First reported 3 Dec 2013•Latest report 16 Apr 2026
Definition
What this concern includes
Includes failures of controls specifically dedicated to responding to patient breathing emergencies, including recognition and assessment of abnormal or absent breathing, airway-protective positioning, access to emergency equipment, staff response, clinical attendance, ambulance activation and related immediate escalation.
Not included
Excludes generic emergency-response, staffing, training or equipment deficiencies that are not directly tied to a patient breathing emergency.
Excludes failures limited to later hospital handover, definitive treatment or post-resuscitation care after the immediate breathing-emergency response was effective.
Excludes non-patient emergencies and emergency responses for hazards unrelated to breathing, airway obstruction or cardiac arrest arising from an unrecognised breathing emergency.
Excludes condition-specific respiratory diagnosis or chronic respiratory-care failures where no immediate breathing-emergency response deficiency is identified.
Reports
27
Distinct published reports
Individual concerns
28
A report can raise multiple concerns
Date range
2013–2026
First to latest report issue date
Stated actions
58
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 Care5
HM Prison and Probation Service3
NHS England3
Association of Ambulance Chief Executives2
College of Policing2
London Ambulance Service NHS Trust2
Ministry of Justice2
Resuscitation Council UK2
Abbotswood1
Aspray House1
British Society For Genetic Medicine1
Bupa Care Homes (GL) Limited1
Cardiac Risk in the Young1
Care Outlook Ltd1
Care UK1
NHS trust12
Ministerial department8
Executive non-departmental public body5
Executive agency3
Health professional body3
Prison or young offender institution3
Private limited company3
Type not available3
Care-home operator2
Healthcare site2
Health-sector membership body2
National policing body2
Police force2
Sub-organisation2
Devolved government1
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.
West London
Concerns raised1
Difficulty among lay people and ambulance call handlers in recognising signs of agonal breathing or cardiac arrest
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.20
Action
Support national initiatives that increase cardiac-arrest recognition, CPR education and first-aid training.
Stated by Association of Ambulance Chief ExecutivesStated in progressThe respondent said that this action was in progress when they made their response on 27 April 2026.
Action
Support Restart a Heart and related public cardiac-arrest awareness and CPR-education initiatives.
Stated by Association of Ambulance Chief ExecutivesStated in progressThe respondent said that this action was in progress when they made their response on 27 April 2026.
Action
Encourage and support Community First Responders across the ambulance sector to provide early CPR and defibrillation.
Stated by Association of Ambulance Chief ExecutivesStated in progressThe respondent said that this action was in progress when they made their response on 27 April 2026.
Action
Use a breathing-rate threshold to support recognition of agonal breathing in NHS Pathways triage.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 27 April 2026.
Action
Presume cardiac arrest in NHS Pathways when a person collapses and becomes unconscious during exercise or sport, including when fitting is reported.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 27 April 2026.
Action
Work with MPDS and NHS Pathways coding sub-groups to consider further measures supporting recognition of agonal breathing or cardiac arrest.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 27 April 2026.
Action
Train CPR participants to recognise agonal breathing and commence CPR when a person is unresponsive and not breathing normally.
Stated by St John AmbulanceStated completedThe respondent said that this action was complete when they made their response on 27 April 2026.
Action
Incorporate updated national guidance into training so CPR is commenced immediately when someone collapses during exercise and is unresponsive.
Stated by St John AmbulanceStated in progressThe respondent said that this action was in progress when they made their response on 27 April 2026.
Action
Strengthen emergency call-taker training with audible agonal-breathing examples, listening-skills guidance and clinical-escalation emphasis.
Stated by South Central Ambulance Service NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 27 April 2026.
Action
Trial the Pre-Sieve Questions Project to reduce pre-sieve questioning and accelerate Nature of Call selection.
Stated by South Central Ambulance Service NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 27 April 2026.
Action
Replace the computer-aided dispatch system and use the pilot outcome to inform its pre-sieve question set.
Stated by South Central Ambulance Service NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 27 April 2026.
