7 March 2023
Open published response
2 Dec2022
West Yorkshire Eastern
Concerns raised3
1. Failure to assess an unresponsive prisoner and consider CPR before death is certified
2. Delays in providing CPR after cardiac arrest
3. Failure to consider placing an unresponsive prisoner in the recovery position
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Update the emergency-response training video and distribute it to training centres and prisons for staff training.
  Stated by HM Prison and Probation ServiceStated in progress
2. Action
  Review first-aid policy and collaborate on updated guidance covering CPR commencement and signposting safer-custody guidance.
  Stated by HM Prison and Probation ServiceStated in progress
3. Action
  Resume local FAW and EFAW training, prioritising night-group staff and extending training to Custodial Managers and other officers.
  Stated by HM Prison and Probation ServiceStated planned
AI-generated summary

Lewis Steven Johnson · 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

Lewis Steven Johnson was found unresponsive with a neck ligature at HMP Wealstun on 12 December 2019 and later died in hospital following a further cardiac arrest. The report raised concerns about the absence of overnight healthcare staff and the prison officers’ delayed and inadequate response, including lack of CPR, defibrillator use and consideration of the recovery position.

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 an unresponsive prisoner and consider CPR before death is certified
Wider context from the report
“(5) The officer acting as ████████ attended the cell but did not think about CPR, believing Mr Johnson to be already dead (notwithstanding that none of the discipline officers present had any medical qualifications to certify death). He had undertaken defibrillator training “many years ago”. ”
Source location
Lewis Steven Johnson · 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
Delays in providing CPR after cardiac arrest
Wider context from the report
“(7) The medical evidence available at the Inquest indicated “Effective CPR more than doubles the chance of someone surviving a cardiac arrest”. Furthermore, the Resuscitation Council UK advises “provide chest compressions as soon as possible after cardiac arrest is confirmed”. ”
Source location
Lewis Steven Johnson · 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 consider placing an unresponsive prisoner in the recovery position
Wider context from the report
“(6) The four prison officers present in the cell did not discuss the need for CPR. The possibility of using a defibrillator was not mentioned. Mr Johnson was left in the cell in a seated position without the wisdom of placing him in the recovery position being considered. ”
Source location
Lewis Steven Johnson · 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
Update the emergency-response training video and distribute it to training centres and prisons for staff training.

Verbatim wording from the response
“In respect of the EFAW training all prison officers receive during their entry level training, all first aid training certificates are valid for three years and although not mandatory, staff are encouraged to undertake refresher training to maintain their basic skills and keep up to date with any changes to first-aid procedures. The initial training for staff includes an HMPPS video which shows how to respond to an emergency situation where a prisoner has attempted suicide. This is currently being updated to reflect changes to policy and equipment available since the original video was produced. This video covers the use of prison issue ligature tools, emergency response codes, placing someone in the recovery position and considerations such as when to initiate first aid and the use of defibrillators.”

Source location
Response from HM Prison & Probation Service
Page 2 · response
Published 19 December 2022
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Review first-aid policy and collaborate on updated guidance covering CPR commencement and signposting safer-custody guidance.

Verbatim wording from the response
“Looking ahead, HMPPS is currently reviewing the first aid policy with the view to replacing this with updated guidance. As the new guidance develops, collaboration will take place amongst teams to ensure there is reference to the commencement of CPR and to ensure we signpost the current safer custody guidance available on the HMPPS intranet which sets out the circumstances in which CPR should be commenced. This is designed to be read in conjunction with the current the Prison Service Instruction which makes clear that all staff must be aware of their responsibilities and of the local procedures that are in place to enable an effective response to medical emergencies.”

Source location
Response from HM Prison & Probation Service
Page 2 · response
Published 19 December 2022
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Resume local FAW and EFAW training, prioritising night-group staff and extending training to Custodial Managers and other officers.

Verbatim wording from the response
“While the delivery of staff training has been severely impacted as a result of restrictions put in place due to the COVID-19 pandemic, with prisons only being able to deliver limited safety critical training, from April 2023 HMP Wealstun will be able to resume the delivery of FAW and EFAW training locally, and will prioritise all those on the dedicated night group, which includes Operation Support Grade staff. The intention is also for all Custodial Managers to receive this training, as well as a significant proportion of the wider officer group, to ensure that an effective emergency response can be provided when required.”

