Recurring concern

Failure to reliably respond to patient breathing emergencies

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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

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.

  1. West Sussex

    AI-generated summary

    Duncan Tomlin · 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

    Duncan Tomlin died on 29 July 2014 after cardiac arrest following the use of drugs and police prone restraint, including handcuffs, leg restraints and incapacitant spray. The report identified concerns about insufficient emphasis on the heightened breathing risks of multiple factors, delayed opportunities to assess and reposition him, inadequate guidance on monitoring, the timing of CPR, and understanding atypical or post-seizure behaviour.

    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

    Inconsistent understanding of when to commence CPR for abnormal or distressed breathing

    Wider context from the report

    “Commencing CPR 4. The evidence relating to current training and training at the time of the death concerned in this inquest indicates that CPR should commence when a person is not breathing normally (described as in 2-3 breaths in 10 seconds for an adult and 3-5 in 10 seconds for small children) or if breathing is distressed (snoring, rasping) known as agonal breathing. The evidence in the inquest was that individual officers of some experience understood CPR should commence when breathing had stopped. Whilst that may be a misunderstanding on the part of individual officers, owing to the importance of commencing CPR at the earliest opportunity when time is critically of the essence, the timing of when CPR should start should be a central point of when training CPR and when reacting to situations akin to that seen in this inquest. ”

    Source location

    Duncan Tomlin · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

    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

    Changes to nationally agreed police training packages require approval through national policing bodies rather than unilateral force action.

    Verbatim wording from the response

    “We are currently delivering nationally agreed training packages and any alteration to these should be agreed nationally with approval of all parties. The benefit in delivering training packages (for all mandatory training, not just Personal Safety Training) is they are consistent across the UK, all police officers are trained in the most current, relevant and up to date thinking which is designed using the latest research and learning from all Forces. We are aware this is currently being reviewed by NPCC and any alterations passed onto Forces in order for them to include in their training. It would be expected these alterations would be completed by the end of 2020.”

    Source location

    2019-0135-Response-by-Sussex-Police
    Page 2 · response
    Published 14 June 2019

    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

    Basic first-aid training provides officers with knowledge and skills suitable for their policing role.

    Verbatim wording from the response

    “Police officers are not trained to the level of medical practitioners. All police officers have basic first aid training (First Aid – Module 2 of the College of Policing curriculum which includes conducting CPR and managing a casualty who is convulsing) which gives them the knowledge and skills suitable for their role. It is the expectation that they recognise signs and symptoms of a wide variety of medical conditions. It is unrealistic to expect officers to have the knowledge of medical professionals, as the risks posed to themselves and others in trying to take action in which they are not trained is too great. Officers will carry out a dynamic risk assessment of any risk posed by a violent individual – whether the violence is caused by a medical condition or otherwise – and make a decision based on that risk assessment at that time”

    Source location

    2019-0135-Response-by-Sussex-Police
    Page 3 · response
    Published 14 June 2019

    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

    Officers cannot reasonably be expected to possess medical professionals’ knowledge because attempting untrained interventions could pose excessive risks.

    Verbatim wording from the response

    “Police officers are not trained to the level of medical practitioners. All police officers have basic first aid training (First Aid – Module 2 of the College of Policing curriculum which includes conducting CPR and managing a casualty who is convulsing) which gives them the knowledge and skills suitable for their role. It is the expectation that they recognise signs and symptoms of a wide variety of medical conditions. It is unrealistic to expect officers to have the knowledge of medical professionals, as the risks posed to themselves and others in trying to take action in which they are not trained is too great. Officers will carry out a dynamic risk assessment of any risk posed by a violent individual – whether the violence is caused by a medical condition or otherwise – and make a decision based on that risk assessment at that time”

    Source location

    2019-0135-Response-by-Sussex-Police
    Page 3 · response
    Published 14 June 2019

    Open published response

  2. Preston and West Lancashire

    AI-generated summary

    Christopher Talbot · 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

    Christopher Talbot, a prisoner at Preston Prison, was found with a plastic bag over his head after being identified as vulnerable and at risk of suicide. Resuscitation initially restored breathing and cardiac output, but he later died in hospital. Concerns included inadequate reception training, the absence of a breathing guard during resuscitation, insufficient sharing of information about similar deaths, and failures to request immediate assistance and maintain constant observation.

