Failure to reliably respond to patient breathing emergencies
First to latest report 3 Dec 2013 — 16 Apr 2026
Reports that mention this concern
27
Times this concern has been raised
28
Stated actions linked to this concern
58
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.
What is 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.
Trends
Reports over time
Reports mentioning this concern, 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
Reports and published responses 27 reports
See individual reports that have raised this concern, and the actions taken in response
Nottinghamshire
Concerns raised2
Emergency response systems failing to ensure an immediate and effective response to concerns about patient breathing
Inadequate staff training for immediate and effective emergency response to concerns about patient breathing
This report raised 3 other concerns. 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.
Gwent
Concerns raised1
Failure of the current ambulance triage algorithm to assign appropriate urgency to choking, breathing difficulty and drowsiness
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Eluned Morgan
Welsh Ambulance Services NHS 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.1
Welsh Ambulance Services NHS Trust
Regularly review Medical Priority Dispatch System code categorisation using clinical and operational data.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Eluned Morgan
Operational concerns about ambulance service delivery are best addressed by the Welsh Ambulance Services Trust.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
West Yorkshire Eastern
Concerns raised1
Failure to consider placing an unresponsive prisoner in the recovery position
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
HM Prison and Probation Service
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
HM Prison and Probation Service
Update the emergency-response training video and distribute it to training centres and prisons for staff training.
Inner South London
Concerns raised1
Failure to provide access to prescribed emergency inhaler medication during public-place police detention
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Department of Health and Social Care
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Department of Health and Social Care
MHRA owns the regulations governing non-prescribed police inhalers and must receive supporting evidence before legislative change can be considered.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Department of Health and Social Care
Responsibility for considering police access to inhalers lies with the Home Office, with Department support.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
West Yorkshire (Western)
Concerns raised1
Lack of clear national emergency and resuscitation guidance for choking emergencies where conventional abdominal thrusts are not possible or effective
Linked responses
NHS England
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.6
Resuscitation Council UK
Add a frequently asked question to the national website explaining the position on choking management when abdominal thrusts are not possible.
Resuscitation Council UK
Set out a stepwise choking-management approach in basic life support guidance, including chest compressions when abdominal thrusts fail or cannot be administered.
Resuscitation Council UK
Assess abdominal-thrust alternatives for people with increased body mass and exclude supine abdominal thrusts from guidance because of safety and effectiveness concerns.
Resuscitation Council UK
Teach healthcare professionals to use laryngoscopes and Magill’s forceps for foreign-body removal under direct vision in the advanced life support course.
Resuscitation Council UK
Include immediate availability of laryngoscopes and Magill’s forceps in quality standards for mental health inpatient care.
Resuscitation Council UK
Assess suction-based airway-clearance devices for safety and effectiveness and determine whether evidence supports routine use.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
NHS England
Resuscitation Council UK has addressed all concerns raised in the report.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Resuscitation Council UK
Existing basic life support guidelines provide a stepwise choking response, including chest compressions suitable for people of any size.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Resuscitation Council UK
Inversion or chair/table manoeuvres will not be introduced because evidence is insufficient and manual handling poses injury risks.
Unable to actThe respondent said that a constraint prevented them from taking the relevant action.
Inner North London
Concerns raised1
Lack of frequent appropriate emergency resuscitation training
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Bupa
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
Bupa
Provide and competency-assess Basic Life Support and DNACPR training, including practical choking and CPR assessment.
Bupa
Have the Internal Lead Inspector attend Basic Life Support training to assess its quality and efficacy.
Bupa
Retrain remaining Highgate staff and ensure they are competent and confident to manage future choking, cardiac arrest and CPR incidents.
Bupa
Consider implementing more frequent competency checks or opportunities to practise chest compressions.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Bupa
Existing evidence indicates Highgate BLS delegates passed competency assessments, disputing that training competence was absent.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
Bupa
Annual BLS training frequency is not out of step with other social care providers.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
Inner North London
Concerns raised1
Delays in calling the rapid response team when non-respiration is suspected
This report raised 7 other concerns. 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.
Manchester South
Concerns raised1
Failure of the asthma triage script to require direct questioning about ineffective breathing
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
NHS England
NHS Lancashire and South Cumbria Integrated Care Board
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
NHS Lancashire and South Cumbria Integrated Care Board
Review progress on ineffective-breathing improvement actions through monthly commissioner-led clinical quality assurance meetings.
NHS England
Hold a learning event for ambulance services and triage-system providers to share best practice on safely identifying ineffective breathing.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
NHS Lancashire and South Cumbria Integrated Care Board
NWAS, not commissioners, decides which clinical decision-support tool operates in the 999 environment; response categories are nationally determined.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
NHS Lancashire and South Cumbria Integrated Care Board
As of January 2021, NWAS was not a national outlier in recognising ineffective breathing and performed similarly to other ambulance services.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
NHS England
When used correctly, the MPDS algorithm identifies life-threatening asthma and results in a Category 1 response.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
London (West)
Concerns raised1
Failure to position an unresponsive patient on the floor for effective resuscitation
This report raised 13 other concerns. 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.
West Sussex
Concerns raised1
Failure to place an incapacitated patient in a position that protects the airway
This report raised 13 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Shaw Healthcare Limited
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Shaw Healthcare Limited
Increase and maintain staff safety training, competency assessment, mandatory-training tracking and first-aider coverage on every shift.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.