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
Distinct published reports
Individual concerns
47
A report can raise multiple concerns
Date range
2013–2026
First to latest report issue date
Stated actions
77
Described in published responses
Reports over time
Reports over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
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
NHS trust14
Ministerial department5
Executive non-departmental public body4
Healthcare site4
Type not available4
Police force3
Prison or young offender institution3
Executive agency2
Prison operator2
Private limited company2
Public limited company2
Residential care home2
Domiciliary care provider1
Health and care professional regulator1
Health and social care service regulator1
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.
Norfolk
Concerns raised1
Lack of training and experience to deal with patient arrest or collapse
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
London (West)
Concerns raised1
Failure to position an unresponsive patient on the floor for effective resuscitation
This report raised 13 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.
East Sussex
Concerns raised1
Lack of protocols or agreements for responding to an unresponsive body
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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Display control-room reminders and regularly issue staff notices requiring correct use of emergency codes and immediate ambulance calls.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 16 August 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The existing two-code medical emergency response system and staff reminders address responses to unresponsive bodies.
Stated by HM Prison and Probation ServiceExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Exeter and Greater Devon
Concerns raised1
Failure to provide mandatory induction training for support officers responding to drug-related collapse
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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
Action
Review drug awareness training delivered to BASS contract colleagues.
Stated by Stonham home groupStated completedThe respondent said that this action was complete when they made their response on 24 March 2017.
Action
Deliver mandatory drug awareness training to new BASS operational colleagues and refresher training to existing colleagues.
Stated by Stonham home groupStated completedThe respondent said that this action was complete when they made their response on 24 March 2017.
Inner North London
Concerns raised1
Failure to treat an unresponsive individual as a medical emergency
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Birmingham and Solihull
Concerns raised1
Insufficient emergency equipment in GP practices
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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.6
Action
Ask the CQC to ensure inspections check that primary care services have equipment and skills to address respiratory emergencies.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 15 July 2016.
Action
Provide defibrillator, oxygen, oximeter and recommended CPR equipment for managing medical emergencies in the practice.
Stated by Wychall Lane SurgeryStated completedThe respondent said that this action was complete when they made their response on 15 July 2016.
Action
Conduct contract visits to ensure GP practices adhere to emergency equipment, training and protocol guidance.
Stated by Birmingham South Central CCGStated plannedThe respondent said that this action was planned when they made their response on 15 July 2016.
Action
Assist the practice involved in the incident to identify and address issues highlighted by the incident.
Stated by Birmingham South Central CCGStated in progressThe respondent said that this action was in progress when they made their response on 15 July 2016.
Action
Circulate learning from the incident to all commissioned GP practices.
Stated by Birmingham South Central CCGStated plannedThe respondent said that this action was planned when they made their response on 15 July 2016.
Action
Circulate incident learning to surrounding clinical commissioning groups for dissemination to their practices.
Stated by Birmingham South Central CCGStated plannedThe respondent said that this action was planned when they made their response on 15 July 2016.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
Except in remote or inaccessible locations, practices may rely on rapid access to emergency services when determining appropriate equipment and training.
Stated by NHS EnglandExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
The CQC is responsible for using its inspection regime to ensure primary care services carry necessary equipment and skills for respiratory emergencies.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
General practice is not an emergency service and is not contracted, equipped or organised to deliver team-based emergency care.
Stated by Wychall Lane SurgeryOutside remitThe respondent said that this matter was outside its role or authority.
Berkshire
Concerns raised1
Delays in commencing CPR for unresponsive patients
This report raised 2 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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Redesign basic life support and automated defibrillator training around realistic ward-based emergencies and required resuscitation procedures.
Stated by West London NHS TrustStated completedThe respondent said that this action was complete when they made their response on 21 April 2016.
Suffolk
Concerns raised2
Inadequate resuscitation training for health care professionals involved in patient care
Failure of health care professionals involved in patient care to respond appropriately to collapse
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.
Suffolk
Concerns raised1
Inadequate resuscitation attempts following collapse
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.
Buckinghamshire
Concerns raised1
Lack of guidance for CPR-trained staff on when to commence CPR
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
Action
Issue interim First Aid Guidance for staff during consultation on the revised policy instruction.
Stated by Governing Governor of HMP Grendon and SpringhillStated completedThe respondent said that this action was complete when they made their response on 5 December 2014.
Action
Publish a revised First Aid at Work policy instruction after consultation.
Stated by Governing Governor of HMP Grendon and SpringhillStated plannedThe respondent said that this action was planned when they made their response on 5 December 2014.
Action
Provide all Grendon and Springhill staff with written advice on responding to a non-breathing person through a booklet, induction and the local intranet.
Stated by Governing Governor of HMP Grendon and SpringhillStated plannedThe respondent said that this action was planned when they made their response on 5 December 2014.
Pin
Get email alerts
Request correction
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.
