Recurring concern

Unreliable availability and readiness of defibrillators for emergency response

Pin Get email alerts Request correction

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. South Yorkshire (Western)

    AI-generated summary

    Abigail Hall · 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

    Abigail Hall died at home on 23 September 2015 from aspiration pneumonitis and viral gastro-enteritis. Evidence at the inquest showed that there was no defibrillator at the premises and Derwent staff were not first aid trained; this position apparently still persisted.

    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 premises

    Wider context from the report

    “During the inquest, evidence showed:- There was no defibrillator at the premises nor were Derwent staff first aid trained. This position apparently still persists. ”

    Source location

    Abigail Hall · Prevention of Future Deaths report
    Page 1 · 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

    Approve the purchase and installation of an automated external defibrillator at the premises.

    Verbatim wording from the response

    “2.3 The purchase and installation of an AED has been approved and this will take place in due course; and”

    Source location

    2018-0286-Response-by-Derwent-Facilities-Management-Limited
    Page 1 · response
    Published 8 January 2019

    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 automated external defibrillator at the premises.

    Verbatim wording from the response

    “2.3 The purchase and installation of an AED has been approved and this will take place in due course; and”

    Source location

    2018-0286-Response-by-Derwent-Facilities-Management-Limited
    Page 1 · response
    Published 8 January 2019

    Open published response
  2. Liverpool and the Wirral

    AI-generated summary

    Jack Riding · 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

    Jack Riding collapsed while playing football after a genetic heart condition caused his heart to stop, and he was declared dead in hospital on 15 August 2018. The report raised concerns about delays in deploying a defibrillator and directing ambulance personnel to the pitch, as well as the adequacy of emergency medical risk assessments, first-aid training, and related procedures. The report stated that these delays could not be said to have contributed to Mr Riding’s death but presented a risk of future death.

    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 prompt access to and deployment of the defibrillator

    Wider context from the report

    “(1) I heard evidence that there was a significant delay in bringing a defibrillator to the pitch where Jack Riding had collapsed. There was a delay of some minutes before the defibrillator was deployed. I make it clear that this could not be said to be a contributing factor in Mr Riding’s death. I have received evidence of the systems in place today for the defibrillator from Goals Soccer Centres plc. It remains a concern to me that when matches are being played that the defibrillator is kept away from the pitch and the deployment of the equipment is dependent on which members of staff are present. I am concerned that any delay in the deployment of this emergency equipment presents a risk of future death. ”

    Source location

    Jack Riding · 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

    Install defibrillators across the entire club estate and maintain them in accessible, monitored reception locations.

    Verbatim wording from the response

    “In 2014 Goals proactively initiated a rollout of Defibrillators across all our clubs. This decision was based on our commitment to safeguarding all of our customers and establishing best practice within our industry. After proactively installing defibrillation units in 2014 across our entire estate, they were sited inside the clubhouses. The decision to place the units inside was based upon recommendations made during consultation to ensure the units remain in good working order. Before these units were purchased, we met with the Head Community Liaison officer for the Scottish Ambulance Association (SAA) and consulted with the British Heart Foundation (BHF) for guidance and best practice on the type of equipment and to ensure that we are providing the most appropriate product for our environment.”

    Source location

    2018-0303-Responses
    Page 4 · response
    Published 13 December 2018

    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

    Install additional defibrillator location signs at clubhouse and changing-facility exits and individual pitch gates.

    Verbatim wording from the response

    “We do recognise speed is the primary factor in getting the Defibrillator to the point of emergency and knowledge of Defibrillator location is vital for customers (staff are aware of equipment locations as this is included within their induction). We have therefore undertaken an additional audit of Defibrillator locations and signage across all facilities (Appendix 2) and as a result will make the following adjustments:”

    Source location

    2018-0303-Responses
    Page 5 · response
    Published 13 December 2018

    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

    Circulate the Emergency First Aid Incident Procedure to all clubs to reinforce emergency roles and responsibilities.

    Verbatim wording from the response

    “In addition to First Aid training, all staff are trained in ‘situational awareness’. This training includes medical emergencies. In particular, the training includes directing a member of staff to go and wait for an ambulance at the nearest accessible entry point to the incident location and to accompany the paramedic crew to the casualty. In the case of Jack Riding this didn’t happen and we acknowledge that this part of the emergency was not handled in line with what Goals training. Since the incident, we have immediately circulated the Emergency First Aid Incident Procedure (appendix 13 in our response dated 18th November) to reaffirm the”

    Source location

    2018-0303-Responses
    Page 5 · response
    Published 13 December 2018

    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

    Finalise and implement the Goals Normal Operating Procedures and Emergency Action Plan across all clubs, incorporating emergency response procedures into regional audits.

