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.
Manchester West
Concerns raised1
Failure to apply an available defibrillator promptly during resuscitation
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.2
Action
Address resuscitation competency of staff involved in the incident through specific Trust competency processes.
Stated by North West Boroughs Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 25 March 2014.
Action
Conduct annual resuscitation practice drills including automated external defibrillator use and document competency outcomes.
Stated by North West Boroughs Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 25 March 2014.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Staff involved in the resuscitation incident complied with mandatory training requirements; the failure concerned following approved procedures instead.
Stated by North West Boroughs Healthcare NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
North London
Concerns raised3
Failure of emergency-response policy to require requesting duty doctor attendance
Failure of nursing staff to respond to collapses in a calm coordinated manner
Lack of clear staff-response guidance for collapses
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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.6
Action
Review the Trust resuscitation policy to address emergency response guidance.
Stated by North London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 7 February 2014.
Action
Update the resuscitation policy with deteriorating-patient actions, an expanded NEWS Score, and a requirement to contact the duty doctor during medical emergencies.
Stated by North London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 7 February 2014.
Action
Display step-by-step breathing-assessment and emergency-response guidance across all Forensic Service ward areas.
Stated by North London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 7 February 2014.
Action
Introduce the step-by-step emergency-response guide in all other inpatient areas.
Stated by North London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 7 February 2014.
Action
Revise and regularly run lifelike-manikin resuscitation assessments and practical sessions across Forensic Service and Trust wards.
Stated by North London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 7 February 2014.
Action
Conduct unannounced resuscitation scenarios across Forensic wards to strengthen emergency response.
Stated by North London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 7 February 2014.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The resuscitation policy already listed actions for determining whether a collapsed patient was breathing and responding to such events.
Stated by North London NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Surrey
Concerns raised1
Unclear alignment of resuscitation training with current guidance
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
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.
