First reported 6 Mar 2014•Latest report 8 Feb 2026
Definition
What this concern includes
Includes failures in the operational use of a defibrillator during resuscitation, including reviewing the device, selecting or activating the appropriate mode, attaching pads correctly, detecting or confirming shockable rhythms, delivering indicated shocks and using an available defibrillator promptly.
Not included
Excludes failures limited to defibrillator availability, maintenance, battery or accessory readiness where the device was not operationally misused or omitted during resuscitation.
Excludes generic defibrillator training or familiarisation deficiencies unless they directly result in unsafe operation during a resuscitation.
Excludes failures of CPR, airway management or other resuscitation actions where defibrillator operation is not the deficient control.
Excludes clinical decisions not to defibrillate when the defibrillator was correctly operated and the decision was otherwise clinically justified.
Reports
9
Distinct published reports
Individual concerns
12
A report can raise multiple concerns
Date range
2014–2026
First to latest report issue date
Stated actions
28
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.
Department of Health and Social Care2
London Ambulance Service NHS Trust2
Association of Ambulance Chief Executives1
Care UK1
Care UK Limited1
Essex Partnership University NHS Foundation Trust1
Greater Manchester Mental Health NHS Foundation Trust1
Ministry of Justice1
North East London NHS Foundation Trust1
Partnerships in Care Limited1
Pentonville Prison1
Physio-Control UK Sales Ltd1
Resuscitation Council UK1
Rochester Prison1
South London and Maudsley NHS Foundation Trust1
NHS trust6
Ministerial department3
Prison or young offender institution3
Company1
Health professional body1
Health-sector membership body1
Independent healthcare provider1
Multi-service care provider1
Private limited company1
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.
Essex
Concerns raised2
Incorrect operation of the defibrillator during initial analysis
Delay in obtaining and attaching the defibrillator
This report raised 29 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
Action
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.
Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 February 2026.
Action
Facilitate life-support refresher sessions for CAMHS staff between mandatory training sessions.
Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 February 2026.
Action
Undertake medical-emergency simulations every three months in inpatient settings and record them using the approved report.
Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 February 2026.
Action
Introduce Resus Link Practitioners across inpatient wards to support simulations, equipment readiness, life-support training, audit and dissemination of updates.
Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 February 2026.
East London
Concerns raised1
Failure to use the on-site defibrillator during an emergency
This report raised 14 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Stated by North East London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 5 May 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Mandatory ILS training already covers oxygen administration and defibrillator use, so these requirements do not need separate training arrangements.
Stated by North East London NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Concerns about care provision and coordination are mainly for the NHS Trust to address.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
West Yorkshire Eastern
Concerns raised1
Failure to consider defibrillator use during a cardiac emergency
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Update the emergency-response training video and distribute it to training centres and prisons for staff training.
Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 19 December 2022.
Action
Resume local FAW and EFAW training, prioritising night-group staff and extending training to Custodial Managers and other officers.
Stated by HM Prison and Probation ServiceStated plannedThe respondent said that this action was planned when they made their response on 19 December 2022.
East London
Concerns raised3
Failure to review the defibrillator during resuscitation
LP15 defibrillator defaulting to manual mode
Failure to activate the LP15 defibrillator in automatic mode
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.9
Action
Train clinical education and standard tutors in human factors so they can deliver the content through the core-skills refresher programme.
Stated by London Ambulance Service NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 27 March 2020.
Action
Deliver human-factors training covering communication, active listening, speaking up and decision-making bandwidth to tutors and relevant clinical staff.
Stated by London Ambulance Service NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 27 March 2020.
Action
Issue clinical guidance mandating initial AED-mode use on LP15 defibrillators during cardiac arrests.
Stated by London Ambulance Service NHS TrustStated completedThe respondent said that this action was complete when they made their response on 27 March 2020.
Action
Place AED-mode reminder stickers on LP15 defibrillators and communicate the change through station management, bulletins and the intranet.
Stated by London Ambulance Service NHS TrustStated completedThe respondent said that this action was complete when they made their response on 27 March 2020.
Action
Review delayed-defibrillation cases and complete thematic analysis to identify contributory factors and mitigation actions.
Stated by London Ambulance Service NHS TrustStated completedThe respondent said that this action was complete when they made their response on 27 March 2020.
Action
Continue reviewing defibrillator procurement options through clinical-equipment tender processes and encourage manufacturers to develop automatic AED-mode functionality.
Stated by London Ambulance Service NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 27 March 2020.
Action
Review resuscitation guidance on manual versus automatic defibrillation for the first cardiac arrest shock.
Stated by Association of Ambulance Chief ExecutivesStated completedThe respondent said that this action was complete when they made their response on 27 March 2020.
Action
Issue revised guidance permitting solo responders to use automatic defibrillator mode until additional help arrives.
Stated by Association of Ambulance Chief ExecutivesStated completedThe respondent said that this action was complete when they made their response on 27 March 2020.
