Recurring concern

Unreliable airway management during emergency care

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First reported 3 Dec 2013•Latest report 31 Mar 2026

Definition

What this concern includes

Includes failures of controls dedicated to emergency airway management, including airway assessment, difficult-airway planning, ventilation, airway adjunct selection or securing, suction, intubation support, airway assistance during resuscitation and management of paediatric or neonatal emergency airways.

Not included

Excludes failures limited to the management of an endotracheal tube after placement where the broader emergency airway-management process is not deficient.
Excludes generic emergency staffing, training, equipment or resuscitation deficiencies unless they directly impair emergency airway management.
Excludes routine respiratory treatment or ventilation outside an emergency airway-management context.
Excludes aspiration-prevention controls during anaesthesia where the dedicated anaesthetic airway-protection process is the supported concern.
Excludes underlying asthma, choking or other clinical conditions where no emergency airway-management control failure is identified.

Reports: 21
Individual concerns: 28
Date range: 2013–2026
Stated actions: 42

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Care UK2

NHS England2

Pentonville Prison2

Association of Ambulance Chief Executives1

Ayuntamiento de La Oliva1

Care Quality Commission1

Care UK Limited1

Civil Aviation Authority1

College of Policing1

Department of Health and Social Care1

East Midlands Ambulance Service NHS Trust1

East of England Ambulance Service NHS Trust1

ENT UK1

Essex Partnership University NHS Foundation Trust1

European Union Aviation Safety Agency1

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.

28 May2019
Teesside and Hartlepool
Concerns raised1
1. Failure to provide first aid and airway-clearing assistance during 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 1
1. Action
  Produce a more user-friendly Choking Risk Assessment in consultation with the SALT team.
  Stated by Rossmere Park Care CentreStated completed
Respondent positions 1
1. Position
  The first HCA did not discover choking; there were no choking signs, and subsequent airway checks found no obstruction.
  Stated by Rossmere Park Care CentreDisputes the concern
AI-generated summary

Gloria Elizabeth MEKINS · 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

Gloria Elizabeth Mekins was a resident at Rossmere Park Care Home when she choked while eating a snack on 2 October 2018 and died at the care home. Concerns included the absence of first aid by the staff member who found her, confusion about the existence of a DNA CPR leading to a delay in first aid, and the care home's failure to investigate or address these issues.

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 first aid and airway-clearing assistance during choking
Wider context from the report
“(1) The Health Care Assistant who initially discovered Ms Mekins choking carried out no first aid, nor did she take any action to try to clear Ms Mekins' mouth or help improve her breathing, eg back slaps or Heimlich manoeuvre. (2) There was confusion as to the existence of a DNA CPR and this led to a delay in the provision of first aid. (3) The Care Home had not undertaken an internal investigation into events surrounding Ms Mekins' death and have not identified the above issues, nor have they attempted to remedy them. The Senior Coroner is concerned that the above issues place residents at the Care Home at risk of serious injury or death. ”
Source location
Gloria Elizabeth MEKINS · Prevention of Future Deaths report
Page 1 · 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
Produce a more user-friendly Choking Risk Assessment in consultation with the SALT team.

Verbatim wording from the response
“It was also apparent from my e-mails with your office that the Choking Risk Assessment used by Rossmere was not easily understood. We therefore liaised in depth with the”

Source location
2019-0171-Response-by-Rossmere-Park-Care-Centre
Page 3 · response
Published 2 August 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
The first HCA did not discover choking; there were no choking signs, and subsequent airway checks found no obstruction.

Verbatim wording from the response
“Although I have addressed your Matters of Concern below, the first point I must make is that your assertion in point 4 – Circumstances of Death – that “staff attended and believed she was choking” is incorrect as there is no evidence in any of the staff statements (which were written soon after the event) that ANY staff believed she was choking at the time of the incident.”

Source location
2019-0171-Response-by-Rossmere-Park-Care-Centre
Page 1 · response
Published 2 August 2019
Open published response
6 Dec2016
Inner North London
Concerns raised2
1. Failure to assess breathing and perform airway manoeuvres during resuscitation
2. Insufficient airway ventilation assistance during 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.
Actions described in response 3
1. Action
  Check that all Care UK clinical staff receive mandatory intermediate life-support training.
  Stated by Care UKStated completed
2. Action
  Develop and circulate a standard operating procedure for emergency response.
  Stated by Care UKStated in progress
3. Action
  Discuss resuscitation and emergency-bag issues regularly during Friday afternoon healthcare training sessions.
  Stated by Care UKStated planned
AI-generated summary

Tedros Habtom KAHSSAY · 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

Tedros Kahssay killed himself by hanging in HM Prison Pentonville about a month after being admitted on a charge of murdering his pregnant partner. Concerns included incomplete transfer and recording of information, shortcomings in reception screening, and significantly deficient and chaotic resuscitation procedures. The report states that he was already dead when resuscitation commenced, while expressing concern for other prisoners requiring first aid.

