8 Feb 2026 Elise Kay Louise Sebastian · Prevention of Future Deaths report Essex
View report summary
Concerns raised 2
Incorrect operation of the defibrillator during initial analysis View source Delay in obtaining and attaching the defibrillator View source
This report raised 29 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Essex Partnership University NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
Essex Partnership University NHS Foundation Trust
Deliver annual face-to-face Immediate Life Support training to registered inpatient nurses and annual Basic Life Support training to non-registered CAMHS inpatient staff.
View source
Essex Partnership University NHS Foundation Trust
Facilitate life-support refresher sessions for CAMHS staff between mandatory training sessions.
View source
Essex Partnership University NHS Foundation Trust
Undertake medical-emergency simulations every three months in inpatient settings and record them using the approved report.
View source
Essex Partnership University NHS Foundation Trust
Introduce Resus Link Practitioners across inpatient wards to support simulations, equipment readiness, life-support training, audit and dissemination of updates.
View source See 1 more action
×
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 Incorrect operation of the defibrillator during initial analysis
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
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 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
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 Deliver annual face-to-face Immediate Life Support training to registered inpatient nurses and annual Basic Life Support training to non-registered CAMHS inpatient staff.
Verbatim wording from the response “The Trust has made the decision to deliver the ‘gold standard’ Resuscitation Council UK Immediate Life Support (RCUK ILS) training to all registered nursing staff working within an inpatient setting. RCUK ILS training was rolled out from September 2022. The one day face to face training is accompanied by a RCUK ILS ‘hard copy’ training manual and is delivered on an annual basis.” Source location 2026-0078 - Response from Essex University Partnership Trust
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 Facilitate life-support refresher sessions for CAMHS staff between mandatory training sessions.
Verbatim wording from the response “The Head of Deteriorating Patient Pathways and Resuscitation Training Officer and The Head of Clinical Transformation have facilitated life support drop in refreshers sessions for EPUT staff working within a CAMHS setting. These sessions are an opportunity for staff to refresh their knowledge of BLS/ILS in small groups, in between their mandatory training sessions, including refreshers on topics such as chest compressions and airway management.” Source location 2026-0078 - Response from Essex University Partnership Trust
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 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
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
Open published response
28 Apr 2023 Winbourne Gregory Charles · Prevention of Future Deaths report East London
View report summary
Concerns raised 1
Failure to use the on-site defibrillator during an emergency View source
This report raised 14 other concerns. They are not shown here because they do not form part of this recurring concern.
×
AI-generated summary
Winbourne Gregory Charles · 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
Winbourne Gregory Charles was found unresponsive on 10 April 2021, suspended on a mental health ward, after being admitted under the Mental Health Act following an attempt to take his own life. The principal concerns included failures in risk assessment, observation practices, emergency response, record keeping, and governance 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 Failure to use the on-site defibrillator during an emergency
Wider context from the report “4. Failures to respond to an emergency adequately – The Trust described the emergency response as chaotic . Staff agreed that they “panicked” and did not follow policy, specific issues include;
a. A ward emergency bell was not sounded,
b. An anti-barricade key was not used to open Mr Charles’ door, instead the door was forced open causing a risk of harm to Mr Charles.
c. A ligature cutter could not be used promptly as it was secured in a box with a combination lock – staff did not know the combination,
d. Duty doctors were not called promptly,
e. Oxygen administration was delayed,
f. An on-site defibrillator was not used by staff
g. Staff could or would not provide a clear and relevant history to paramedics.
” Source location Winbourne Gregory Charles · Prevention of Future Deaths report
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 Conduct monthly resuscitation drills covering emergency alarms, equipment, oxygen, defibrillation, clinical handover and cardiac-checklist use.
Verbatim wording from the response “4. Risk management (shortcomings in responding to the emergency) – the Coroner found that the Trust did not respond to the | 5. | Resus drills which include all of these elements are taking place monthly. | 1. Resus drills to take place monthly” Source location NELFT NHS Foundation Trust Action Plan
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 Mandatory ILS training already covers oxygen administration and defibrillator use, so these requirements do not need separate training arrangements.
Verbatim wording from the response “e. Oxygen administration was delayed.” Source location NELFT NHS Foundation Trust Action Plan
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 Concerns about care provision and coordination are mainly for the NHS Trust to address.