Source location
Response from HM Prison & Probation Service
Page 2 · response
Published 19 December 2022
Open published response
12 Sep2022
East London
Concerns raised1
1. Failure of nursing cardiac-arrest response to follow resuscitation guidelines
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 8
1. Action
  Conduct monthly physical-health simulation training across inpatient units and continue emergency simulations on Cazaubon Ward.
  Stated by East London NHS Foundation TrustStated in progress
2. Action
  Add a weekly ward-managers agenda item to plan East Ham Care Centre simulation exercises.
  Stated by East London NHS Foundation TrustStated completed
3. Action
  Provide further Immediate Life Support training to the two staff members involved in the incident.
  Stated by East London NHS Foundation TrustStated completed
1. Action
  Discuss resuscitation policy and emergency-management topics during Cazaubon Ward staff away days.
  Stated by East London NHS Foundation TrustStated completed
2. Action
  Advise Cazaubon Ward staff to use the DNACPR forms red folder as the first emergency reference.
  Stated by East London NHS Foundation TrustStated completed
3. Action
  Provide an electronic DNACPR alert in RiO as a secondary aid.
  Stated by East London NHS Foundation TrustStated completed
4. Action
  Include CPR status formally in every Cazaubon Ward nursing-shift handover.
  Stated by East London NHS Foundation TrustStated completed
5. Action
  Amend resuscitation policy to emphasise RiO recording, CPR communication and early defibrillator use.
  Stated by East London NHS Foundation TrustStated planned
AI-generated summary

Delina Etienne · 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

Delina Etienne, who had schizo-affective disorder and was an inpatient receiving treatment, was found unresponsive in bed on 7 May 2021 and was declared deceased at the scene. The report identifies concerns about the chaotic response to her cardiac arrest, including failure to follow resuscitation procedures and an erroneous assumption that a DNACPR order was in place. It also identifies concerns about failures to escalate raised blood pressure and chest pain, assess VTE risk, and disclose the resuscitation error.

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 nursing cardiac-arrest response to follow resuscitation guidelines
Wider context from the report
“1. The response of the nursing team to a cardiac arrest was chaotic, and failed to follow trust and national guidelines designed to maximise the effectiveness of resuscitation. ”
Source location
Delina Etienne · 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
Conduct monthly physical-health simulation training across inpatient units and continue emergency simulations on Cazaubon Ward.

Verbatim wording from the response
“Physical health simulations training is facilitated across the ELFT Trust inpatient units. Simulation training sessions are being undertaken at least monthly in all units. Emergency simulations have also taken place on Cazaubon Ward on the following dates and are ongoing.”

Source location
Response from East London NHS Foundation Trust
Page 2 · response
Published 5 October 2022
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Add a weekly ward-managers agenda item to plan East Ham Care Centre simulation exercises.

Verbatim wording from the response
“From 10.10.22 a weekly ward managers meeting now has an agenda item to plan a simulation exercise for that week within the East Ham Care Centre unit.”

Source location
Response from East London NHS Foundation Trust
Page 2 · response
Published 5 October 2022
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Provide further Immediate Life Support training to the two staff members involved in the incident.

Verbatim wording from the response
“The Trust identified particular concerns about two members of staff involved in the incident. The two members of staff have subsequently attended further Immediate Life Support Training. The training highlights the action to be taken by a staff member who finds a patient/person in a physical health emergency including a person with no pulse or other life signs. It teaches staff how to start compressions, get help, apply, and use an automated defibrillator machine (AED), check the paper copy of any do not attempt resuscitation prescription, call for an emergency ambulance and continuing resuscitation until paramedics take over and make any decision about discontinuing that attempt.”

Source location
Response from East London NHS Foundation Trust
Page 2 · response
Published 5 October 2022
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Discuss resuscitation policy and emergency-management topics during Cazaubon Ward staff away days.

Verbatim wording from the response
“The existing Trust policy on ‘Resuscitation’ has been discussed at Cazaubon Ward staff away days organised by the Cazaubon ward Matron and the following topics were discussed:”

Source location
Response from East London NHS Foundation Trust
Page 2 · response
Published 5 October 2022
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Advise Cazaubon Ward staff to use the DNACPR forms red folder as the first emergency reference.

Verbatim wording from the response
“All Cazaubon Ward staff have been advised on the location of the DNACPR forms red folder, and that this is the first point of reference in a medical emergency.”