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 assess breathing and perform airway manoeuvres during resuscitation
Wider context from the report
“7. The resuscitation led by the two nurses occupying the positions of primary (Hotel 7) and secondary (Hotel 12) leads for emergency healthcare in the prison that night, was significantly lacking in the following ways. • The nurse with primary responsibility for emergency care in the prison did not have a proper understanding of the nature of a code red and a code blue prison medical emergency. (I have raised this issue in the past.) • One minute and twelve seconds elapsed after nurse arrival before any substantive care was given. The action during that one minute and twelve seconds did not appear to progress the resuscitation attempt. • There seemed no clear demarcation of roles and responsibilities during the resuscitation. Of course these may change as those giving resuscitation tire, but the changes seemed haphazard. • There was no checking for breath or airway manoeuvre at the outset or at any time during the resuscitation. • There was no checking for pulse at the outset, before commencing chest compressions, or at any time during the resuscitation. The lead nurse attempted to justify this by saying that she had not wanted to waste time. This was despite the first action upon finding the casualty being to apply a blood pressure cuff, on the basis that this was part of the nurse assessment. • When giving evidence, the lead nurse appeared to conflate the casualty who is in cardiorespiratory arrest with the casualty who is merely unconscious. She repeatedly talked about the need to give cardiopulmonary resuscitation (CPR) to an unconscious casualty. She said that, at the time she started chest compressions, she did not know whether Mr Kahssay was breathing or not breathing. • When CPR was given, chest compressions were ineffective, being too quick and too shallow. • There was only one brief attempt to use an ambubag, the majority of the resuscitation taking place without airway assistance or with a non rebreathe oxygen mask. • It appeared that one oxygen cylinder was empty, as it had to be changed for another. The nurse leading the resuscitation described it as chaotic. That is indeed how it appeared to me from her description and from viewing the bodycam footage. I was and remain very gravely concerned, not in this respect for Mr Kahssay who was in fact already dead when resuscitation commenced, but for anyone else in the prison in need of first aid. ”
Source location
Tedros Habtom KAHSSAY · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Insufficient airway ventilation assistance during resuscitation
Wider context from the report
“7. The resuscitation led by the two nurses occupying the positions of primary (Hotel 7) and secondary (Hotel 12) leads for emergency healthcare in the prison that night, was significantly lacking in the following ways. • The nurse with primary responsibility for emergency care in the prison did not have a proper understanding of the nature of a code red and a code blue prison medical emergency. (I have raised this issue in the past.) • One minute and twelve seconds elapsed after nurse arrival before any substantive care was given. The action during that one minute and twelve seconds did not appear to progress the resuscitation attempt. • There seemed no clear demarcation of roles and responsibilities during the resuscitation. Of course these may change as those giving resuscitation tire, but the changes seemed haphazard. • There was no checking for breath or airway manoeuvre at the outset or at any time during the resuscitation. • There was no checking for pulse at the outset, before commencing chest compressions, or at any time during the resuscitation. The lead nurse attempted to justify this by saying that she had not wanted to waste time. This was despite the first action upon finding the casualty being to apply a blood pressure cuff, on the basis that this was part of the nurse assessment. • When giving evidence, the lead nurse appeared to conflate the casualty who is in cardiorespiratory arrest with the casualty who is merely unconscious. She repeatedly talked about the need to give cardiopulmonary resuscitation (CPR) to an unconscious casualty. She said that, at the time she started chest compressions, she did not know whether Mr Kahssay was breathing or not breathing. • When CPR was given, chest compressions were ineffective, being too quick and too shallow. • There was only one brief attempt to use an ambubag, the majority of the resuscitation taking place without airway assistance or with a non rebreathe oxygen mask. • It appeared that one oxygen cylinder was empty, as it had to be changed for another. The nurse leading the resuscitation described it as chaotic. That is indeed how it appeared to me from her description and from viewing the bodycam footage. I was and remain very gravely concerned, not in this respect for Mr Kahssay who was in fact already dead when resuscitation commenced, but for anyone else in the prison in need of first aid. ”
Source location
Tedros Habtom KAHSSAY · Prevention of Future Deaths report
Page 4 · 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
Check that all Care UK clinical staff receive mandatory intermediate life-support training.