Verbatim wording from the response “Your report raises concerns over the provision and coordination of care that Winbourne received at North East London NHS Foundation Trust, which are mainly for the Trust to address. I understand that the Trust has already carefully considered the matters of concern in your report and has provided you with a comprehensive response as well as a copy of its action plan setting out the actions to be taken to improve care quality and patient safety.” Source location Response from Department of Health and Social Care
Open published response
2 Dec 2022 Lewis Steven Johnson · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 1
Failure to consider defibrillator use during a cardiac emergency View source
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
×
AI-generated summary
Lewis Steven Johnson · 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
Lewis Steven Johnson was found unresponsive with a neck ligature at HMP Wealstun on 12 December 2019 and later died in hospital following a further cardiac arrest. The report raised concerns about the absence of overnight healthcare staff and the prison officers’ delayed and inadequate response, including lack of CPR, defibrillator use and consideration of the recovery position.
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 consider defibrillator use during a cardiac emergency
Wider context from the report “(6) The four prison officers present in the cell did not discuss the need for CPR. The possibility of using a defibrillator was not mentioned . Mr Johnson was left in the cell in a seated position without the wisdom of placing him in the recovery position being considered.
” Source location Lewis Steven Johnson · Prevention of Future Deaths report
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 Update the emergency-response training video and distribute it to training centres and prisons for staff training.
Verbatim wording from the response “In respect of the EFAW training all prison officers receive during their entry level training, all first aid training certificates are valid for three years and although not mandatory, staff are encouraged to undertake refresher training to maintain their basic skills and keep up to date with any changes to first-aid procedures. The initial training for staff includes an HMPPS video which shows how to respond to an emergency situation where a prisoner has attempted suicide. This is currently being updated to reflect changes to policy and equipment available since the original video was produced. This video covers the use of prison issue ligature tools, emergency response codes, placing someone in the recovery position and considerations such as when to initiate first aid and the use of defibrillators.” Source location Response from HM Prison & Probation Service
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 Resume local FAW and EFAW training, prioritising night-group staff and extending training to Custodial Managers and other officers.
Verbatim wording from the response “While the delivery of staff training has been severely impacted as a result of restrictions put in place due to the COVID-19 pandemic, with prisons only being able to deliver limited safety critical training, from April 2023 HMP Wealstun will be able to resume the delivery of FAW and EFAW training locally, and will prioritise all those on the dedicated night group, which includes Operation Support Grade staff. The intention is also for all Custodial Managers to receive this training, as well as a significant proportion of the wider officer group, to ensure that an effective emergency response can be provided when required.” Source location Response from HM Prison & Probation Service
Open published response
12 Mar 2020 Mitica Marin · Prevention of Future Deaths report East London
View report summary
Concerns raised 3
Failure to review the defibrillator during resuscitation View source LP15 defibrillator defaulting to manual mode View source Failure to activate the LP15 defibrillator in automatic mode View source
Linked responses
Association of Ambulance Chief Executives Department of Health and Social Care London Ambulance Service NHS Trust Physio-Control UK Sales Ltd Resuscitation Council UK
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 9
London Ambulance Service NHS Trust
Train clinical education and standard tutors in human factors so they can deliver the content through the core-skills refresher programme.
View source
London Ambulance Service NHS Trust
Deliver human-factors training covering communication, active listening, speaking up and decision-making bandwidth to tutors and relevant clinical staff.
View source
London Ambulance Service NHS Trust
Issue clinical guidance mandating initial AED-mode use on LP15 defibrillators during cardiac arrests.
View source
London Ambulance Service NHS Trust
Place AED-mode reminder stickers on LP15 defibrillators and communicate the change through station management, bulletins and the intranet.
View source
London Ambulance Service NHS Trust
Review delayed-defibrillation cases and complete thematic analysis to identify contributory factors and mitigation actions.
View source
London Ambulance Service NHS Trust
Continue reviewing defibrillator procurement options through clinical-equipment tender processes and encourage manufacturers to develop automatic AED-mode functionality.
View source
Association of Ambulance Chief Executives
Review resuscitation guidance on manual versus automatic defibrillation for the first cardiac arrest shock.
View source
Association of Ambulance Chief Executives
Issue revised guidance permitting solo responders to use automatic defibrillator mode until additional help arrives.