    Verbatim wording from the response

    “In addition, the subsequent independent review of Health and Safety (commissioned following the incident) has provided a new draft document (Appendix 3) called “Goals Normal Operating Procedures and Emergency Action Plan 2019” which was created on the back of the updated “Goals First Aid risk assessment” (Appendix 9). The “Goals Normal Operating Procedures and Emergency Action Plan 2019” specifically includes (in section 2) an Emergency Action Plan for a variety of emergency scenarios. This documentation and actions within it have been agreed and a timeline for rollout across the business is as follows:”

    Source location

    2018-0303-Responses
    Page 6 · response
    Published 13 December 2018

    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 all club staff with scenario-based emergency First Aid training, including on-site role-play, video learning and annual refreshers.

    Verbatim wording from the response

    “As part of this rollout, situational training and emergency First Aid scenario training will be provided and role-played by all club staff and refreshed annually. Details of this can be found in the response to the training concern detailed in S5 (3).”

    Source location

    2018-0303-Responses
    Page 6 · response
    Published 13 December 2018

    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

    The response disputes that there was a significant delay in accessing or deploying the defibrillator during the incident.

    Verbatim wording from the response

    “We firmly refute that there was a significant delay to the Defibrillator being accessed or used. CCTV footage sent previously (appendix 10 in our response dated 18th November) showed our rapid response time of less than 1 minute from staff receiving the information that the Defibrillator was required and taking it out onto the pitch. Although we do not have exterior CCTV footage to verify timings to and from the pitch, Appendix 1 highlights the distances between pitches and the facility clubhouse and reception which is less than 100m from the clubhouse to the pitch. This distance is much shorter than in many other sports-related leisure”

    Source location

    2018-0303-Responses
    Page 4 · response
    Published 13 December 2018

    Open published response
  3. Inner North London

    AI-generated summary

    Catherine Mary GIBBON · 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

    Catherine Mary Gibbon suffered a seizure while swimming at a gym on 1 June 2018 and remained face down in the water for around ten minutes. She sustained a hypoxic-ischaemic brain injury following non-fatal drowning and died. Concerns included inadequate pool monitoring and CCTV arrangements, a broken camera, insufficient staff training and emergency equipment, and gaps in first-aid certification systems.

    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 poolside

    Wider context from the report

    “8. There was a defibrillator in the gym, but there was not another at poolside. ”

    Source location

    Catherine Mary GIBBON · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  4. East Riding and Hull

    AI-generated summary

    Hayley Emma GASCOIGNE · 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

    Hayley Emma GASCOIGNE became unwell at Hull Crown Court after feeling dizzy and sick, then collapsed and was taken to Hull Royal Infirmary, where she was pronounced dead. The concern was that the court complex did not appear to have a defibrillator, despite evidence that prompt defibrillation can improve survival in certain cardiac dysrhythmias.

    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 defibrillator availability in court buildings

    Wider context from the report

    “Expert evidence was heard that in the presence of a “shockable cardiac dysrhythmia” such as ventricular fibrillation, the administration of a shock from a defibrillator can restore the normal cardiac rhythm and that the longer the application of such a shock is delayed, the greater the likelihood is that the patient will succumb to this untoward cardiac event. A number of public buildings are provided with defibrillation apparatus, but our preliminary enquiries indicate that the Hull Combined Court Centre did not have one at material times. The Independent Accident and Emergency Expert believes that all buildings should be equipped with such an apparatus given that the quicker a shock is applied the greater the probability is that a patient will survive. I would ask you to reply to me within 56 days as to whether the Court Complex now has a defibrillator or whether there are plans in place for such an apparatus to be secured. If there are no plans then I would require you to tell me why this is not being considered given the obvious benefit of having such equipment available in public places. I am copying this report to HM Courts and Tribunals Services to bring the problem of lack of defibrillators in public buildings such as Courts to their attention. ”

    Source location

    Hayley Emma GASCOIGNE · 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

    Install a defibrillator at Hull Combined Court Centre.

    Verbatim wording from the response

    “In respect of actions to be taken, I can confirm that Hull Combined Court Centre now has a defibrillator located on site, and staff have been briefed accordingly.”

    Source location

    HG-Response
    Page 1 · response
    Published 1 October 2018

    Open published response
  5. Inner South London

    AI-generated summary

    Yunis Malik Hadi · 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

    On 28 January 2018, Yunis Malik Hadi choked and collapsed while eating a snack at a Sunday school, and could not be resuscitated despite CPR efforts. The concerns included inadequate first-aid training for volunteers, lack of emergency medical equipment such as a defibrillator, and insufficient oversight of training, supervision and child safeguarding.

    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 a defibrillator

    Wider context from the report

    “(2) A lack of emergency medical equipment i.e. a defibrillator. ”

    Source location

    Yunis Malik Hadi · 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

    There is no legal requirement for the Centre to have a defibrillator.

    Verbatim wording from the response

    “There is no requirement in law for an establishment to have a defibrillator, however, following a conversation between Lambeth Council’s Senior Schools and Education Improvement Adviser (1st August 2018), the Chair of Trustees of the Centre has advised that a defibrillator and training would be purchased.”