Verbatim wording from the response
“All clinical staff that are employed by Care UK have ILS as a mandatory training requirement. A check has been undertaken to ensure that all Care UK clinical staff are receiving the ILS training. This has been confirmed to be the case.”

Source location
2016-0437-Response-by-Care-UK.pdf
Page 3 · response
Published 6 December 2016
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
Develop and circulate a standard operating procedure for emergency response.

Verbatim wording from the response
“In addition to this, the healthcare team plan to discuss issues relating to resuscitation and use of emergency bags regularly in their Friday afternoon training sessions. A SOP for emergency response is in development by the national team and is due for circulation shortly.”

Source location
2016-0437-Response-by-Care-UK.pdf
Page 3 · response
Published 6 December 2016
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
Discuss resuscitation and emergency-bag issues regularly during Friday afternoon healthcare training sessions.

Verbatim wording from the response
“In addition to this, the healthcare team plan to discuss issues relating to resuscitation and use of emergency bags regularly in their Friday afternoon training sessions. A SOP for emergency response is in development by the national team and is due for circulation shortly.”

Source location
2016-0437-Response-by-Care-UK.pdf
Page 3 · response
Published 6 December 2016
Open published response
14 Oct2016
Surrey
Concerns raised1
1. Lack of an action plan for obtaining assistance during airway loss or difficulty placing a pacemaker wire
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.
AI-generated summary

Peter John Keep · 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

Peter John Keep, an 82-year-old man, was admitted after a fall and underwent pacemaker insertion for Mobitz type 2 heart block. During the difficult procedure he received several sedative and analgesic doses, lost his airway, and suffered cardiac tamponade from perforation of the right ventricle; he later had a cardiac arrest and died in intensive care. The principal concerns included inappropriate and inconsistent sedation, inadequate sedation policies and training, and a lack of action plans for procedure intolerance, airway loss, or difficulty placing the pacemaker wire.

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 an action plan for obtaining assistance during airway loss or difficulty placing a pacemaker wire
Wider context from the report
“6. Lack of an action plan as to who to call for assistance in circumstances when a patient's airway is lost or there is difficulty in placing a pacemaker wire. ”
Source location
Peter John Keep · Prevention of Future Deaths report
Page 2 · concerns
Open source report
19 Jul2016
London Inner (South)
Concerns raised1
1. Failure to make SGA use conditional on laryngoscopy to detect foreign body airway obstruction
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.
AI-generated summary

ROSEMARIE DEES · 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

Rosemarie Dees died at home on 18 April 2016 after choking on a boiled sweet and losing consciousness. The medical cause of death was recorded as asphyxia caused by a food bolus in the larynx. The report raised concern that use of a supra-glottic airway may be inhibited by an undetected foreign-body airway obstruction.

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 make SGA use conditional on laryngoscopy to detect foreign body airway obstruction
Wider context from the report
“that the use of an SGA may be inhibited by an undetected foreign body airway obstruction. Such an obstruction might be spotted if the use of an SGA was made conditional on the carrying out of a laryngoscopy which it is understood will soon be LAS protocol. ”
Source location
ROSEMARIE DEES · Prevention of Future Deaths report
Page 2 · concerns
Open source report
15 Jul2016
Birmingham and Solihull
Concerns raised2
1. Inadequate ventilation during resuscitation in GP practices
2. Failure to use suction during resuscitation in GP practices
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 4
1. Action
  Assist the practice involved in the incident to identify and address issues highlighted by the incident.
  Stated by Birmingham South Central CCGStated in progress
2. Action
  Circulate learning from the incident to all commissioned GP practices.
  Stated by Birmingham South Central CCGStated planned
3. Action
  Circulate incident learning to surrounding clinical commissioning groups for dissemination to their practices.
  Stated by Birmingham South Central CCGStated planned
1. Action
  Ask the CQC to ensure inspections check that primary care services have equipment and skills to address respiratory emergencies.
  Stated by NHS EnglandStated completed
Respondent positions 5
1. Position
  The CQC is responsible for using its inspection regime to ensure primary care services carry necessary equipment and skills for respiratory emergencies.
  Stated by NHS EnglandRedirects responsibility
1. Position
  General practice is not an emergency service and is not contracted, equipped or organised to deliver team-based emergency care.
  Stated by Wychall Lane SurgeryOutside remit
2. Position
  Suction facilities should not be mandated nationally because training should prioritise recognising emergencies rather than maintaining suction skills.
  Stated by NHS EnglandNo action considered necessary
3. Position
  GP practices do not need to maintain suction equipment because its use is extremely rare and competence would be difficult to maintain.
  Stated by Wychall Lane SurgeryNo action considered necessary
4. Position
  Regular GP practices need not maintain suction equipment because its use is extremely rare and competence would be difficult to maintain.
  Stated by Birmingham South Central CCGNo action considered necessary
AI-generated summary