View source
London Ambulance Service NHS Trust
Incorporate AED-mode use and cardiac-arrest priority training into mandatory quarterly core-skills refresher training.
View source See 6 more actions
×
AI-generated summary
Mitica Marin · 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
Mitica Marin, aged 35, was found unresponsive at home on 11 April 2019 and died in hospital after prolonged resuscitation attempts. The cause of death was unascertained. The LAS investigation identified a four-minute delay in delivering the first defibrillator shock while Mr Marin was in a shockable rhythm, associated with the defibrillator being used in manual rather than automatic mode.
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 review the defibrillator during resuscitation
Wider context from the report “The LAS serious incident investigation identified a 4-minute delay between LP15 defibrillator pads being placed on Mr Marin’s chest and the administration of the first shock. During this period Mr Marin’s heart was in a shockable rhythm.
Paramedic A accepted that they had not reviewed the defibrillator as they were distracted by events.
Paramedic A did not activate the defibrillator in “automatic” mode. Had this setting been applied, any shockable rhythm would have been detected and an alert would have prompted the paramedic to shock to the patient.
This is not an isolated incident, the LAS conceded that it had undertaken a review of similar cases of delayed defibrillation. The review found that a factor was that the LP15 defibrillator model, defaults to manual mode requiring the user to switch to automatic mode before use.
2 studies cited by the LAS indicated that every minute a patient is delayed effective resuscitation; their prospects of survival diminishes by between 10-22%.
The LAS have introduced remedial measures to prevent such actions occurring, incorporating; training on the use of the LP15, labelling on units and the issuing of revised guidance.
If the LP15 defaulted to automatic mode or on start-up required, the choice of manual or automatic mode it is possible that such delays could be avoided.
I understand that procurement decisions regarding the future supply of defibrillators are imminent.
” Source location Mitica Marin · Prevention of Future Deaths report
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 LP15 defibrillator defaulting to manual mode
Wider context from the report “The LAS serious incident investigation identified a 4-minute delay between LP15 defibrillator pads being placed on Mr Marin’s chest and the administration of the first shock. During this period Mr Marin’s heart was in a shockable rhythm.
Paramedic A accepted that they had not reviewed the defibrillator as they were distracted by events.
Paramedic A did not activate the defibrillator in “automatic” mode. Had this setting been applied, any shockable rhythm would have been detected and an alert would have prompted the paramedic to shock to the patient.
This is not an isolated incident, the LAS conceded that it had undertaken a review of similar cases of delayed defibrillation. The review found that a factor was that the LP15 defibrillator model, defaults to manual mode requiring the user to switch to automatic mode before use.
2 studies cited by the LAS indicated that every minute a patient is delayed effective resuscitation; their prospects of survival diminishes by between 10-22%.
The LAS have introduced remedial measures to prevent such actions occurring, incorporating; training on the use of the LP15, labelling on units and the issuing of revised guidance.
If the LP15 defaulted to automatic mode or on start-up required, the choice of manual or automatic mode it is possible that such delays could be avoided.
I understand that procurement decisions regarding the future supply of defibrillators are imminent.
” Source location Mitica Marin · Prevention of Future Deaths report
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 Failure to activate the LP15 defibrillator in automatic mode
Wider context from the report “The LAS serious incident investigation identified a 4-minute delay between LP15 defibrillator pads being placed on Mr Marin’s chest and the administration of the first shock. During this period Mr Marin’s heart was in a shockable rhythm.
Paramedic A accepted that they had not reviewed the defibrillator as they were distracted by events.
Paramedic A did not activate the defibrillator in “automatic” mode. Had this setting been applied, any shockable rhythm would have been detected and an alert would have prompted the paramedic to shock to the patient.
This is not an isolated incident, the LAS conceded that it had undertaken a review of similar cases of delayed defibrillation. The review found that a factor was that the LP15 defibrillator model, defaults to manual mode requiring the user to switch to automatic mode before use.
2 studies cited by the LAS indicated that every minute a patient is delayed effective resuscitation; their prospects of survival diminishes by between 10-22%.
The LAS have introduced remedial measures to prevent such actions occurring, incorporating; training on the use of the LP15, labelling on units and the issuing of revised guidance.
If the LP15 defaulted to automatic mode or on start-up required, the choice of manual or automatic mode it is possible that such delays could be avoided.
I understand that procurement decisions regarding the future supply of defibrillators are imminent.