Source location
Response from East London NHS Foundation Trust
Page 2 · response
Published 5 October 2022
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Provide an electronic DNACPR alert in RiO as a secondary aid.

Verbatim wording from the response
“A DNACPR electronic alert is now available within the RiO medical records as a secondary aid.”

Source location
Response from East London NHS Foundation Trust
Page 2 · response
Published 5 October 2022
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Include CPR status formally in every Cazaubon Ward nursing-shift handover.

Verbatim wording from the response
“CPR status is now a formal part of the handover for each nursing shift on Cazaubon Ward.”

Source location
Response from East London NHS Foundation Trust
Page 2 · response
Published 5 October 2022
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Amend resuscitation policy to emphasise RiO recording, CPR communication and early defibrillator use.

Verbatim wording from the response
“The author of the Trust policy for resuscitation will amend the policy to emphasise the correct procedure for recording in RiO and communicating CPR, and the use of a defibrillator at the earliest opportunity.”

Source location
Response from East London NHS Foundation Trust
Page 2 · response
Published 5 October 2022
Open published response
18 Aug2022
West Yorkshire Eastern
Concerns raised1
1. Failure to ensure nursing staff are trained and familiar with emergency systems for responding to patient collapse
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Check for new temporary staff at every shift start and complete a signed first-shift induction covering emergency and resuscitation procedures, equipment locations and reporting processes.
  Stated by Leeds Teaching Hospitals NHS TrustStated completed
Respondent positions 1
1. Position
  Existing qualification, training, induction, audit and spot-check arrangements are considered sufficient to ensure temporary ED staff understand emergency procedures.
  Stated by Leeds Teaching Hospitals NHS TrustExisting arrangements considered sufficient
AI-generated summary

John Francis Heffron · 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

John Francis Heffron, a 50-year-old wheelchair user, was found confused in his flat and later suffered a cardiac arrest while alone in an A&E cubicle. There was a delay in initiating CPR, including delays in making a crash call and ascertaining his DNAR status; he was resuscitated but sustained a hypoxic brain injury and died in hospital. The concerns included bank and agency nursing staff’s familiarity with emergency procedures, training and induction, and the adequacy and independence of the Trust’s investigation.

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 nursing staff are trained and familiar with emergency systems for responding to patient collapse
Wider context from the report
“(5) Evidence taken at the inquest indicated the collapse and/or death of a patient in the ED is known to occur sometimes. It is a foreseeable risk. Hence there is a need for the nursing staff to be trained and familiar with the emergency systems in place, in order to be able to respond appropriately. ”
Source location
John Francis Heffron · 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
Check for new temporary staff at every shift start and complete a signed first-shift induction covering emergency and resuscitation procedures, equipment locations and reporting processes.

Verbatim wording from the response
“Following the patient’s death, and during the investigation into the care provided before it, the Trust identified deficiencies in the training provided for bank and agency staff about the crash call process used by the ED teams and action has been taken to address these.”

Source location
Response from The Leeds Teaching Hospital
Page 3 · response
Published 3 October 2022
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 qualification, training, induction, audit and spot-check arrangements are considered sufficient to ensure temporary ED staff understand emergency procedures.

Verbatim wording from the response
“(6) In December 2021 the Trust followed a framework employment checklist for temporary workers on temporary assignments, to establish their qualifications and training prior to them starting work in the ED. This still remains the case. Staff allocated by the preferred provider to work in the EDs should only be staff with prior ED experience. Checks made cover the individual’s qualifications, skills and experience, their DBS status and completion of the Trust’s mandatory and priority training (including refresher training and updating); resuscitation training forms part of this. A CV is received for each candidate in order to verify skills and experience based on previous employment history.”

Source location
Response from The Leeds Teaching Hospital
Page 3 · response
Published 3 October 2022
Open published response
11 May2022
Inner North London
Concerns raised1
1. Lack of frequent appropriate emergency resuscitation training
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
  Provide and competency-assess Basic Life Support and DNACPR training, including practical choking and CPR assessment.
  Stated by BupaStated completed
2. Action
  Have the Internal Lead Inspector attend Basic Life Support training to assess its quality and efficacy.
  Stated by BupaStated planned
3. Action
  Retrain remaining Highgate staff and ensure they are competent and confident to manage future choking, cardiac arrest and CPR incidents.
  Stated by BupaStated planned
1. Action
  Consider implementing more frequent competency checks or opportunities to practise chest compressions.
  Stated by BupaStated planned
Respondent positions 2
1. Position
  Existing evidence indicates Highgate BLS delegates passed competency assessments, disputing that training competence was absent.
  Stated by BupaDisputes the concern
1. Position
  Annual BLS training frequency is not out of step with other social care providers.
  Stated by BupaDisputes the concern
AI-generated summary