Sydney Mya Neil · 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

Sydney Mya Neil suffered from severe brittle asthma and died at Birmingham Children's Hospital after collapsing at a GP surgery following breathing difficulties. The report raised concerns about inadequate ventilation, lack of suction and lack of oxygen during resuscitation, and whether GP practices have sufficient expertise and equipment for emergencies.

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
Inadequate ventilation during resuscitation in GP practices
Wider context from the report
“Once Sydney collapsed in the GP surgery there was inadequate ventilation for 8 minutes. No suction was used nor was oxygen provided. I am concerned about the level of expertise in GP practices when resuscitation is required and whether they have sufficient equipment to deal with emergency situations. ”
Source location
Sydney Mya Neil · Prevention of Future Deaths report
Page 1 · concerns
Open source report
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 use suction during resuscitation in GP practices
Wider context from the report
“Once Sydney collapsed in the GP surgery there was inadequate ventilation for 8 minutes. No suction was used nor was oxygen provided. I am concerned about the level of expertise in GP practices when resuscitation is required and whether they have sufficient equipment to deal with emergency situations. ”
Source location
Sydney Mya Neil · Prevention of Future Deaths report
Page 1 · 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
Assist the practice involved in the incident to identify and address issues highlighted by the incident.

Verbatim wording from the response
“The CCG has been assisting the practice involved in this incident to identify and address issues that have been highlighted by this unfortunate incident and it is the intention of the CCG to circulate any learning from this incident across all GP practices that we are responsible for commissioning. We will also circulate this learning to surrounding CCGs so that they may also disseminate these lessons to their practices.”

Source location
2016-0256-Response-by-Birmingham-South-Central-Clinical-Commissioning-Group
Page 2 · response
Published 15 July 2016
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
Circulate learning from the incident to all commissioned GP practices.

Verbatim wording from the response
“The CCG has been assisting the practice involved in this incident to identify and address issues that have been highlighted by this unfortunate incident and it is the intention of the CCG to circulate any learning from this incident across all GP practices that we are responsible for commissioning. We will also circulate this learning to surrounding CCGs so that they may also disseminate these lessons to their practices.”

Source location
2016-0256-Response-by-Birmingham-South-Central-Clinical-Commissioning-Group
Page 2 · response
Published 15 July 2016
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
Circulate incident learning to surrounding clinical commissioning groups for dissemination to their practices.

Verbatim wording from the response
“The CCG has been assisting the practice involved in this incident to identify and address issues that have been highlighted by this unfortunate incident and it is the intention of the CCG to circulate any learning from this incident across all GP practices that we are responsible for commissioning. We will also circulate this learning to surrounding CCGs so that they may also disseminate these lessons to their practices.”

Source location
2016-0256-Response-by-Birmingham-South-Central-Clinical-Commissioning-Group
Page 2 · response
Published 15 July 2016
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
Ask the CQC to ensure inspections check that primary care services have equipment and skills to address respiratory emergencies.

Verbatim wording from the response
“I have asked ████████ Head of Primary Care Commissioning, NHS”

Source location
2016-0256-Response-by-NHS-England
Page 3 · response
Published 15 July 2016
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 CQC is responsible for using its inspection regime to ensure primary care services carry necessary equipment and skills for respiratory emergencies.

Verbatim wording from the response
“The Care Quality Commission (CQC) as the regulator of general practice needs to be assured that practices are able to immediately respond to the needs of a person who becomes seriously ill. The CQC does not have explicit guidance around emergency equipment; however does state that if the practice does not have oxygen they are unlikely to be able to demonstrate they are equipped for dealing with emergencies.²”

Source location
2016-0256-Response-by-NHS-England
Page 3 · response
Published 15 July 2016
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
General practice is not an emergency service and is not contracted, equipped or organised to deliver team-based emergency care.

Verbatim wording from the response
“We have taken advice from the Local Medical Committee and General Practice Committee (GPC) of the BMA who commissioned ████████ who is a senior GP who has held roles including provision of and teaching of immediate care, now known as Pre-Hospital Emergency Medicine and is chair of BASICS Education Ltd, who aim to improve emergency care outside hospital, to comment on the care the Practice provided to Miss Neil and provide his general thoughts on this incident. He states general practice and general practitioners are not an emergency service…… General practitioners who very, very infrequently have to deal with life threatening emergencies and are neither equipped, contracted nor organised to deliver such team based emergency care.”

