Recurring concern

Unreliable availability and readiness of defibrillators for emergency response

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First reported 30 Aug 2013•Latest report 8 May 2026

Definition

What this concern includes

Includes failures of dedicated arrangements to provide, position, maintain, check, equip, access or promptly deploy defibrillators for emergency response, including absence at a required location, missing batteries or pads, delayed replacement, unreliable readiness status, and failures that prevent the device from being used when needed.

Not included

  • Excludes staff training or familiarisation deficiencies where the defibrillator was available and ready and the unsafe condition is solely operator competence; use the existing defibrillator-use training concern where applicable.
  • Excludes CPR, first-aid or broader resuscitation-performance failures not involving the availability, readiness or deployment of a defibrillator.
  • Excludes general clinical-equipment shortages or maintenance failures not specifically involving defibrillator readiness or emergency access.
  • Excludes downstream clinical treatment or emergency-service delays after a functioning defibrillator was available and appropriately deployed.
Reports
21

Distinct published reports

Individual concerns
22

A report can raise multiple concerns

Date range
2013–2026

First to latest report issue date

Stated actions
15

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 Commission2
NHS England2
Ayuntamiento de La Oliva1
Bourne Leisure Limited1
Care UK1
Choice Support1
Cygnet Behavioural Health Limited1
Department for Transport1
Department of Health and Social Care1
Derwent Facilities Management Limited1
DW Fitness First1
East Sussex Healthcare NHS Trust1
Essex Partnership University NHS Foundation Trust1
First Aid Cover Ltd1
Gloucestershire Health and Care 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.

  1. West London

    AI-generated summary

    Jake Daniel Taylor · 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

    Jake Daniel Taylor, aged 19, suffered a cardiac arrest at his care home on 16 January 2025 and died in Kingston hospital on 20 January 2025. The report identified delays in first aid and concerns about the lack of individual emergency planning, staff training, immediately available equipment, and airway training and equipment.

    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

    Unavailability of a defibrillator on site

    Wider context from the report

    “No planning for this foreseeable emergency. Inadequate staff training (to always conduct CPR if no decision to the contrary) No defibrillator on site and staff misunderstanding of the function of a defibrillator. No airway training and equipment although Registered Nursing staff have this within their competencies. I consider that individual emergency planning for those service users with recognised high tier needs and life-threatening risk profiles is essential to ensure best possible outcomes and care tailored to their needs. Medical emergencies in this cohort of patients are predictable but are likely to happen suddenly and unexpectedly. In this case the staff were not able to respond and their evidence to the court demonstrated that they felt unprepared and uncertain about what to do. This is a situation that could be replicated throughout the services that care for individuals such as Jake. Those commissioning the services should consider if the individual emergency care planning is comprehensive and complete and reviewed where appropriate. ”

    Source location

    Jake Daniel Taylor · 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

    Require providers to assess AED need and provide, maintain and govern AED equipment with appropriate staff training.

    Verbatim wording from the response

    “c. Availability and Use of Defibrillators All commissioned providers will be required to:”

    Source location

    Response from NHS South West London ICB
    Page 3 · response
    Published 2 July 2026

    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

    Purchase and install an AED at Roy Kinnear House.

    Verbatim wording from the response

    “Choice Support will purchase an AED to be installed at Roy Kinnear House. We are liaising with Quality Assurance Commissioners and the ICB. Timescales: Completed and delivered on 8th June 2026”

    Source location

    Response from Choice Support
    Page 4 · response
    Published 2 July 2026

    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

    Oversight of AED defibrillators in healthcare settings is assigned to the Care Quality Commission.

    Verbatim wording from the response

    “The Care Quality Commission (CQC) are responsible for the oversight of AED defibrillators in health care settings. Whilst the CQC does not mandate that care homes have to have an AED onsite, they do require care homes to be able to handle medical emergencies. The CQC Regulation 12 (Safe Care and Treatment) further mandates that providers assess and mitigate risks, ensuring staff are appropriately trained and equipped. This includes consideration of emergency equipment such as AEDs, particularly in settings with residents at increased cardiac risk, as encouraged by NHS England and RC UK guidance. Failure to provide necessary training, equipment, or clear documentation represents a breach of expected standards of safe and effective care.”