” Source location Mitica Marin · Prevention of Future Deaths report
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 Train clinical education and standard tutors in human factors so they can deliver the content through the core-skills refresher programme.
Verbatim wording from the response “Further to the evidence you heard in respect of training, in addition the LAS is continuing to progress ‘human factors training’ to focus on optimising staff performance through better understanding of behavioural interactions with each other and the environment. This is especially pertinent for operational staff who deal with chaotic, emotional scenes and where no two scenes are the same.” Source location 2020-0066-Response-from-London-Ambulance-Service-NHS-Trust-Redacted
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 Deliver human-factors training covering communication, active listening, speaking up and decision-making bandwidth to tutors and relevant clinical staff.
Verbatim wording from the response “A further six staff are due to undertake the ‘Train the Trainer’ program. We also have a full day of training in areas specific to human factors (communication, active listening, speaking up as part of a team, and how bandwidth impacts decisions and communications) which we hope to be in a position to roll out in July/August” Source location 2020-0066-Response-from-London-Ambulance-Service-NHS-Trust-Redacted
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 Issue clinical guidance mandating initial AED-mode use on LP15 defibrillators during cardiac arrests.
Verbatim wording from the response “Paramedic A cited the training actions the LAS had undertaken around the fundamental importance of prompt defibrillation, where clinically indicated. In addition to this, the LAS has produced clinical update material to mandate that on all cardiac arrests the LP15 defibrillator should initially be placed in AED mode.” Source location 2020-0066-Response-from-London-Ambulance-Service-NHS-Trust-Redacted
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 Place AED-mode reminder stickers on LP15 defibrillators and communicate the change through station management, bulletins and the intranet.
Verbatim wording from the response “From August 2019 large yellow indicators (stickers) with ‘push analyse for AED mode’ were placed on LP15 defibrillators to act as an alert reminder to users to switch the machine into AED mode. This was communicated to staff via station management as well an update in our Routine Information Bulletin (RIB) which is emailed to all staff and also available on the intranet. We have also sought to ensure that devices used in training reflect this change.” Source location 2020-0066-Response-from-London-Ambulance-Service-NHS-Trust-Redacted
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 Review delayed-defibrillation cases and complete thematic analysis to identify contributory factors and mitigation actions.
Verbatim wording from the response “It was also recognised that the delay in defibrillation of Mr Marin was not an isolated incident for the Trust. In order to address incidents of delayed defibrillation, the LAS undertook a review of similar cases and completed a thematic analysis report in December 2019. The updated Action Plan from this report is attached for your reference.” Source location 2020-0066-Response-from-London-Ambulance-Service-NHS-Trust-Redacted
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 Continue reviewing defibrillator procurement options through clinical-equipment tender processes and encourage manufacturers to develop automatic AED-mode functionality.
Verbatim wording from the response “Efforts are being made to investigate devices which have in-built technology to potentially bypass the need for a clinician to have to remember to put the device in AED mode (for example, a device that would automatically switch the device to AED mode when defibrillator pads were applied). At this point in time, we have not located a specific device on the market with this functionality which is also sufficiently robust for the ambulance market.” Source location 2020-0066-Response-from-London-Ambulance-Service-NHS-Trust-Redacted
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 Review resuscitation guidance on manual versus automatic defibrillation for the first cardiac arrest shock.
Verbatim wording from the response “Last year we undertook an extensive review of the resuscitation sections of our clinical practice guidelines. We considered the issue of using manual or automatic mode for delivering the first shock in a cardiac arrest situation and we issued our revised guidance to the UK ambulance services in June 2019. The section of our guidance pertaining to manual or automatic mode is detailed below:” Source location 2020-0066-Response-from-Association-of-Ambulance-Redacted
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 Issue revised guidance permitting solo responders to use automatic defibrillator mode until additional help arrives.
Verbatim wording from the response “Last year we undertook an extensive review of the resuscitation sections of our clinical practice guidelines. We considered the issue of using manual or automatic mode for delivering the first shock in a cardiac arrest situation and we issued our revised guidance to the UK ambulance services in June 2019. The section of our guidance pertaining to manual or automatic mode is detailed below:” Source location 2020-0066-Response-from-Association-of-Ambulance-Redacted
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 Incorporate AED-mode use and cardiac-arrest priority training into mandatory quarterly core-skills refresher training.