Source location
2016-0256-Response-by-Wychall-Lane-Surgery
Page 2 · response
Published 15 July 2016
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
Suction facilities should not be mandated nationally because training should prioritise recognising emergencies rather than maintaining suction skills.

Verbatim wording from the response
“In relation to the requirement for suction facilities to facilitate ventilator support, I have sought the views of NHS England’s National Clinical Directors. Whilst a number of practices will have some access to suction facilities, it was not felt that this should become a national requirement of primary care. BTS guidance highlights the risks associated with ventilatory support and non-invasive ventilation, (NIV) in severe asthma. It is the view of my Clinical Directors therefore better to target training in primary care on recognising an emerging emergency situation rather than to attempt to train and maintain skills in using suction equipment in challenging emergency situations. As a result, I do not feel it appropriate to mandate all general practices to purchase and maintain suction facilities which would necessarily include ensuring all relevant staff are appropriately trained.”

Source location
2016-0256-Response-by-NHS-England
Page 3 · response
Published 15 July 2016
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
GP practices do not need to maintain suction equipment because its use is extremely rare and competence would be difficult to maintain.

Verbatim wording from the response
“We have met with Birmingham South Central CCG and after a detailed significant event analysis they have stated:- “All organisations providing primary care should also have appropriate equipment and drugs for managing other life-threatening emergencies (e.g. anaphylaxis). The CCG would expect all staff to be trained to deliver basic CPR to patients, to have this training updated on a regular basis and have appropriate protocols in place to deal with such emergencies. In respect of suction being available, the CCG view would be that there would be no requirement for GP practices to have suction available on a regular basis as the use of such equipment would be extremely rare and it would be difficult for GPs to maintain their competence in using this type of equipment.”

Source location
2016-0256-Response-by-Wychall-Lane-Surgery
Page 2 · response
Published 15 July 2016
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
Regular GP practices need not maintain suction equipment because its use is extremely rare and competence would be difficult to maintain.

Verbatim wording from the response
“In respect of suction being available, the CCG view would be that there would be no requirement for GP practices to have suction available on a regular basis since the use of such equipment would be extremely rare and it would be difficult for GPs to maintain their competence in using this type of equipment. Similarly the CCG would not expect a GP to be able to intubate a patient or to have the equipment available to undertake this procedure as this would not be within the regular skill set of a GP. This view is based on the Resuscitation Council (UK) guidance that identifies these equipment and competencies are required for GPs having an extended role in aspects such as urgent and emergency care rather than generic general practice.”

Source location
2016-0256-Response-by-Birmingham-South-Central-Clinical-Commissioning-Group
Page 2 · response
Published 15 July 2016
Open published response
18 Apr2016
West Yorkshire (Western)
Concerns raised1
1. Lack of suction equipment for clearing airways
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.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Carl Lee Thompson · 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

Carl Lee Thompson died from drowning on 10 August 2015 after being overwhelmed by surf and waves while bathing in the sea in Fuerteventura. Concerns included inadequate or defective lifesaving and resuscitation equipment, lifeguards’ lack of training in its use, and delays in obtaining replacement equipment and emergency medical assistance.

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 suction equipment for clearing airways
Wider context from the report
“• The emergency bag did not contain suction equipment to clear the airways • A hole in the ambubag used in the resuscitation attempts prevented the flow of oxygen • The defibrillator used during resuscitation was inoperable given it was found to have no batteries • Delay of 45 minutes to obtain a replacement defibrillator • Absence of equipment to dry the casualty • Substantial delay before the arrival of the ambulance and doctor for emergency treatment. ”
Source location
Carl Lee Thompson · Prevention of Future Deaths report
Page 2 · concerns
Open source report
10 Dec2015
London Inner (South)
Concerns raised1
1. Lack of joint guidance for front-of-neck access during a “Can’t Intubate Can’t Oxygenate” emergency involving anaesthetists and ENT surgeons
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Work with DAS and AAGBI to support anaesthetists in achieving and maintaining competence in surgical cricothyroidotomy through professional development and curriculum development.
  Stated by ENT UK and Royal College of AnaesthetistsStated planned
2. Action
  Raise surgeons’ awareness of appropriate emergency airway techniques through journal editorials, curriculum advocacy and emphasis on a standard surgical approach.
  Stated by ENT UK and Royal College of AnaesthetistsStated planned
AI-generated summary

Ololade Olaobaju · 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

Ololade Olaobaju was treated for progressive respiratory failure following community-acquired pneumonia and was transferred to intensive care for mechanical ventilation. After unsuccessful attempts at intubation, needle cricothyroidotomy and “Quicktrack”, she suffered a cardiac arrest during an attempted surgical tracheostomy and could not be resuscitated. The report identified a concern that existing guidance did not cover the preferred front-of-neck access when anaesthetists and ENT surgeons were both present, particularly in a rapidly deteriorating “Can’t Intubate Can’t Oxygenate” situation.