    Source location

    Response from NHS England
    Page 3 · response
    Published 2 July 2026

    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

    AEDs are not routinely installed across services; installation is determined through service-specific risk assessment and governance processes.

    Verbatim wording from the response

    “We recognise the concern regarding the absence of an on-site AED. Choice Support does not routinely install defibrillators unless determined through risk assessment and governance processes. We will be taking actions against this.”

    Source location

    Response from Choice Support
    Page 4 · response
    Published 2 July 2026

    Open published response
  2. Essex

    AI-generated summary

    Elise Kay Louise Sebastian · 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

    Elise Kay Louise Sebastian tied a fatal ligature in her room on Longview Ward on 17 April 2021 and died two days later in hospital. The principal concerns included inadequate and falsified observations, insufficiently trained and staffed ward personnel, poor communication about ligaturing and self-harm, medication-recording errors, failures involving Oxevision, and other care and record-keeping deficiencies.

    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

    Delay in obtaining and attaching the defibrillator

    Wider context from the report

    “10. Whilst this did not directly cause Elise’s death, there were plenty of staff who responded quickly to the emergency when Elise was found unresponsive but there was a delay: a. bringing the grab bag to this emergency b. obtaining and attaching the defibrillator. c. In notifying the duty doctor who was not contacted for over 40 minutes. d. The expert witness was of the opinion once the defibrillator was attached, it was being switched on and off in the first few minutes. When looking at the machine analysis there appeared to be 3 analysis checks on the machine within the first few minutes when the machine is set to conduct analysis at set intervals which is inconsistent with this. ”

    Source location

    Elise Kay Louise Sebastian · Prevention of Future Deaths report
    Page 5 · 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

    Undertake medical-emergency simulations every three months in inpatient settings and record them using the approved report.

    Verbatim wording from the response

    “The Essex Partnership NHS Foundation Trust’s CPR procedure document (CLPG14A) states the Ward Manager, Matron or Service Manager/Clinical lead for each inpatient setting, will be responsible for ensuring that medical emergency simulations are undertaken every three months in the clinical environment. Each inpatient setting must record when a medical emergency simulation is facilitated, using the approved ‘Medical Emergency Simulation Practice Report’”

    Source location

    2026-0078 - Response from Essex University Partnership Trust
    Page 12 · response
    Published 13 February 2026

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Introduce Resus Link Practitioners across inpatient wards to support simulations, equipment readiness, life-support training, audit and dissemination of updates.

    Verbatim wording from the response

    “The Trust has also introduced the role of Resus Link Practitioners (RLP) to all inpatient ward settings. These volunteers will play a key role in strengthening the response to medical emergency situations within the wards. The role is open to all nurses and HCAs/support workers and the RLP will act as a link between the Resuscitation and Deteriorating Patient Group and their ward, promoting best practice and raising awareness. The RLP will:”

    Source location

    2026-0078 - Response from Essex University Partnership Trust
    Page 13 · response
    Published 13 February 2026

    Open published response
  3. Inner North London

    AI-generated summary

    Nonie Atshiki · 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

    Nonie Atshiki, aged 35, was found dead in the stairwell of the hostel where she lived shortly after 4am on 13 July 2024. Her medical cause of death was acute cardiac failure associated with cocaine use and long-term alcohol excess. The report raised concerns that the hostel’s night concierge had no first aid training from St Mungo’s, there was no defibrillator, and no cardiopulmonary resuscitation was attempted after her discovery.