Verbatim wording from the response “This has also been incorporated this into the core skills refresher (CSR) training which all clinical staff undergo in the LAS.” Source location 2020-0066-Response-from-London-Ambulance-Service-NHS-Trust-Redacted
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 Automatic defibrillator start-up is not considered safer; manual defibrillation is preferred for advanced life support because it may improve survival outcomes.
Verbatim wording from the response “Although defibrillators can be set to start up in either automatic or manual mode, the latter is preferred. This is because when used correctly, studies have shown that a manual mode results in greater chance of return of spontaneous circulation and subsequent survival to hospital discharge, compared with an automatic mode. Manual defibrillation is therefore recommended for advanced life support, as delivered by ambulance paramedics.” Source location 2020-0066-Response-from-Resusciation-Council-UK-Redacted
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 Deciding or recommending which defibrillator ambulance services should purchase is outside the organisation’s responsibility as a membership organisation.
Verbatim wording from the response “We are aware that there are a number of types of defibrillators in use in UK ambulance service, however, it is not our responsibility as a membership organisation to decide or recommend which device an ambulance service should purchase.” Source location 2020-0066-Response-from-Association-of-Ambulance-Redacted
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 concerns inaccurately reflect LP15 capabilities because it can be configured to power on in either automatic or manual defibrillation mode.
Verbatim wording from the response “After consultation with the manufacturer of the LP15 device, I can advise that the LP15 monitor/defibrillator is designed with the ability to be configured to power on in either automatic or manual defibrillation mode based on the clinical protocols of the health system. Accordingly, I respectfully submit that the Coroner’s Concerns listed at Section 5 of the Report do not accurately reflect the capabilities of the LP15 device.” Source location 2020-0066-Response-from-Stryker-Corporation-Physio-Control-Redacted
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 Existing LP15 configuration capability is considered sufficient, so no action is proposed in relation to the report.
Verbatim wording from the response “Due to the existing capability of the LP15 to be configured to power on in either automatic or manual defibrillation mode, Stryker does not propose to take any action in relation to the Report.” Source location 2020-0066-Response-from-Stryker-Corporation-Physio-Control-Redacted
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 Professional organisations should determine appropriate defibrillator default settings according to local protocols, intended use and available guidance.
Verbatim wording from the response “Professional organisations are best placed to determine the appropriate default settings according to their local protocols and intended use, taking into account available guidance.” Source location 2020-0066-Response-from-Dept.-Health-and-Social-Care-Redacted
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 Changing the defibrillator default to AED mode is not practical for everyday use because the device also functions as a clinical monitoring tool.
Verbatim wording from the response “I understand that the London Ambulance Service has considered if changing the default setting of the LIFEPAK 15 to AED mode could improve clinical outcomes. The London Ambulance Service has decided, for reasons set out in its response to your report, that this is not practical for every-day use given the device’s functionality as both a clinical monitoring tool and defibrillator.” Source location 2020-0066-Response-from-Dept.-Health-and-Social-Care-Redacted
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 Future defibrillator procurement is a matter for individual ambulance services.
Verbatim wording from the response “In relation to future procurement of defibrillators, this is a matter for individual ambulance services. I am advised that the London Ambulance Service is looking to source devices that have in-built technology to negate the need for the user to actively select the mode of operation. I understand that such a device has not been located but that, where it can, the London Ambulance Service is encouraging manufacturers to consider this functional requirement for future models.” Source location 2020-0066-Response-from-Dept.-Health-and-Social-Care-Redacted
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 device's current manual default mode is considered acceptable based on the ambulance service's rationale, subject to monitoring for continuing delays.
Verbatim wording from the response “Finally, my officials have drawn this matter to the attention of the MHRA and also Professor ████████, the National Clinical Director for Heart Disease at NHSEI. Following discussion with clinical colleagues, Professor ████████ has advised that the current default mode of the device being manual, rather than automatic, is acceptable having considered the rationale of the London Ambulance Service deliberations on this matter. Professor ████████ has recommended that, if further monitoring and analysis of data shows continuing evidence of delays, consideration should be given to changing the default setting of the device and this advice has been shared with the London Ambulance Service.” Source location 2020-0066-Response-from-Dept.-Health-and-Social-Care-Redacted
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 Setting LP15 defibrillators to AED mode by default was considered impractical because of operational use and potential unintended consequences.