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 joint guidance for front-of-neck access during a “Can’t Intubate Can’t Oxygenate” emergency involving anaesthetists and ENT surgeons
Wider context from the report
“(1) For the purposes of the inquest I received an expert report from Dr Andrew Hartle. Reference was also made to the Difficult Airway Society Guidelines 2004 and 2015. The DAS guidelines suggest that, for an anaesthetist, an appropriate progression would be to undertake surgical (scalpel) cricothyroidotomy after unsuccessful cannula cricothyroidotomy. In this case, an ENT surgeon (clinical fellow grade) arrived and took over before scalpel cricothyroidotomy was attempted. The ENT surgeon decided to attempt tracheostomy rather than scalpel cricothyroidotomy. The benefit of tracheostomy is that it would have provided a more permanent airway. The evidence was that this is an unusual situation and that the experience of all the witnesses was therefore limited in performing emergency cricothyroidotomy and emergency tracheostomy. I concluded that the decision as to whether to opt for tracheostomy or scalpel cricothyroidotomy was a clinical judgment made in the light of the circumstances at the time. However, this was rapidly deteriorating situation and the ENT surgeon accepted that scalpel cricothyroidotomy may have been a simpler procedure. This became a “Can’t Intubate Can’t Oxygenate” situation in which both anaesthetists and ENT surgeons were present. My understanding is that the DAS guidelines are provided for anaesthetists. Different considerations may apply to ENT surgeons. The question as to the preferred mode of front of neck access in this situation therefore appears not to be covered by the existing guidelines. Individual practitioners faced with such a situation are likely to have limited experience. My understanding is that there is currently no joint guidance to cover this type of situation when both anaesthetists and ENT surgeons are present. ”
Source location
Ololade Olaobaju · 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
Work with DAS and AAGBI to support anaesthetists in achieving and maintaining competence in surgical cricothyroidotomy through professional development and curriculum development.

Verbatim wording from the response
“• We will work together (DAS, RCoA, AAGBI) to help anaesthetists of all grades (trainee, Consultant, SAS) to achieve and maintain competence in performing surgical cricothyroidotomies. This will be achieved by:- o Encouraging personal development activities and Continuing Professional Development o Developing the curriculum for anaesthetists-in-training.”

Source location
Ololade-Olabaju-Response
Page 3 · response
Published 15 December 2015
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
Raise surgeons’ awareness of appropriate emergency airway techniques through journal editorials, curriculum advocacy and emphasis on a standard surgical approach.

Verbatim wording from the response
“• We will take actions to raise awareness amongst surgeons of the issues discussed, and particularly the best choice of surgical technique. We will do this by:- o Submitting an editorial to the key ENT journals (Clinical Otolaryngology and The British Journal of Oral and Maxillofacial Surgery (BJOAMS)), as well as the British Journal of Anaesthesia. o Contacting the President of the Royal College of Surgeons asking for the surgical management of an airway crisis to be incorporated into the training curriculum for surgeons-in-training. o We will emphasise to surgeons the need for a standard surgical approach in these cases.”