    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

    Unavailability of a defibrillator at the hostel

    Wider context from the report

    “I heard evidence at inquest that the night concierge who found Ms Atshiki had not had any first aid training from St Mungo’s. He said that he had undergone first aid training elsewhere in the past, but he did not know whether the hostel had a defibrillator. It did not. Whilst not relevant in this case, I was told that the hostel does stock naloxone (used in the emergency treatment of opiate/opioid toxicity), but that the night concierge is not trained in its use. The evidence at inquest was that there are only ever two members of staff working at the hostel at night, of which the night concierge is one. After Ms Atshiki’s discovery, the night concierge stayed with her as she lay across the stairs, while the other member of staff stayed by the front door to open it when the ambulance service arrived. Nobody at the hostel attempted to perform cardiopulmonary resuscitation on Ms Atshiki. There is no evidence that if CPR had been performed it would have changed the outcome for Ms Atshiki. However, in another situation it might. And in another situation it might be the second member of staff who falls ill. That would only leave the night concierge to attempt resuscitation. ”

    Source location

    Nonie Atshiki · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Review potential expansion of defibrillator access, including locations, acquisition criteria, local-authority offers and possible purchases.

    Verbatim wording from the response

    “Whilst it is my understanding that there is no legal requirement for housing associations to provide defibrillators, we will review the potential for expanding our access to defibrillators in key locations, particularly in 24-hour hostels where the risk of health emergencies is higher. This review will include where defibrillators are already located in our services, the criteria for a service obtaining a defibrillator, taking up offers of free defibrillators from Local Authorities where available, and considering whether to purchase them, where not. This review will be completed by May 2025.”

    Source location

    Response from St Mungo's
    Page 11 · response
    Published 18 December 2024

    Open published response
  4. Cumbria

    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

    Unavailability of a defibrillator for attempted resuscitation in the care home

    Wider context from the report

    “(2) To Care Quality Commission. You requested a note of the outcome of this case and please accept this report as such. I imagine you will be making further enquiries. There was no defibrillator in the home at the time of this incident although I am told one has now been installed. I was told that it is not a requirement for care homes to have one. If staff in these homes are expected to attempt resuscitation should provision be required? ”

    Source location

    James Reginald Capstick · 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

    Requiring care homes to install defibrillators falls outside the regulator’s role and remit.

    Verbatim wording from the response

    “We have given careful consideration to the concerns raised in relation to whether it should be a requirement for care homes to have a defibrillator however this falls outside of the role and remit of CQC. We should clarify that the role and remit of CQC does not extend to prescribing how providers must meet the regulations stipulated, we place the onus and responsibility on providers themselves to make decisions around how best to deliver care safely and assure us of the same. There is no legal requirement for care homes to install equipment such as defibrillators but if they were to do so then there would be an expectation that staff are appropriately trained in how to use such equipment safely.”

    Source location

    Response from CQC
    Page 2 · 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

    Care providers are responsible for deciding how to deliver care safely and demonstrating compliance to the regulator.

    Verbatim wording from the response

    “We have given careful consideration to the concerns raised in relation to whether it should be a requirement for care homes to have a defibrillator however this falls outside of the role and remit of CQC. We should clarify that the role and remit of CQC does not extend to prescribing how providers must meet the regulations stipulated, we place the onus and responsibility on providers themselves to make decisions around how best to deliver care safely and assure us of the same. There is no legal requirement for care homes to install equipment such as defibrillators but if they were to do so then there would be an expectation that staff are appropriately trained in how to use such equipment safely.”

    Source location

    Response from CQC
    Page 2 · 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

    Without defibrillators, suitable resuscitation policies, procedures and trained staff are considered an appropriate alternative.

    Verbatim wording from the response

    “Where equipment such as defibrillators are not installed, we would expect a provider to be able to demonstrate that they have suitable policies and procedures in place to ensure appropriate resuscitation methods can be carried out if required by suitably trained staff.”

    Source location

    Response from CQC
    Page 2 · response
    Published 9 August 2024

    Open published response
  5. Gloucestershire

    AI-generated summary

    Severine Alexia Kelly · 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

    Severine Alexia Kelly, who was detained under the Mental Health Act and accommodated at Wotton Lawn Hospital, choked on a sandwich provided by hospital staff on 1 October 2022 and died at the hospital. Concerns included out-of-date training for some bank staff, inadequate updating of risk assessments after a previous choking incident, difficulties contacting emergency services, delays in paramedic attendance, uncertainty about when to call an ambulance, and an AED with an apparently non-working internal clock.