Verbatim wording from the response “Our Clinical Practice Development Manager gave evidence setting out that it was technically possible for the LP15 defibrillator to be set to AED mode as default, which would require the user to actively have to switch it off when managing a patient who did not require defibrillation. He went on to explain that this option has been considered by the Trust’s medical directorate but the evidence gathered in consideration of the best option to mitigate against clinicians being distracted and/or overwhelmed managing multiple tasks at a busy scene, indicates that to set the LP15 defibrillator to AED mode as default was not overtly practical for a day to day use.” Source location 2020-0066-Response-from-London-Ambulance-Service-NHS-Trust-Redacted
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 No sufficiently robust defibrillator with automatic AED-mode functionality has been found for ambulance use.
Verbatim wording from the response “Your report also requests that I address the matter of procurement decisions regarding the future supply of defibrillators.” Source location 2020-0066-Response-from-London-Ambulance-Service-NHS-Trust-Redacted
Open published response
30 Oct 2019 Robert Thomas GINN · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 1
Incorrect application of defibrillator pads View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
Care UK
Require annual Immediate Life Support training for employed resuscitation staff and monitor compliance through monthly dashboards and the Resuscitation Committee.
View source
Care UK
Contract for additional prison-scenario Immediate Life Support training sessions beyond annual recertification across Care UK sites.
View source
Care UK
Film selected scenario-based resuscitation exercises for use in in-house training and induction.
View source
Care UK
Request CCTV or body-worn-camera footage after on-site custody deaths involving resuscitation and review it through immediate and internal learning reviews.
View source See 1 more action
×
AI-generated summary
Robert Thomas GINN · 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
Robert Thomas Ginn hanged himself in his cell at HM Prison Pentonville and was discovered at around 1.05am on 29 November 2018. Concerns were raised about the quality of the nurse-led resuscitation attempt, including failure to check breathing, inadequate oxygenation, variable chest compressions, lack of coaching, and incorrectly applied defibrillator pads.
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 Incorrect application of defibrillator pads
Wider context from the report “9. The defibrillator pads were incorrectly applied by the nursing team , rendering the defibrillator reading unreliable .
” Source location Robert Thomas GINN · Prevention of Future Deaths report
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 annual Immediate Life Support training for employed resuscitation staff and monitor compliance through monthly dashboards and the Resuscitation Committee.
Verbatim wording from the response “Our policy for the standards of training for employed staff within our Health in Justice service who respond to resuscitation is Immediate Life Support (ILS) training, provided by Resuscitation Council accredited trainers. Although the requirement from the Resuscitation Council is that attendee’s repeat this on a 3 yearly cycle, we mandate that all Care UK employed staff complete this annually. Assurance around the compliance of this training is monitored via monthly performance dashboards and reported to Care UK’s Resuscitation Committee.” Source location Response from Care UK
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 Contract for additional prison-scenario Immediate Life Support training sessions beyond annual recertification across Care UK sites.
Verbatim wording from the response “Going forwards, we will contract with our ILS training provider to deliver additional training sessions, including some prison scenario based training. These will be in addition to the annual re-certification sessions. We anticipate that this will be rolled out across our sites nationally over 2020. In addition our intention is to film some of these scenario-based training exercises for use at in-house training events and induction.” Source location Response from Care UK
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 Film selected scenario-based resuscitation exercises for use in in-house training and induction.
Verbatim wording from the response “Going forwards, we will contract with our ILS training provider to deliver additional training sessions, including some prison scenario based training. These will be in addition to the annual re-certification sessions. We anticipate that this will be rolled out across our sites nationally over 2020. In addition our intention is to film some of these scenario-based training exercises for use at in-house training events and induction.” Source location Response from Care UK
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 Request CCTV or body-worn-camera footage after on-site custody deaths involving resuscitation and review it through immediate and internal learning reviews.