Cristofaro PRIOLO · 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

Cristofaro Priolo, an 80-year-old man with progressive Alzheimer’s dementia who lived in a nursing home, choked on cauliflower cheese on 25 November 2020 and died. The report identifies concerns that his food was not prepared or fed in accordance with his assessed needs, and that staff failed to provide appropriate first aid, recognise cardiac arrest, and attempt effective CPR.

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 frequent appropriate emergency resuscitation training
Wider context from the report
“A BUPA internal investigation has already taken place and identified some learning points. However, there are matters outstanding around training and audit. Obviously, the cauliflower for Mr Priolo should have been prepared properly for him by the catering staff, but quite apart from that, Mr Priolo’s carers were never assessed when they were feeding him. Whilst the carer who was feeding him when he choked knew that he needed small, soft mouthfuls that he should be allowed to swallow completely before offering the next, that is not what happened. He was fed a large quantity of cauliflower cheese, it seems relatively quickly, that was undercooked to the point of being almost raw, making it much too hard for him to swallow safely. Staff, including qualified nursing staff, then failed to give appropriate first aid. Even 18 months after the event when they were giving evidence in court this week – the inquest had been delayed to allow a police investigation – some staff were unable to describe the correct treatment for choking. Most significantly, nursing staff failed to recognise that Mr Priolo had suffered a cardiac arrest. They then failed to attempt CPR. After the arrival of paramedics, one member of nursing staff did attempt to give chest compressions, but these were ineffective. That is likely to be the result of panic and distress. These are common feelings in an emergency situation, but the risk of them overwhelming resuscitation efforts may be reduced by frequent appropriate training. ”
Source location
Cristofaro PRIOLO · 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
Provide and competency-assess Basic Life Support and DNACPR training, including practical choking and CPR assessment.

Verbatim wording from the response
“• Training around Basic Life Support (“BLS” – the content of which includes addressing and dealing with choking incidents and CPR) and DNACPRs. This training involved an online/classroom based training session, as well as a practical session, where learners are practically assessed, and are not deemed competent until the trainer is satisfied that a learner is competent. We are mindful of your on-going concerns in relation to those nurses who gave evidence during the inquest, and we have said more on this point below – see “concerns 3, 4 & 5”, below.”

Source location
Response from BUPA Care Services
Page 1 · response
Published 12 May 2022
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Have the Internal Lead Inspector attend Basic Life Support training to assess its quality and efficacy.

Verbatim wording from the response
“9. Our Internal Lead Inspector will attend training in Basic Life Support (BLS) to assess the quality and efficacy of the training provided internally by Bupa. To reassure you, our BLS and Emergency First Aid at Work trainers are all qualified and trained by external training providers. During this training our staff are evaluated and leave the classroom assessed as competent. This includes a practical assessment of delivery of chest compressions.”

Source location
Response from BUPA Care Services
Page 4 · response
Published 12 May 2022
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Retrain remaining Highgate staff and ensure they are competent and confident to manage future choking, cardiac arrest and CPR incidents.

Verbatim wording from the response
“10. Given the concerns raised at inquest regarding the competence of some of The Highgate staff, we will ensure that those who remain within The Highgate are retrained, competent and confident to manage any further incidents in the future.”

Source location
Response from BUPA Care Services
Page 4 · response
Published 12 May 2022
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Consider implementing more frequent competency checks or opportunities to practise chest compressions.

Verbatim wording from the response
“We will, however, consider whether or not to implement more frequent competency checks, or opportunities to practice chest compressions. It should be kept in mind though that nurses have a professional obligation to take responsibility and ensure that they feel confident to carry out their role and maintain their competencies in line with NMC requirements.”

Source location
Response from BUPA Care Services
Page 4 · response
Published 12 May 2022
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 evidence indicates Highgate BLS delegates passed competency assessments, disputing that training competence was absent.