Source location
Ololade-Olabaju-Response
Page 3 · response
Published 15 December 2015
Open published response
3 Jul2015
Manchester West
Concerns raised1
1. Lack of mandatory carriage of airway adjuncts, suction equipment, bag-valve-mask equipment and defibrillators on all aircraft
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Engage Member States to reconsider defibrillator carriage through available-data analysis and an initial discussion at the scheduled advisory-group meeting.
  Stated by European Union Aviation Safety AgencyStated planned
2. Action
  Write to Ryanair about carrying AEDs on its fleet.
  Stated by Irish Aviation AuthorityStated completed
Respondent positions 6
1. Position
  Passengers are not at increased risk of sudden cardiac arrest, which is exceptionally rare on short-haul flights, and defibrillators often do not succeed.
  Stated by Dame Deirdre HuttonDisputes the concern
1. Position
  Existing voluntary carriage, regulatory consideration requirements and evidence review make mandating general carriage of this equipment currently difficult to justify.
  Stated by Dame Deirdre HuttonExisting arrangements considered sufficient
2. Position
  The UK cannot act alone to introduce legal changes because mandating the equipment would require significant international agreement.
  Stated by Dame Deirdre HuttonUnable to act
3. Position
  EASA must consider regulatory changes for EU operators, while ICAO must consider them for non-European operators.
  Stated by Dame Deirdre HuttonRedirects responsibility
4. Position
  Existing EASA and ICAO arrangements, including operator risk assessments, are considered sufficient; AED carriage is not strictly required.
  Stated by Irish Aviation AuthorityExisting arrangements considered sufficient
5. Position
  Operators are responsible for deciding whether to carry AEDs based on the particular needs and risk assessment of each operation.
  Stated by Irish Aviation AuthorityRedirects responsibility
AI-generated summary

Davina Tavener · 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

Davina Tavener died on 1 November 2014 after collapsing during a Ryanair flight from Manchester to Lanzarote. Cardiopulmonary resuscitation continued until the aircraft landed, but the aircraft did not carry airway adjuncts, suction equipment, a bag-valve-mask or a defibrillator. The report raised concerns that the absence of this equipment could contribute to future deaths and called for review of the requirements for medical equipment on aircraft.

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 mandatory carriage of airway adjuncts, suction equipment, bag-valve-mask equipment and defibrillators on all aircraft
Wider context from the report
“The Regulations do not require Aircraft to carry the equipment requested by ████████ and the minimum requirement is to carry the equipment carried by Ryanair on Flight FR2131. It was accepted that Ryanair was operating within the Regulations in relation to medical equipment on Flight FR2131. iii. The evidence at the Inquest confirmed that some Airlines do carry the equipment requested by ████████, even though there is no Regulation for such equipment to be carried. Evidence was given that the equipment is carried on some long haul flights as opposed to short haul flights but it was accepted that the differential is not relevant in view of the fact that a cardiac arrest can occur at any time whether the Aircraft is ten minutes into a flight or ten hours into a flight. iv. ████████ gave evidence, supported by the Pathologist, that when someone has suffered a cardiac arrest, time is of the essence and the equipment requested by her could be critical in an attempt to save life. ████████ confirmed that a defibrillator would be critical to survival in cardiac events and a defibrillator would give someone the best chance of survival in a situation where there is a cardiac arrest. The evidence confirmed that for every one minute when activity in the heart has stopped the chance of survival reduces by ten percent and the availability of a defibrillator at the earliest time would increase the chance of survival. Both ████████ and the Pathologist gave evidence that an airway adjunct, suction equipment, bag-valve-mask and a defibrillator should be carried on all Aircraft as a mandatory provision of medical equipment to assist in the treatment and resuscitation of a passenger on an Aircraft and to give a passenger the best chance of survival until the Aircraft can reach the nearest destination. The provision of the aforementioned equipment would be used for the reasons explained in ████████ evidence and detailed in paragraph 4.4 of this report. v. Evidence was given that all the above equipment is now available as relatively inexpensive portable equipment and, in particular, a defibrillator is very simple to operate in that the defibrillator will announce instructions in relation to use by the operator. vi. It may be felt that cases of sudden cardiac arrest on Aircraft are very rare but Airlines carrying defibrillators have led to lives being saved and the saving of a single life would justify the availability of equipment on all Aircraft for use as and when a medical emergency arises. The Federal Aviation Authority has required US Airlines to carry a defibrillator on flights since 1994. vii. The evidence raised concerns that there is a risk that future deaths will occur unless action is taken to review the above issues. ”
Source location
Davina Tavener · 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
Engage Member States to reconsider defibrillator carriage through available-data analysis and an initial discussion at the scheduled advisory-group meeting.

Verbatim wording from the response
“We will therefore engage with our Member States to reconsider the situation through analysis of available data. We will launch a first discussion on this matter at our next meeting with Member”

Source location
2015-0252-Response-by-EASA
Page 1 · response
Published 3 July 2015
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
Write to Ryanair about carrying AEDs on its fleet.

Verbatim wording from the response
“Regarding the carriage of AED’s on short-haul aircraft, there may be very little impact on the actual overall statistics. Notwithstanding that, I can confirm that the Chief Executive of the IAA has written to the Chief Executive of Ryanair on the matter. Further to that correspondence, it is our understanding that Ryanair are now positively reviewing the”

Source location
2015-0252-Response-by-IAA
Page 2 · response
Published 3 July 2015
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
Passengers are not at increased risk of sudden cardiac arrest, which is exceptionally rare on short-haul flights, and defibrillators often do not succeed.