    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 AED internal clocks to function

    Wider context from the report

    “An AED used on the 1 October 2022 appeared not to have a working internal clock. ”

    Source location

    Severine Alexia Kelly · Prevention of Future Deaths report
    Page 1 · 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 AED internal clocks are functioning; although they cannot be reset to Greenwich Mean Time, each activation records a timed event log.

    Verbatim wording from the response

    “The AEDs used by the Trust are iPad SP1s supplied by Welmedical. We have liaised with Welmedical and can confirm that the internal clocks on all devices are working but are set at the point of manufacturing. This function cannot be changed by the end user and remains unaffected by any local calibration and replacement battery installation. Importantly though, each time the AED is activated, it keeps a timed log of all events within the episode as with the event involving Miss Kelly. This timed log forms the record of the response, but this record will not necessarily align with Greenwich Mean Time.”

    Source location

    Response from Gloucestershire Health and Care NHS Foundation Trust
    Page 3 · response
    Published 23 February 2024

    Open published response
  6. Dorset

    AI-generated summary

    BENJAMIN DAVID MCQUEEN · 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

    Benjamin McQueen drowned on 14 November 2018 during a military diving exercise in Portland Harbour, Dorset, after experiencing complications during the dive and being recovered unconscious from the seabed. The concerns included the lack of a spare breathing-apparatus cylinder for the stand-by diver, accelerated safety-critical training, the absence of a dedicated defibrillator, and inconsistent minimum safety-pressure guidance for breathing apparatus.

    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

    Unavailability of a defibrillator for dive support staff on safety boats or land

    Wider context from the report

    “(3) Ben was lifted unconscious from the sea bed and Cardio Pulmonary Resuscitation was immediately started. A defibrillator was also applied, but this was only available because it was carried by a Harbour Patrol vessel which came to assist. I am concerned that in such safety-critical military diving training, the dive support staff did not have available to them a defibrillator of their own either on the supporting safety boats or on land. This did not cause or contribute to Ben’s death but could lead to future fatalities. ”

    Source location

    BENJAMIN DAVID MCQUEEN · 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

    Ensure all ab initio high-risk dive training sites have a defibrillator available at immediate notice.

    Verbatim wording from the response

    “After consideration and consultation with INM and the MDCC, I am assured that all ab initio (high risk) dive training sites have a defibrillator available at immediate notice. Further, military subject matter experts in conjunction with their civilian and NATO counterparts will now undertake a review of best medical practice and evidence of the effective use of defibrillators and their application in a military maritime environment, specifically for a drowned victim.”

    Source location

    Response from Ministry of Defence
    Page 4 · response
    Published 10 August 2023

    Open published response
  7. Black Country

    AI-generated summary

    Charles Evans · 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

    Charles Evans, a resident at Hibiscus House, choked on food in the communal dining room on 29 May 2022, suffered cardiac arrest and severe hypoxic brain injury, and died in hospital the following day. The concerns included inadequate CPR and first-aid provision, absence of a defibrillator and emergency communication arrangements, insufficient staffing and emergency procedures in the dining room, and weaknesses in risk assessment and reporting processes.

