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.
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.
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.
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.
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
Regularly review Medical Priority Dispatch System code categorisation using clinical and operational data.
Stated by Welsh Ambulance Services NHS TrustStated completedThe respondent said that this action was complete when they made their response on 24 January 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Operational concerns about ambulance service delivery are best addressed by the Welsh Ambulance Services Trust.
Stated by Eluned MorganRedirects 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.
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
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.
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.
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
MHRA owns the regulations governing non-prescribed police inhalers and must receive supporting evidence before legislative change can be considered.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Responsibility for considering police access to inhalers lies with the Home Office, with Department support.
Stated by Department of Health and Social CareRedirects 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
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
Add a frequently asked question to the national website explaining the position on choking management when abdominal thrusts are not possible.
Stated by Resuscitation Council UKStated plannedThe respondent said that this action was planned when they made their response on 16 September 2022.
Action
Set out a stepwise choking-management approach in basic life support guidance, including chest compressions when abdominal thrusts fail or cannot be administered.
Stated by Resuscitation Council UKStated completedThe respondent said that this action was complete when they made their response on 16 September 2022.
Action
Assess abdominal-thrust alternatives for people with increased body mass and exclude supine abdominal thrusts from guidance because of safety and effectiveness concerns.
Stated by Resuscitation Council UKStated completedThe respondent said that this action was complete when they made their response on 16 September 2022.
Action
Teach healthcare professionals to use laryngoscopes and Magill’s forceps for foreign-body removal under direct vision in the advanced life support course.
Stated by Resuscitation Council UKStated completedThe respondent said that this action was complete when they made their response on 16 September 2022.
Action
Include immediate availability of laryngoscopes and Magill’s forceps in quality standards for mental health inpatient care.
Stated by Resuscitation Council UKStated completedThe respondent said that this action was complete when they made their response on 16 September 2022.
Action
Assess suction-based airway-clearance devices for safety and effectiveness and determine whether evidence supports routine use.
Stated by Resuscitation Council UKStated completedThe respondent said that this action was complete when they made their response on 16 September 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
Resuscitation Council UK has addressed all concerns raised in the report.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Existing basic life support guidelines provide a stepwise choking response, including chest compressions suitable for people of any size.
Stated by Resuscitation Council UKExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Inversion or chair/table manoeuvres will not be introduced because evidence is insufficient and manual handling poses injury risks.
Stated by Resuscitation Council UKUnable 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.
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
Provide and competency-assess Basic Life Support and DNACPR training, including practical choking and CPR assessment.
Stated by BupaStated completedThe respondent said that this action was complete when they made their response on 12 May 2022.
Action
Have the Internal Lead Inspector attend Basic Life Support training to assess its quality and efficacy.
Stated by BupaStated plannedThe respondent said that this action was planned when they made their response on 12 May 2022.
Action
Retrain remaining Highgate staff and ensure they are competent and confident to manage future choking, cardiac arrest and CPR incidents.
Stated by BupaStated plannedThe respondent said that this action was planned when they made their response on 12 May 2022.
Action
Consider implementing more frequent competency checks or opportunities to practise chest compressions.
Stated by BupaStated plannedThe respondent said that this action was planned when they made their response on 12 May 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Existing evidence indicates Highgate BLS delegates passed competency assessments, disputing that training competence was absent.
Stated by BupaDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Annual BLS training frequency is not out of step with other social care providers.
Stated by BupaDisputes 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.
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.
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.
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
Review progress on ineffective-breathing improvement actions through monthly commissioner-led clinical quality assurance meetings.
Stated by NHS Lancashire and South Cumbria Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 8 March 2021.
Action
Hold a learning event for ambulance services and triage-system providers to share best practice on safely identifying ineffective breathing.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 8 March 2021.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
NWAS, not commissioners, decides which clinical decision-support tool operates in the 999 environment; response categories are nationally determined.
Stated by NHS Lancashire and South Cumbria Integrated Care BoardRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
As of January 2021, NWAS was not a national outlier in recognising ineffective breathing and performed similarly to other ambulance services.
Stated by NHS Lancashire and South Cumbria Integrated Care BoardDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
When used correctly, the MPDS algorithm identifies life-threatening asthma and results in a Category 1 response.
Stated by NHS EnglandDisputes 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.
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.
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.
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
Increase and maintain staff safety training, competency assessment, mandatory-training tracking and first-aider coverage on every shift.
Stated by Shaw Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 23 August 2019.
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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.