Verbatim wording from the response “Following a death in custody where resuscitation has taken place on site, a request is made to the prison for the opportunity to view or receive a copy of any CCTV or body worn camera footage so that this can be reviewed as part of Care UK’s 72hr immediate review process and Internal Learning Review. This is to enable us to identify issues or concerns and to assist in improving clinical care and identifying training needs.” Source location Response from Care UK
Open published response
21 Apr 2017 Najeeb Katende · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 1
Failure to use a defibrillator in AED mode when first attending or when uncertain about heart-rhythm interpretation View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
×
AI-generated summary
Najeeb Katende · 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
Najeeb Katende collapsed at school while in cardiac arrest and was not defibrillated for about 24 minutes because his initially shockable rhythm was interpreted as non-shockable. He was later defibrillated but died in hospital; the medical cause of death was Sudden Cardiac Death Syndrome. Concerns included the failure to cross-check the rhythm interpretation and the use and interpretation of the defibrillator device.
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 use a defibrillator in AED mode when first attending or when uncertain about heart-rhythm interpretation
Wider context from the report “2. Evidence was also given from other Ambulance staff that:
• Despite the presence of other staff between 10.12am and 10.36am, no cross check was made as to whether Najeeb had a shockable rhythm;
• If an Automated External Defibrillator, such as those used by members of the public had been applied, this would have detected a shockable rhythm and would have proceeded to defibrilate Najeeb.
3. I consider that it would be of great benefit if LAS were to take the following steps, namely training and instruction to staff:
• Actively cross check with another clinician whether a shockable rhythm is present when attending an incident of this sort;
• Use the defibrillator in AED mode when first attending as a matter of routine, or at the very least if uncertain when interpreting a heart rhythm ;
• Further educate on the interpretation of shockable rhythms from readings provided by defibrillator devices.
” Source location Najeeb Katende · Prevention of Future Deaths report
Open source report
15 May 2016 Ronnie Olliffe · Prevention of Future Deaths report Mid Kent and Medway
View report summary
Concerns raised 1
Failure to consider or use an available defibrillator when appropriate View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
×
AI-generated summary
Ronnie Olliffe · 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
Ronnie Olliffe collapsed in his cell at HMP Rochester on 1 October 2014 and was later confirmed dead at the scene; the medical cause of death was anabolic steroid-related cardiac hypertrophy. Concerns included failures to issue a required Code Blue, inadequate understanding that this would summon an ambulance, and failure to consider or use an available defibrillator.
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 consider or use an available defibrillator when appropriate
Wider context from the report “1) there was a failure to issue a Code Blue pursuant to both a local and national policy in circumstances where it was appropriate to do so
2) there was a lack of understanding as to what consequences flowed from the issuing of a Code Blue, namely that an ambulance would be summoned immediately
3) there was a failure to consider or use a defibrillator when it was appropriate to do so and when one was available
” Source location Ronnie Olliffe · Prevention of Future Deaths report
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 Issue emergency-response policy guidance and brief staff on responsibilities, code use, ambulance summoning, and defibrillator deployment.
Verbatim wording from the response “All night staff have been issued with a personal copy of Prison Service Instruction (PSI) 03/2013 Medical Emergency Response Codes and have each signed to say they understand the PSI and are fully aware of their responsibilities. A Notice to Staff setting out the policy has been issued and the remaining staff have been briefed at staff engagement sessions.” Source location 2016-0224-Response-by-NOMS
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 defibrillator-use demonstrations and guidance on defibrillator deployment and location.
Verbatim wording from the response “The Notice to Staff described above also explains the process for the deployment of defibrillators and their location within the prison. A demonstration of the use of a defibrillator was provided during the July 2016 staff engagement session, and the Safer Custody team will follow this up so that all staff know when and how to use them.” Source location 2016-0224-Response-by-NOMS
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 Follow up with staff to ensure they know when and how to use defibrillators.
Verbatim wording from the response “The Notice to Staff described above also explains the process for the deployment of defibrillators and their location within the prison. A demonstration of the use of a defibrillator was provided during the July 2016 staff engagement session, and the Safer Custody team will follow this up so that all staff know when and how to use them.” Source location 2016-0224-Response-by-NOMS
Open published response
25 Mar 2014 Margaret Walker · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 1
Failure to apply an available defibrillator promptly during resuscitation View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
×
AI-generated summary
Margaret Walker · 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
Margaret Walker, a detained patient at the Sephton Unit, was found unresponsive on 7 August 2012 and later diagnosed as having died from coronary artery disease. Concerns included inconsistent diabetes care, delays and omissions in obtaining and communicating medication and blood-test information, inadequate clinical-record documentation, and the defibrillator not being applied before ambulance personnel arrived.
