First reported 16 Dec 2013•Latest report 20 Feb 2026
Definition
What this concern includes
Includes failures of resuscitation-specific training, competence assessment, refresher provision, guidance alignment, practical preparation and supporting aids where these affect staff ability to recognise when resuscitation is required and deliver it safely across healthcare and comparable care settings.
Not included
Excludes general first-aid or emergency-response training deficiencies where resuscitation competence is not the identified unsafe condition.
Excludes failures of resuscitation equipment availability, serviceability or deployment where staff competence is not deficient.
Excludes clinical errors during resuscitation where the responsible staff had appropriate resuscitation competence and the problem lies in another control.
Excludes generic training, staffing or communication deficiencies not specifically tied to resuscitation competence.
Reports
30
Distinct published reports
Individual concerns
32
A report can raise multiple concerns
Date range
2013–2026
First to latest report issue date
Stated actions
51
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.
Care Quality Commission4
HM Prison and Probation Service4
NHS England3
Department of Health and Social Care2
Wandsworth Prison2
Barons Park Care1
Birmingham and Solihull Mental Health NHS Foundation Trust1
Bupa Care Homes (GL) Limited1
Camino Healthcare Limited1
College of Policing1
East Kent Hospitals University NHS Foundation Trust1
East London NHS Foundation Trust1
Edgware Community Hospital1
Father of the deceased1
Foreign, Commonwealth & Development Office1
NHS trust8
Executive agency4
Health and social care service regulator4
Ministerial department4
Executive non-departmental public body3
Healthcare site3
Prison or young offender institution3
Type not available3
Health and care professional regulator2
Nursing home2
Police force2
Private limited company2
Residential care home2
Care-home operator1
Domiciliary care provider1
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.
Inner North London
Concerns raised1
Failure of first aid staff to provide complete resuscitation measures
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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Create and require staff to complete a separate online medical-emergency vehicle course covering emergency response, basic life support and related vehicle incidents, with an 80% pass threshold.
Stated by Serco Group plcStated completedThe respondent said that this action was complete when they made their response on 24 February 2026.
Northumberland
Concerns raised1
Failure to ensure staff have current Basic Life Support and First Aid at Work training
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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.6
Action
Operate an electronic training platform with expiry alerts and scheduled weekly compliance reports for home managers.
Stated by Hill Care GroupStated completedThe respondent said that this action was complete when they made their response on 30 July 2025.
Action
Require Regional Managers to check compliance with mandatory and refresher training through governance systems.
Stated by Hill Care GroupStated completedThe respondent said that this action was complete when they made their response on 30 July 2025.
Action
Verify agency workers’ training credentials before shifts and reiterate mandatory training requirements to the agency supplier.
Stated by Hill Care GroupStated completedThe respondent said that this action was complete when they made their response on 30 July 2025.
Action
Reissue Basic Life Support and IDDSI/Dysphagia training electronically with defined completion timeframes.
Stated by Hill Care GroupStated in progressThe respondent said that this action was in progress when they made their response on 30 July 2025.
Action
Deliver face-to-face emergency first aid training to all staff by 14 October 2025.
Stated by Hill Care GroupStated in progressThe respondent said that this action was in progress when they made their response on 30 July 2025.
Action
Use revised agency induction forms to verify first aid, mandatory training, modified-diet awareness and daily nutritional-report awareness.
Stated by Hill Care GroupStated completedThe respondent said that this action was complete when they made their response on 30 July 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The measures described are considered sufficient to satisfy the concerns, so no further safety work is proposed.
Stated by Hill Care GroupNo action considered necessaryThe respondent said that no further action was needed.
Manchester South
Concerns raised1
Failure to verify agency staff competence to deliver CPR and First Aid
This report raised 8 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
Bring Approved Premises night shifts in house when the external Double Waking Night Cover contract ends in March 2026.
Stated by Ministry of JusticeStated plannedThe respondent said that this action was planned when they made their response on 22 January 2025.
Action
Monitor external agency compliance with contractual requirements for HMPPS-standard training, including First Aid, CPR and defibrillator use.
Stated by Ministry of JusticeStated in progressThe respondent said that this action was in progress when they made their response on 22 January 2025.
Cumbria
Concerns raised1
Failure to retain and apply basic resuscitation training
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
Provide basic life-support training for all senior staff and registered nurses.