    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

    Unavailability of breathing guards for senior officers during resuscitation

    Wider context from the report

    “(2) A Senior Officer gave mouth to mouth resuscitation to Mr Talbot without the use of a guard. It is understood that although mandatory for more junior officers at HMP Preston, carrying a breathing guard at all times is discretionary for certain senior grades. Lack of such a guard might put an officer in personal danger when attempting to revive a prisoner or dissuade that officer from intervening, with potential adverse consequences for the prisoner. ”

    Source location

    Christopher Talbot · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. Inner North London

    AI-generated summary

    Samuel Rodney Darren BLAIR · 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

    Rodney Blair, who had a history of paranoid schizophrenia, alcohol dependency, multiple drug use and depression, was remanded in custody at HM Prison Pentonville and was found hanging in his cell on 2 August 2015. The inquest concluded that his death was suicide, with several contributing factors. Concerns included gaps in assessment and management of his mental health and antidepressant treatment, and delays and procedural issues in the prison emergency response.

    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

    Restricted immediate access to the emergency defibrillator

    Wider context from the report

    “7. The substance misuse nurse in the detoxification wing did respond immediately. He took his emergency bag with him to Mr Blair’s cell, but did not take the defibrillator stored in the same room as the bag. He later had to leave Mr Blair to retrieve the defibrillator, because it is stored in the nurses’ room and only nurses have the key. ”

    Source location

    Samuel Rodney Darren BLAIR · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  4. Inner North London

    AI-generated summary

    Caragh Melling · 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

    Caragh Melling collapsed at home after an episode of dizziness and died shortly after arriving at hospital following unsuccessful resuscitation attempts. The ambulance call triage failed to recognise her agonal breathing, and the report raised concerns that the NHS Pathways system lacked a tool to identify inadequate breathing and that it was unclear whether action was being taken to address this.

    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

    Lack of a triage tool to recognise agonal or inadequate breathing

    Wider context from the report

    “(1) I heard evidence from the Ambulance Trust that a previous triage system included a tool which could recognise the presence of agonal or inadequate breathing. The call handler would record every point at which the patient was noted to inspire. The tool would then alert the call handler to the presence of inadequate breathing. The Ambulance Trust noted that their current triage system, NHS Pathways, does not include this tool. They have instituted a local ‘workaround’; a question that asks whether the patient’s breathing is ‘noisy’. If this is answered affirmatively, agonal breathing is presumed and the call categorised as the fastest response time being required (R1). I heard evidence that NHS Pathways were contacted in 2014 to raise the absence of the breathing analysis tool as being a cause for concern. No action appears to have been taken. I also understand that the Medical Director of the Ambulance Trust has again raised concerns at the national level but it is unclear whether any action is being taken. ”

    Source location

    Caragh Melling · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  5. Inner North London

    AI-generated summary

    Yusuf ABDISMAD · 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

    Yusuf died from meningococcal septicaemia after his mother called 999 and was advised to call 111; by the time the London Ambulance Service arrived, he was in cardiac arrest. The principal concern was that the emergency medical dispatcher used a potentially confusing method to assess whether Yusuf was conscious, alongside difficulties recognising possible signs of meningitis.

    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 of 111 call handlers to escalate reports of absent breathing for immediate paramedic attendance

    Wider context from the report

    “During the 111 call, Yusuf’s mother said at one point that Yusuf was not breathing. Rather than responding to this as a red flag that required immediate paramedic attendance and asking for London Ambulance Service to be notified, the LCW call handler felt she wanted to probe further. Evidence in court from the 111 service was that call handlers would benefit from further training in recognisingagonal breathing. I appreciate that 111 is not intended as an emergency service, but they are likely from time to time to take calls that are or become urgent. ”

    Source location

    Yusuf ABDISMAD · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  6. South Yorkshire (Western)

    AI-generated summary

    Anthony Offord · 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

    Anthony Offord collapsed at a friend's flat on 16 April 2013 and died two days later from hypoxic brain injury following a delay in providing support to a lone responder. The report raised concerns about the lack of consideration of alternative support, the absence of a requirement to involve a manager when a stand-off caused delay, and insufficient training for emergency medical dispatch staff to recognise signs of respiratory difficulty such as snoring in an unresponsive person.

    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

    Lack of training for Emergency Medical Dispatch staff to recognise signs of respiratory difficulty

    Wider context from the report

    “(1) There is (apparently) no training given to Emergency Medical Dispatch staff as to signs of respiratory difficulty including the well known relevance of snoring in a person who cannot be roused. This may perhaps require an amendment to the breathing diagnostic tool? ”

    Source location

    Anthony Offord · Prevention of Future Deaths report
    Page 3 · concerns

    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

    Provide EMD staff with structured training and recurrent certification covering recognition of ineffective and agonal breathing.

    Verbatim wording from the response

    “All EMD’s employed by the Trust undergo a robust training programme. This includes the following:”

    Source location

    2014-0396-Response-by-Yorkshire-Ambulance-Service-NHs-Trust
    Page 1 · response
    Published 8 September 2014

    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 Trust cannot unilaterally amend the internationally approved breathing diagnostic tool because it lacks the necessary authority.