Verbatim wording from the response
“We did, however, make enquiries with our Learning and Development team as to the training provided to staff at Highgate, including some of those who gave evidence at the inquest. We wanted to be sure that there had been no issue with their engagement or competency checks. The feedback from our trainer on the BLS training delivered at Highgate was that all delegates (which would include some of those who gave evidence during the inquest) had all passed first time and had a completed competency assessment on file, which confirmed, amongst other things, competent to deliver CPR and how to respond to a choking incident. However, the relevant staff will attend further training to ensure competency.”

Source location
Response from BUPA Care Services
Page 4 · response
Published 12 May 2022
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
Annual BLS training frequency is not out of step with other social care providers.

Verbatim wording from the response
“11. We also note your comments in relation to the frequency of training. At present, BLS is scheduled on an annual basis, although during the pandemic, there was a time during which practical assessments by trainers could not take place, due to measures put in place to comply with government guidance and infection prevention control measures. To the best of our knowledge, the frequency of our training is not out of step with other social care providers and our focus will be as outlined above, which is ensuring the quality and competency of our trainers, the content of our training and the competency checks, to ensure staff leave training confident and competent.”

Source location
Response from BUPA Care Services
Page 4 · response
Published 12 May 2022
Open published response
18 Mar2022
Inner North London
Concerns raised4
1. Failure of nursing staff to enter the seclusion room without a doctor present during an emergency
2. Delays in calling the rapid response team when non-respiration is suspected
3. Inadequate resuscitation training and emergency-equipment familiarity among the only available doctor
1. Failure to enter a seclusion room promptly when non-respiration is suspected
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

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

Gary OTTWAY · 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

Gary Ottway, aged 41, died after being found in cardiac arrest while detained alone in a seclusion room under constant nursing observation during a severe mental health episode. The report raised concerns about whether observation was constant or effective, delays in entering the room and obtaining emergency equipment, gaps in available medical training and resources, and ineffective chest compressions. The inquest determined that he died from natural causes involving two heart conditions.

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 nursing staff to enter the seclusion room without a doctor present during an emergency
Wider context from the report
“5. The junior doctor was the last person to attend the resuscitation and told me he did so after the rapid response team, yet no one had entered the seclusion room by the time he arrived. It may be that there was a (perhaps unconscious) reluctance to enter the room without a doctor, despite the presence of the rapid response (nursing) team. But by the time the junior doctor got to the door (and immediately identified that Mr Ottway was not breathing, at least six and a half to seven minutes had elapsed since the first two nurses saw no evidence of respiration. This was well outside the three to four minute window of opportunity for resuscitation without inevitable brain damage or death. ”
Source location
Gary OTTWAY · Prevention of Future Deaths report
Page 3 · 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
Delays in calling the rapid response team when non-respiration is suspected
Wider context from the report
“4. The senior duty nurse told me that the nurses would not enter the seclusion room until the rapid response team was present, but he did not call the rapid response team as soon as he suspected that Mr Ottway was not breathing. Instead, he started by going to get one of the other nurses, which took a couple of minutes; then he rang the duty doctor; and only after that did he radio for the rapid response team. ”
Source location
Gary OTTWAY · 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
Inadequate resuscitation training and emergency-equipment familiarity among the only available doctor
Wider context from the report
“7. The junior (and only) doctor called to assist in the attempted resuscitation was not familiar with the contents of the emergency grab bag, told me that it would not have occurred to him to ask for any equipment to assist with ventilations other than a pocket mask, and explained that he was not trained in giving adrenaline or any other medicines for resuscitation. As he was the only medical resource available in the case of an emergency, these seem significant gaps. ”
Source location
Gary OTTWAY · Prevention of Future Deaths report
Page 3 · 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 enter a seclusion room promptly when non-respiration is suspected
Wider context from the report
“When the senior duty nurse and the nurse undertaking continuous observation noted that they could not see evidence of respiration, they did not immediately enter the seclusion room where Mr Ottway lay, because they deemed that unsafe following his earlier violent behaviour. ”
Source location
Gary OTTWAY · Prevention of Future Deaths report
Page 2 · concerns
Open source report
2 Dec2021
Inner North London
Concerns raised1
1. Failure of school staff to attempt cardiopulmonary resuscitation when a child becomes unresponsive
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
  Deliver Basic Life Support and CPR training to 70 staff on 12 and 14 January 2022 as part of regular training.
  Stated by Swiss Cottage School - Development & Research CentreStated planned
AI-generated summary

Alaynah Khadija AHMED · 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

Khadija suffered a cardiac arrest at school on 1 July 2021 and died a week later from a hypoxic brain injury. The principal concern was that the teaching assistant had not been trained in CPR and no staff member attempted CPR when Khadija became unresponsive; frequent CPR training was identified as needing consideration.