Action
Incorporate AED-mode use and cardiac-arrest priority training into mandatory quarterly core-skills refresher training.
Stated by London Ambulance Service NHS TrustStated completedThe respondent said that this action was complete when they made their response on 27 March 2020.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.10
Position
Automatic defibrillator start-up is not considered safer; manual defibrillation is preferred for advanced life support because it may improve survival outcomes.
Stated by Resuscitation Council UKDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Deciding or recommending which defibrillator ambulance services should purchase is outside the organisation’s responsibility as a membership organisation.
Stated by Association of Ambulance Chief ExecutivesOutside remitThe respondent said that this matter was outside its role or authority.
Position
The concerns inaccurately reflect LP15 capabilities because it can be configured to power on in either automatic or manual defibrillation mode.
Stated by Physio-Control UK Sales LtdDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Existing LP15 configuration capability is considered sufficient, so no action is proposed in relation to the report.
Stated by Physio-Control UK Sales LtdExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Professional organisations should determine appropriate defibrillator default settings according to local protocols, intended use and available guidance.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Changing the defibrillator default to AED mode is not practical for everyday use because the device also functions as a clinical monitoring tool.
Stated by Department of Health and Social CareUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Future defibrillator procurement is a matter for individual ambulance services.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The device's current manual default mode is considered acceptable based on the ambulance service's rationale, subject to monitoring for continuing delays.
Stated by Department of Health and Social CareExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Setting LP15 defibrillators to AED mode by default was considered impractical because of operational use and potential unintended consequences.
Stated by London Ambulance Service NHS TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
No sufficiently robust defibrillator with automatic AED-mode functionality has been found for ambulance use.
Stated by London Ambulance Service NHS TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Inner North London
Concerns raised1
Incorrect application of defibrillator pads
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
Action
Require annual Immediate Life Support training for employed resuscitation staff and monitor compliance through monthly dashboards and the Resuscitation Committee.
Stated by Care UKStated completedThe respondent said that this action was complete when they made their response on 13 December 2019.
Action
Contract for additional prison-scenario Immediate Life Support training sessions beyond annual recertification across Care UK sites.
Stated by Care UKStated plannedThe respondent said that this action was planned when they made their response on 13 December 2019.
Action
Film selected scenario-based resuscitation exercises for use in in-house training and induction.
Stated by Care UKStated plannedThe respondent said that this action was planned when they made their response on 13 December 2019.
Action
Request CCTV or body-worn-camera footage after on-site custody deaths involving resuscitation and review it through immediate and internal learning reviews.
Stated by Care UKStated completedThe respondent said that this action was complete when they made their response on 13 December 2019.
Inner North London
Concerns raised1
Failure to use a defibrillator in AED mode when first attending or when uncertain about heart-rhythm interpretation
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Mid Kent and Medway
Concerns raised1
Failure to consider or use an available defibrillator when appropriate
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
Action
Issue emergency-response policy guidance and brief staff on responsibilities, code use, ambulance summoning, and defibrillator deployment.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 15 May 2016.
Action
Provide defibrillator-use demonstrations and guidance on defibrillator deployment and location.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 15 May 2016.
Action
Follow up with staff to ensure they know when and how to use defibrillators.
Stated by HM Prison and Probation ServiceStated plannedThe respondent said that this action was planned when they made their response on 15 May 2016.
Manchester West
Concerns raised1
Failure to apply an available defibrillator promptly during resuscitation
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Address resuscitation competency of staff involved in the incident through specific Trust competency processes.
Stated by North West Boroughs Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 25 March 2014.
Action
Conduct annual resuscitation practice drills including automated external defibrillator use and document competency outcomes.
Stated by North West Boroughs Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 25 March 2014.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Staff involved in the resuscitation incident complied with mandatory training requirements; the failure concerned following approved procedures instead.
Stated by North West Boroughs Healthcare NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
West Sussex
Concerns raised1
Failure to use an available ward defibrillator
This report raised 12 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
Action
Implement monthly emergency incident drills to practise CPR and related emergency skills.
Stated by Partnerships in Care Group LimitedStated completedThe respondent said that this action was complete when they made their response on 6 March 2014.
Action
Deliver company-wide Immediate Life Support training, including defibrillator use, to qualified nurses and doctors.
Stated by Partnerships in Care Group LimitedStated completedThe respondent said that this action was complete when they made their response on 6 March 2014.
Action
Provide CPR and defibrillator training with competency sign-off and repeat training where staff do not meet the required standard.
Stated by Partnerships in Care Group LimitedStated completedThe respondent said that this action was complete when they made their response on 6 March 2014.
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Includes failures in the operational use of a defibrillator during resuscitation, including reviewing the device, selecting or activating the appropriate mode, attaching pads correctly, detecting or confirming shockable rhythms, delivering indicated shocks and using an available defibrillator promptly.