Stated by WESTMORLAND HEALTHCARE LIMITEDStated completedThe respondent said that this action was complete when they made their response on 9 August 2024.
Action
Conduct daily walk-round audits that test staff knowledge of ABCDE assessment and recognition of cardiac arrest.
Stated by WESTMORLAND HEALTHCARE LIMITEDStated completedThe respondent said that this action was complete when they made their response on 9 August 2024.
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 completedThe respondent said that this action was complete when they made their response on 9 August 2024.
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 progressThe respondent said that this action was in progress when they made their response on 9 August 2024.
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 completedThe respondent said that this action was complete when they made their response on 9 August 2024.
Action
Keep the decision not to impose an interim order under review pending new information.
Stated by Nursing and Midwifery CouncilStated in progressThe respondent said that this action was in progress when they made their response on 9 August 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Without defibrillators, suitable resuscitation policies, procedures and trained staff are considered an appropriate alternative.
Stated by Care Quality CommissionExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
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 necessaryThe respondent said that no further action was needed.
Inner West London
Concerns raised1
Lack of clarity in first aid training on the use of rescue breaths during resuscitation attempts
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.
Coventry
Concerns raised1
Delays in commencing and deficiencies in the quality of CPR by care staff
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.3
Action
Provide face-to-face basic life-support and Level 1 first-aid training covering choking recognition, immediate response and escalation; training has reached 82% of staff.
Stated by J&K PartnershipStatus at responseThe respondent said that this action was partly complete when they made their response on 29 April 2024.
Action
Deliver a face-to-face three-day Level 3 first-aid qualification to all service shift leaders.
Stated by J&K PartnershipStated plannedThe respondent said that this action was planned when they made their response on 29 April 2024.
Action
Introduce tabletop emergency exercises alongside face-to-face training and continuing e-learning.
Stated by J&K PartnershipStated completedThe respondent said that this action was complete when they made their response on 29 April 2024.
Manchester South
Concerns raised1
Reduction in paediatric middle grades' practical experience in neonatal resuscitation
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.4
Action
Require all core trainees to spend time in a neonatal setting during training.
Stated by Royal College of Paediatrics and Child HealthStated plannedThe respondent said that this action was planned when they made their response on 13 November 2023.
Action
Use a formal supervisor assessment to confirm trainee readiness for tier 2 rota work.
Stated by Royal College of Paediatrics and Child HealthStated completedThe respondent said that this action was complete when they made their response on 13 November 2023.
Action
Require general paediatric specialty trainees to spend time in a neonatal setting.
Stated by Royal College of Paediatrics and Child HealthStated plannedThe respondent said that this action was planned when they made their response on 13 November 2023.
Action
Maintain mandatory specialty-level capabilities for neonatal resuscitation and airway management.
Stated by Royal College of Paediatrics and Child HealthStated completedThe respondent said that this action was complete when they made their response on 13 November 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Specific mandatory neonatal placements are unnecessary because capabilities can be acquired in most settings, with all trainees spending time in a neonatal setting.
Stated by Royal College of Paediatrics and Child HealthExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Mandatory non-invasive airway skills, readiness assessment, consultant support and current Newborn Life Support status provide safe preparation for neonatal resuscitation.
Stated by Royal College of Paediatrics and Child HealthExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Swansea and Neath Port Talbot
Concerns raised1
Failure to provide staff with CPR training
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing policy of calling emergency services and relying on qualified medical professionals is considered sufficient; CPR training will not be added.
Stated by J D Wetherspoon PLCExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Cambridgeshire and Peterborough
Concerns raised1
Lack of training on blood transfusion during neonatal 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.1
Action
Adopt a low threshold for blood transfusion during resuscitation, preferring blood boluses over fluids in line with 2021 NLS guidance.
Stated by North West Anglia NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 23 May 2023.
Inner South London
Concerns raised1
Failure of nurses to provide effective 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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Publish service specifications requiring prison healthcare providers to develop emergency-response protocols and CPR training.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 31 January 2023.
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Includes failures of resuscitation-specific training, competence assessment, refresher provision, guidance alignment, practical preparation and supporting aids where these affect staff ability to recognise when resuscitation is required and deliver it safely across healthcare and comparable care settings.