Action
Review another ambulance service’s video-assisted resuscitation guidance pilot to assess whether implementation would benefit local telephone triage.
Stated by South Central Ambulance Service NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 27 April 2026.
Action
Use a less-than-one-breath-per-ten-seconds threshold in NHS Pathways to support recognition of agonal breathing.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 27 April 2026.
Action
Presume collapse with unconsciousness during exercise or sport, including reported fitting, to be cardiac arrest regardless of apparent regular breathing.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 27 April 2026.
Action
Work with MPDS and NHS Pathways coding sub-groups to consider further measures helping the public recognise agonal breathing or cardiac arrest.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 27 April 2026.
Action
Revise SCA, first-aid and defibrillator training content to incorporate current guidance, case learning and clearer emergency-response instructions.
Stated by The Football AssociationStated completedThe respondent said that this action was complete when they made their response on 27 April 2026.
Action
Require tutors to reinforce key SCA-response messages and show abnormal-breathing videos at every face-to-face course.
Stated by The Football AssociationStated completedThe respondent said that this action was complete when they made their response on 27 April 2026.
Action
Publish simplified guidance directing people to suspect cardiac arrest when an unresponsive person has abnormal breathing.
Stated by Resuscitation Council UKStated completedThe respondent said that this action was complete when they made their response on 27 April 2026.
Action
Work with NHS England through NHS Pathways to support standardised dispatch algorithms and telephone-assisted CPR instructions.
Stated by Resuscitation Council UKStated in progressThe respondent said that this action was in progress when they made their response on 27 April 2026.
Action
Strengthen public education campaigns, including an annual Restart a Heart focus on recognising and raising awareness of agonal breathing.
Stated by Resuscitation Council UKStated plannedThe respondent said that this action was planned when they made their response on 27 April 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
Training and education of ambulance staff and the public, including defibrillator use, are outside the organisation’s responsibilities.
Stated by Association of Ambulance Chief ExecutivesOutside remitThe respondent said that this matter was outside its role or authority.
Position
Pre-sieve questions cannot be integrated into the current computer-aided dispatch system because of its technological limitations.
Stated by South Central Ambulance Service NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
NHS England will respond on concerns about recognising agonal breathing or cardiac arrest, defibrillator use, and cascade communication of hereditary conditions.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Inner North London
Concerns raised1
Failure to recognise breathing difficulty and place an unresponsive person in the recovery position
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Northumberland
Concerns raised1
Delays in care assistant intervention when a resident shows signs of choking
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Reissue Basic Life Support and IDDSI/Dysphagia training electronically with defined completion timeframes.
Stated by Hill Care GroupStated in progressThe respondent said that this action was in progress when they made their response on 30 July 2025.
Action
Deliver face-to-face emergency first aid training to all staff by 14 October 2025.
Stated by Hill Care GroupStated in progressThe respondent said that this action was in progress when they made their response on 30 July 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The measures described are considered sufficient to satisfy the concerns, so no further safety work is proposed.
Stated by Hill Care GroupNo action considered necessaryThe respondent said that no further action was needed.
Kent and Medway
Concerns raised1
Failure to maintain prison officers’ first aid and basic life support competence during physical restraint
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.2
Action
Re-issue the national first aid refresher framework defining emergency first aid, workplace first aid and establishment cover requirements.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 30 July 2025.
Action
Create bespoke first-on-scene care videos for prison officers and frontline staff covering potential emergency scenarios.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 30 July 2025.
East London
Concerns raised1
Failure to commence chest compressions promptly after breathing stops
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
Action
Deliver lessons-learned, anti-choking, first-aid and competency training to permanent, agency, care and non-care staff, including refresher training.
Stated by Aspray HouseStated completedThe respondent said that this action was complete when they made their response on 23 July 2025.
Action
Review the Swallowing Difficulties and Basic Life Support, Resuscitation and DNARCPR policies for compliance with relevant guidance.
Stated by Aspray HouseStated completedThe respondent said that this action was complete when they made their response on 23 July 2025.