    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

    Unavailability of a defibrillator on site

    Wider context from the report

    “During the course of the inquest I heard evidence from Faye Cadogan Registered Manager Hibiscus House and Norma Chambers Catering Assistant at Hibiscus House. 1. None of the Carers employed at Hibiscus House had any training in CPR. The carer on duty was qualified to Level 2 Diploma in Health & Social care which does not include any training in first aid; 2. At the time of the incident there were no staff members trained in CPR (Coroner was told this had been rectified post Mr Evans death); 3. There was no Registered First Aider at the premises; 4. There was no defibrillator on site; 5. There was no requirement for any staff to be on duty in the communal dining room during mealtimes despite the fact the Hibiscus House could cater for residents with special dietary requirements; 6. There was no emergency bell/alarm or telephone in the residents’ dining room. Staff were expected to use their mobile phone to call for help; 7. There was no procedure for what should happen in an emergency situation (in this instance the catering staff member who found Mr Evans located a carer instead of calling 999 themselves; 8. Staff did not know who else was on duty at any given time; 9. There was no proper procedure in place for staff to report concerns about residents; 10. No further risk assessments were being conducted if a resident returned to Hibiscus House after a hospital admission to ensure the facility could still meet the needs of the resident (Coroner was told staff relied on a discharge summary and/or the GP); 11. Post inquest, the Coroner noted the CQC Inspection report for Hibiscus House Domiciliary Care Agency dated July 2019 which rated the facility as ‘requiring improvement’. The Coroner is concerned to establish whether the service provider put forward an action plan following the CQC Inspection setting out what they would do to improve the standards of quality and safety and whether the CQC monitored any progress towards said plan. ”

    Source location

    Charles Evans · 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

    Seek quotations for purchasing a permanently located on-site defibrillator.

    Verbatim wording from the response

    “There is no compulsory requirement to purchase a defibrillator to comply with the Health and Safety (First-Aid) Regulations 1981. Hibiscus however have actively sought quotes for the purchase of a defibrillator which can be kept permanently on the premises. Once an appropriate defibrillator has been purchased, Hibiscus will ensure that all staff are aware of its location when contacting the emergency services and are fully trained in its use.”

    Source location

    Response from Hibiscus House
    Page 3 · response
    Published 4 November 2022

    Open published response
  8. West Sussex

    AI-generated summary

    James Joseph MANNING · 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 Joseph Manning, aged two, choked on a piece of sausage at Butlins, Bognor Regis, on 6 June 2018, suffered a cardiac arrest and hypoxic ischaemic brain injury, and died in hospital on 20 June 2018. The concerns included delays and weaknesses in healthcare referral, follow-up and information-sharing systems, and shortcomings in the management of health and safety, incident reporting, first-aid provision and emergency procedures at Bourne Leisure sites.

    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

    Insufficient availability of AEDs in key site areas

    Wider context from the report

    “d) I was concerned to hear evidence that many months after this tragic incident during Tots Week, installation of an external phone line and sufficient AEDs in key areas such as restaurants and swimming pool areas had not been completed. ”

    Source location

    James Joseph MANNING · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report
  9. Inner North London

    AI-generated summary

    César Cuauhtémoc González Barrón · 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

    César Cuauhtémoc González Barrón died while performing as a Mexican wrestler at a Lucha Libre event. After he lost consciousness and suffered cardiac arrest, there were delays in recognising the emergency, summoning assistance, starting CPR and providing effective resuscitation. The report also identified inadequate event briefing, unclear emergency roles and procedures, communication difficulties, delayed ambulance access, and a confused handover to ambulance staff.

    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 timely availability of a defibrillator at the emergency location

    Wider context from the report

    “4. When the first aider was summoned urgently, the member of staff who had alerted her said that she was needed for a performer, but did not tell her what had happened. She had no understanding of the nature of the emergency. The member of staff did not wait for her. He did not offer to help carry her equipment. She tried to follow him but did not know where she was going. The first aider did not take the defibrillator with her when she first went to the ring, she said in court because she was not expecting a cardiac arrest. There was a second defibrillator in the venue, but she did not know where it was, she did not ask for it and nobody brought it. ”

    Source location

    César Cuauhtémoc González Barrón · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  10. West Yorkshire Eastern

    AI-generated summary

    Scott Marsden · 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

    Scott Marsden died after receiving a blow to the chest during a kickboxing bout. The report raised concern that there was no defibrillator at the Marshalls Arts College.

    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

    Absence of a defibrillator at Marshalls Arts College

    Wider context from the report

    “(1) That there is no Defibrillator at the Marshalls Arts College. ”

    Source location

    Scott Marsden · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
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Data last updated 7 September 2026