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 school staff to attempt cardiopulmonary resuscitation when a child becomes unresponsive
Wider context from the report
“I heard that the teaching assistant looking after Khadija was not trained by the school in cardiopulmonary resuscitation and that, when Khadija became unresponsive, CPR was not attempted by any staff member. It is highly unlikely that CPR would have changed the outcome for Khadija. The cause of her cardiac arrest was an airway compromised by mucous plugging, that even a highly trained paramedic crew was unable to clear. However, CPR might make a difference for another child, or even for a staff member. To put the lack of CPR in context, the care that Khadija received from the school before the arrest seemed to be of a very high standard, even drawing comment from a paediatric intensive care consultant giving evidence at inquest. He told me that many nurses at Great Ormond Street Hospital would not have been able to administer the treatment that Khadija’s teaching assistant did on 1 July 2021. She was quick to recognise that something was wrong and quick to act appropriately. However, it seems to me that the school would benefit from consideration being given to frequent CPR training. ”
Source location
Alaynah Khadija AHMED · 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 Basic Life Support and CPR training to 70 staff on 12 and 14 January 2022 as part of regular training.

Verbatim wording from the response
“I am writing to confirm that the school is completing this recommendation on 12th January, 14th January, and within our annual training cycle.”

Source location
2021-0410-Response-from-Swiss-Cottage-School_Published
Page 1 · response
Published 8 December 2021
Open published response
11 Aug2020
Inner North London
Concerns raised1
1. Failure to commence CPR when a reversible cause for collapse overrides a DNAR order
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.
Respondent positions 1
1. Position
  The Trust disputes that an immediate reversible cause existed to override the DNAR order, concluding that no airway obstruction was present.
  Stated by Barts Health NHS TrustDisputes the concern
AI-generated summary

Moses Victor Boardman · 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

Moses Victor Boardman, an elderly and frail man, was mistakenly discharged to his home instead of sheltered accommodation, where he was found without heating, light or food and subsequently readmitted to hospital after a further cerebrovascular accident. While assessed as being at risk of aspiration and requiring supervised feeding, he was later found eating a whole fruit unsupervised, suffered a choking incident, and died at 04.48. The substantive concerns included discharge and transport safeguards, failure to escalate missed care visits, monitoring of patients fed at risk, and the response to a potential reversible cause of collapse when a DNACPR order was in place.

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 commence CPR when a reversible cause for collapse overrides a DNAR order
Wider context from the report
“6. The RLH failure to commence CPR when a potential reversible cause for collapse existed that would override the effect of the DNAR order. ”
Source location
Moses Victor Boardman · 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
The Trust disputes that an immediate reversible cause existed to override the DNAR order, concluding that no airway obstruction was present.

Verbatim wording from the response
“It’s clear from staff statements that Mr Boardman had taken a bite out of the kiwi fruit before it was removed at 2000. At 0200 he is heard coughing and when the nurse attends she finds him unresponsive. Although he has a DNR order the cardiac arrest team is called. They arrive and find him unresponsive with agonal breathing. This type of breathing would not occur with any form of upper airway obstruction; it was also six hours after he had taken a bite of the kiwi fruit. This related to poor blood flow to the brain, fitting with the description of him having an impalpable pulse. In view of no immediate reversible cause, such as an airway obstruction the DNR order was followed and the gentleman passed away peacefully two hours later.”

Source location
2020-0160-Response-from-Barts-Health-NHS-Trust_Redacted.pdf
Page 3 · response
Published 22 October 2020
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure of nursing staff to call ambulances without prior senior clinician approval

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 perform and respond appropriately to basic checks and signs of life 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.6

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

Concerns raised2

Failure to activate emergency alarms immediately

Failure to promptly inform and coordinate with the site co-ordinator during emergencies

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

Concerns raised3

Failure to assess an unresponsive prisoner and consider CPR before death is certified

Delays in providing CPR after cardiac arrest

Failure to consider placing an unresponsive prisoner in the recovery position

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

Concerns raised1

Failure of nursing cardiac-arrest response to follow resuscitation guidelines

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.8

Actions described in response 2

Respondent positions 1

Actions described in response 6

Respondent positions 1

Actions described in response 3

Actions described in response 3

Actions described in response 8