Action
Display a colour-coded choking flow chart in nursing stations and pictorial choking first-aid posters in dining areas.
Stated by Aspray HouseStated completedThe respondent said that this action was complete when they made their response on 23 July 2025.
Action
Add dementia-related choking-risk and CPR warnings to the Care Notes of every resident with a dementia diagnosis.
Stated by Aspray HouseStated completedThe respondent said that this action was complete when they made their response on 23 July 2025.
North Yorkshire and York
Concerns raised1
Delayed nursing response to information about choking
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The nurse’s response to the choking was only briefly delayed because they were administering medication to another patient.
Stated by York and Scarborough Teaching Hospitals NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
East London
Concerns raised1
Failure to follow the emergency protocol for choking
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.4
Action
Deliver first-aid, basic-life-support and choking emergency-response training to all staff.
Stated by SerencroftStated completedThe respondent said that this action was complete when they made their response on 30 July 2024.
Action
Reissue grab files to all units and regularly discuss their emergency guidance at team meetings.
Stated by SerencroftStated completedThe respondent said that this action was complete when they made their response on 30 July 2024.
Action
Hold regular emergency-response workshops to embed training and strengthen practical staff confidence.
Stated by SerencroftStated plannedThe respondent said that this action was planned when they made their response on 30 July 2024.
Action
Display emergency-response posters throughout the building.
Stated by SerencroftStated completedThe respondent said that this action was complete when they made their response on 30 July 2024.
Manchester North
Concerns raised1
Failure to provide training on recognising agonal breathing
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.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Complete the FALP review and update learning outcomes to cover agonal gasps, cardiac arrest recognition and basic life support.
Stated by College of PolicingStated completedThe respondent said that this action was complete when they made their response on 28 June 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Individual forces are responsible for developing FALP learning materials, including video content, under local clinical governance procedures.
Stated by College of PolicingRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The reviewed FALP and new PPST are considered to provide policing with the necessary skills to preserve life and keep the public safe.
Stated by College of PolicingExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
West Sussex, Brighton and Hove
Concerns raised1
Failure to attempt life-saving techniques
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.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.6
Action
Purchase and use a choking vest for hands-on basic life support training.
Stated by Care Outlook LtdStated completedThe respondent said that this action was complete when they made their response on 7 June 2024.
Action
Develop a lesson plan for practical choking recognition and response training using the choking vest.
Stated by Care Outlook LtdStated completedThe respondent said that this action was complete when they made their response on 7 June 2024.
Action
Roll out standalone practical choking-response sessions using the choking vest across services.
Stated by Care Outlook LtdStated in progressThe respondent said that this action was in progress when they made their response on 7 June 2024.
Action
Provide amended choking-vest training through mandatory induction and refresher basic life support sessions.
Stated by Care Outlook LtdStated completedThe respondent said that this action was complete when they made their response on 7 June 2024.
Action
Create and publish an online recorded choking-response training session with practical demonstrations for staff refreshers.
Stated by Care Outlook LtdStated in progressThe respondent said that this action was in progress when they made their response on 7 June 2024.
Action
Increase dysphagia and modified-diets e-learning refreshers to an annual frequency.
Stated by Care Outlook LtdStated completedThe respondent said that this action was complete when they made their response on 7 June 2024.
Essex
Concerns raised1
Failure to provide guidance on inflation pressure when securing a paediatric airway adjunct in life-threatening asthma
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
AACE is not constituted to mandate or instruct ambulance services on responsive safety measures.
Stated by Association of Ambulance Chief ExecutivesOutside remitThe respondent said that this matter was outside its role or authority.
Position
Individual clinicians and employing organisations must ensure airway competency and determine advanced airway skills and adjuncts used.
Stated by Association of Ambulance Chief ExecutivesRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Pin
Get email alerts
Request correction
Includes failures of controls specifically dedicated to responding to patient breathing emergencies, including recognition and assessment of abnormal or absent breathing, airway-protective positioning, access to emergency equipment, staff response, clinical attendance, ambulance activation and related immediate escalation.