    Verbatim wording from the response

    “Specific training in relation to breathing difficulties is incorporated in the above programme and this particular element is heavily embedded in the triage tool. The AMPDS provides the call taker with information about ineffective and agonal breathing and how to recognise this. A breathing diagnostic tool is available to aid the EMD in making decisions about patient’s breathing.”

    Source location

    2014-0396-Response-by-Yorkshire-Ambulance-Service-NHs-Trust
    Page 2 · response
    Published 8 September 2014

    Open published response

  7. Inner North London

    AI-generated summary

    Abdullahi Sharif ABOKAR · 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

    Abdullahi Sharif Abokar, a 22-year-old patient detained under section 3 of the Mental Health Act, was found hanging from smoke alarm wires on a secure mental health ward on 16 June 2012 and died five days after being taken to hospital. Concerns included staff not asking him about suicidal thoughts and significant shortcomings in the conduct of resuscitation, including compromised ventilatory support and uncertainty about airway management.

    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 provide effective airway ventilation during resuscitation

    Wider context from the report

    “2. Resuscitation The psychiatry doctor who attended the resuscitation in progress (approximately seven minutes after Mr Abokar was discovered), found an ambubag mask on Mr Abokar’s face, but no ambubag connected and no person holding the mask. The nurse who had been in charge of Mr Abokar’s airway said that she had been giving him mouth to mouth resuscitation, though no other witness in the room saw this. No explanation was provided as to why she would have given mouth to mouth rather than use the ambubag present (even if the ambubag was not connected to a flow of oxygen). The nurse had left Mr Abokar in the middle of resuscitation, simply to go out into the corridor and ascertain the whereabouts of the paramedic. She said that she had left Mr Abokar’s airway in the care of another member of staff, but she did not know who that person was, and all other members of staff in the room denied that his airway was ever left in their charge. She was out of the room for 50 seconds. The paramedic attending Mr Abokar after resuscitation had been ongoing for quite some minutes, said that Mr Abokar’s head was not tilted back sufficiently, and the ambubag reservoir was not inflated because the oxygen cylinder, whilst connected, was not switched on. Neither of the paramedic’s observations was accepted by the nurse with control of the airway, though he clearly has a great deal more experience of resuscitation than she. The nurse also said that a colleague, though she did not know who, had connected the ambubag to the first oxygen cylinder; and then a colleague, either the same colleague or a different one, she did not know, had connected the ambubag to a second cylinder; though all other members of staff in the room denied that they had done this. It appears that Mr Abokar’s ventilatory support was significantly compromised by the way in which it was conducted. It was entirely unclear what impact, if any, this had on Mr Abokar’s potential recovery, though that would not necessarily be the case for another patient in a similar position. ”

    Source location

    Abdullahi Sharif ABOKAR · Prevention of Future Deaths report
    Page 2 · concerns

    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

    Approve and implement a revised Trust Resuscitation Policy aligned with national guidance and learning from the inquest.

    Verbatim wording from the response

    “a) A revised Trust Resuscitation Policy was approved by the Trust’s Quality Committee in November 2013, containing changes in line with national guidance and also directly related to learning from this inquest’s findings.”

    Source location

    2013-0323-Response-by-Camden-Islington-NHS-Foundation-Trust
    Page 4 · response
    Published 23 February 2014

    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 six-monthly CPR simulation exercises across inpatient units, with committee monitoring.

    Verbatim wording from the response

    “d) Due to the infrequent occurrences of CPR within mental health hospital settings, our inpatient units will now perform simulation exercises every 6 months to ensure staff get practice in performing CPR. The matron from each unit has responsibility for organising these, under the guidance of the Deputy Director of Nursing. The first such exercises will take place in April 2014. The exercises will be monitored through our committee structure.”

    Source location

    2013-0323-Response-by-Camden-Islington-NHS-Foundation-Trust
    Page 5 · response
    Published 23 February 2014

    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 specialist oxygen-use training using live oxygen cylinders during training sessions.

    Verbatim wording from the response

    “f) Training in use of oxygen will now be provided by an independent company contracted to provide this for the Trust. This is a specialist Health and Safety firm. The Trust will ensure that live oxygen cylinders are provided for each training session for this purpose, which will enable staff undergoing training to familiarise themselves fully with the cylinder and how it functions, including the sound it makes when activated. The Deputy Director of Nursing has responsibility for organising this. The Trust will also recommend to the National Resuscitation Council that this should be a component of in-hospital Life support training, as it is not currently stipulated as”

    Source location

    2013-0323-Response-by-Camden-Islington-NHS-Foundation-Trust
    Page 5 · response
    Published 23 February 2014

    Open published response
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Data last updated 7 September 2026