    Source location

    2018-0209-Response-by-London-Borough-of-Lambeth
    Page 2 · response
    Published 14 August 2018

    Open published response
  6. Manchester City

    AI-generated summary

    Lucy Francesca Goldstone · 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

    Lucy Francesca Goldstone had a severe asthma attack and became unresponsive on a tram in Manchester city centre on 7 April 2016. Despite CPR by bystanders and ambulance clinicians, she died at Manchester Royal Infirmary; the recorded cause of death was bronchial asthma and aspiration of food material. The report raised concern about the availability of automated external defibrillators on trams and tram stops, and indicated that updated information and guidance would be sought.

    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 automated external defibrillator availability on trams and tram stops

    Wider context from the report

    “I was informed that in relation to the availability of Automated Electronic Defibrillator that no AEDs are provided on any of the trams or any of the tram stops on the network, and that it is not a legal requirement or industry standard practise for AEDs to be available across the various tram networks in the United Kingdom. ”

    Source location

    Lucy Francesca Goldstone · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
  7. Inner South London

    AI-generated summary

    James O’Brien · 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 O’Brien collapsed in his room at Churchill Hospital on the night of 8/9 December 2015 and died at St Thomas’ Hospital on 9 December 2015. Concerns included delays in starting resuscitation, calling an ambulance and bringing the defibrillator, inappropriate defibrillator attachment, inadequate information provided to ambulance services, and failures in staff training, induction and ward familiarity. The inquest concluded that the emergency response by hospital staff was inadequate and that earlier intervention might have made a difference.

    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

    Delays in bringing the defibrillator

    Wider context from the report

    “(4) There was a delay of about 8 minutes in bringing the defibrillator. ”

    Source location

    James O’Brien · 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 former operator no longer controls future hospital safety steps, which fall to the successor operator.

    Verbatim wording from the response

    “The Churchill Hospital was at the date of Mr O’Brien’s death operated by Cambian Healthcare Limited which was then part of our Group. However, in December 2016 we sold our adult services division, including Cambian Healthcare Limited. The Group, therefore, no longer has any executive responsibility in relation to the hospital. Cambian Healthcare Limited is now a subsidiary of Cygnet Healthcare Limited and its Chief Executive Officer is Dr Tony Romero.”

    Source location

    2017-0082-Response-by-Cambian-Group-PLC
    Page 1 · response
    Published 24 March 2017

    Open published response
  8. Inner North London

    AI-generated summary

    Samuel Rodney Darren BLAIR · 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

    Rodney Blair, who had a history of paranoid schizophrenia, alcohol dependency, multiple drug use and depression, was remanded in custody at HM Prison Pentonville and was found hanging in his cell on 2 August 2015. The inquest concluded that his death was suicide, with several contributing factors. Concerns included gaps in assessment and management of his mental health and antidepressant treatment, and delays and procedural issues in the prison emergency response.

    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

    Restricted immediate access to the emergency defibrillator

    Wider context from the report

    “7. The substance misuse nurse in the detoxification wing did respond immediately. He took his emergency bag with him to Mr Blair’s cell, but did not take the defibrillator stored in the same room as the bag. He later had to leave Mr Blair to retrieve the defibrillator, because it is stored in the nurses’ room and only nurses have the key. ”

    Source location

    Samuel Rodney Darren BLAIR · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report
  9. West Yorkshire (Western)

    AI-generated summary

    Carl Lee Thompson · 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

    Carl Lee Thompson died from drowning on 10 August 2015 after being overwhelmed by surf and waves while bathing in the sea in Fuerteventura. Concerns included inadequate or defective lifesaving and resuscitation equipment, lifeguards’ lack of training in its use, and delays in obtaining replacement equipment and emergency medical assistance.

    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 a functioning defibrillator is immediately available

    Wider context from the report

    “• The emergency bag did not contain suction equipment to clear the airways • A hole in the ambubag used in the resuscitation attempts prevented the flow of oxygen • The defibrillator used during resuscitation was inoperable given it was found to have no batteries • Delay of 45 minutes to obtain a replacement defibrillator • Absence of equipment to dry the casualty • Substantial delay before the arrival of the ambulance and doctor for emergency treatment. ”

    Source location

    Carl Lee Thompson · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  10. Cheshire

    AI-generated summary

    CHRISTOPHER RICARDO WILLIAMS · 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

    Christopher Ricardo Williams was detained under the Mental Health Act and resident in a medium secure unit when he became unresponsive and was pronounced dead at the scene on 6 November 2013. The inquest concluded that the death was from natural causes, with the medical cause recorded as massive pulmonary embolism. Concerns included a defibrillator not working, failure to check it daily, absence of a cross-check system, and no hospital policy for managing sudden or unexpected deaths.

    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 check defibrillator equipment daily for serviceability

    Wider context from the report

    “(2) The defibrillator had not been checked on 5 November, although there was a requirement for the equipment to be checked daily for serviceability by the nursing staff. ”

    Source location

    CHRISTOPHER RICARDO WILLIAMS · 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

    Defibrillator malfunction

    Wider context from the report

    “(1) The defibrillator machine did not work, even when the battery pack was changed. ”

    Source location

    CHRISTOPHER RICARDO WILLIAMS · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
Back to top

Data last updated 7 September 2026