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 apply an available defibrillator promptly during resuscitation
Wider context from the report “(3) When Mrs Walker was found unresponsive at approximately 6.00am on the morning of the 7th August 2012, cardio-pulmonary resuscitation was appropriately commenced and continued and a defibrillator was obtained. However the defibrillator was not applied prior to the arrival of ambulance personnel who then applied their own defibrillator, which did not reveal a heart rhythm suitable for a shock to be given.
” Source location Margaret Walker · Prevention of Future Deaths report
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 Address resuscitation competency of staff involved in the incident through specific Trust competency processes.
Verbatim wording from the response “In this case, while the staff involved in the incident were compliant with their mandatory training requirements they had not appropriately followed the Trust approved Resuscitation policy and procedures in relation to the use of the automated external defibrillator. I would like to reassure you that this has been addressed with the staff in question who has undergone specific Trust processes in relation to their competency.” Source location 2014-0134-Response-by-5-Boroughs-Partnership-NHS-Foundation-Trust
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 Conduct annual resuscitation practice drills including automated external defibrillator use and document competency outcomes.
Verbatim wording from the response “In line with NPSA and RCUK guidelines, it is recommended that services undertake practice drills to support further learning within the clinical environment. The Trust operates an annual practice drill schedule that includes use of an automated external defibrillator. Practice drills are undertaken by the Trust resuscitation trainers to ensure correct standards of practice are demonstrated. Staff are assessed against the RCUK competency framework during practice drills; the outcomes of practice drills are documented to identify areas of good practice and areas requiring improvement. Local actions plans are agreed to address any areas of concern. Records are available which evidence that Sephton Ward have had 4 practice drills completed between November 2012 and January 2014.” Source location 2014-0134-Response-by-5-Boroughs-Partnership-NHS-Foundation-Trust
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 Staff involved in the resuscitation incident complied with mandatory training requirements; the failure concerned following approved procedures instead.
Verbatim wording from the response “In line with National Patient Safety Agency (NPSA) RRO10 “Resuscitation in Mental Health and Learning Disability inpatient settings” (November 2008) and Resuscitation Council UK (RCUK) requirements, all medical staff and registered nurses working within inpatient settings are expected to be competent to the standard of Immediate Life Support (ILS). All support workers are expected to be competent to the standard of Basic Life Support (BLS).” Source location 2014-0134-Response-by-5-Boroughs-Partnership-NHS-Foundation-Trust
Open published response
6 Mar 2014 Natasha Raghoo · Prevention of Future Deaths report West Sussex
View report summary
Concerns raised 1
Failure to use an available ward defibrillator View source
This report raised 12 other concerns. They are not shown here because they do not form part of this recurring concern.
×
AI-generated summary
Natasha Raghoo · 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
Natasha Raghoo was admitted to The Dene Hospital in April 2012 for treatment related to bipolar disorder and was later detained under section 2 of the Mental Health Act. She was found unresponsive in bed on 5 May 2012 and died from anaphylactic shock caused by an unknown allergen. Concerns included inconsistent physical observations, lack of ECG assessment, staff training in resuscitation and defibrillator use, and communication and handover problems.
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 use an available ward defibrillator
Wider context from the report “1. During the course of the evidence, concern was expressed concerning the training that staff had received in the techniques of cardio pulmonary resuscitation and the use of the defibrillator. The latter was reported not to have been used by hospital staff although available on the ward .
” Source location Natasha Raghoo · Prevention of Future Deaths report
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 Implement monthly emergency incident drills to practise CPR and related emergency skills.
Verbatim wording from the response “Lessons Learned and changes made” Source location 2014-0100-Response-by-Partnership-in-Care
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 Deliver company-wide Immediate Life Support training, including defibrillator use, to qualified nurses and doctors.
Verbatim wording from the response “In 2013, and subsequent to the death, PiC implemented a company-wide training programme to move from the provision of Basic Life Support to Immediate Life Support. This training has been delivered to all qualified nurses and doctors across PiC. This training specifically includes the use of the defibrillator.” Source location 2014-0100-Response-by-Partnership-in-Care
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 CPR and defibrillator training with competency sign-off and repeat training where staff do not meet the required standard.
Verbatim wording from the response “Cardio Pulmonary Resuscitation (CPR) and Defibrillator Training” Source location 2014-0100-Response-by-Partnership-in-Care
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.