Verbatim wording from the response
“In terms of possible changes to the current regulations on compulsory carriage of defibrillators, the CAA’s current view as set out on its Aviation Health Unit website, is that cases of sudden cardiac arrest are very rare when compared to the number of passengers carried. The evidence from those airlines that have been carrying them on a voluntary basis is that although a few lives are saved, in most cases the use of a defibrillator is not successful. This is partly because some of the cases are not due to ventricular fibrillation (the most common cause of cardiac arrest) and therefore a defibrillator will not be able to restore a normal rhythm. Also even if a normal heart rhythm can be restored, the cause of the abnormal rhythm – such as a heart attack – cannot be treated until the person gets to hospital and this can take several hours.”

Source location
2015-0252-Response-by-CAA
Page 2 · response
Published 3 July 2015
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
Existing voluntary carriage, regulatory consideration requirements and evidence review make mandating general carriage of this equipment currently difficult to justify.

Verbatim wording from the response
“Some airlines do carry defibrillators on a voluntary basis – particularly those operating on long haul sectors or mixed long haul and short sectors. The EASA regulations require operators to consider carrying them, depending on the type of their operations and other factors, such as passenger demographics (age etc). In the case of an airline operating only short haul routes, with flight durations of typically up to 3-4 hours (but often much shorter), the likelihood of a passenger who was well at the time of boarding having a significant medical event during the flight, let alone a cardiac arrest, is exceptionally small.”

Source location
2015-0252-Response-by-CAA
Page 2 · response
Published 3 July 2015
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 UK cannot act alone to introduce legal changes because mandating the equipment would require significant international agreement.

Verbatim wording from the response
“It would be for EASA to consider the need for any change in the Regulations which apply to EU operators and for ICAO to consider this in relation to non-European operators. In either case, this”

Source location
2015-0252-Response-by-CAA
Page 2 · response
Published 3 July 2015
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
EASA must consider regulatory changes for EU operators, while ICAO must consider them for non-European operators.

Verbatim wording from the response
“It would be for EASA to consider the need for any change in the Regulations which apply to EU operators and for ICAO to consider this in relation to non-European operators. In either case, this”

Source location
2015-0252-Response-by-CAA
Page 2 · response
Published 3 July 2015
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
Existing EASA and ICAO arrangements, including operator risk assessments, are considered sufficient; AED carriage is not strictly required.

Verbatim wording from the response
“All AOC holders are in full compliance with the recommendations of European Aviation Safety Agency (EASA) and International Civil Aviation Organisation (ICAO).”

Source location
2015-0252-Response-by-IAA
Page 2 · response
Published 3 July 2015
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
Operators are responsible for deciding whether to carry AEDs based on the particular needs and risk assessment of each operation.

Verbatim wording from the response
“Namely the acceptable means of compliance to the rule concerned (CAT.IDE.A.225), listing the content of the Emergency Medical Kit, recommend operators to determine through risk assessment the need to carry the defibrillator. So there is no strict requirement for operators, but only a recommendation based on the result of a risk assessment.”

Source location
2015-0252-Response-by-IAA
Page 2 · response
Published 3 July 2015
Open published response
17 Apr2014
Plymouth, Torbay & South Devon
Concerns raised1
1. Unavailability of airway support during time-critical patient transfer for CT
This report raised 8 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.
AI-generated summary

Karen Lesley Peters · 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

Karen Peters suffered a fall and head injury in hospital on 28 March 2013, subsequently developing an acute subdural haemorrhage and dying on 29 March 2013 after delays in transfer to neurosurgical care. Concerns included nursing staffing and agency staff deployment, handover quality, neurological observations and escalation, administration of contraindicated anticoagulation, availability of airway support, and delays and coordination issues affecting time-critical transfer.

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 airway support during time-critical patient transfer for CT
Wider context from the report
“2. At 06.15 hours on 29 March, Karen was found to have a GCS of 6. She was sent for an immediate CT Scan and this was completed within 45 minutes, which I found to be commendable. I heard evidence, however, from a ████████ who was the F1 doctor who took Karen to the CT scanner. He told me that no airway support was available to him at that time. He felt exposed and it was plain that Karen was similarly exposed. Fortunately, there were no complications during the course of the Scan, but it is easy to see that in similar circumstances, a problem could develop that the Junior doctor looking after the patient would be unable to resolve. I would be grateful if you could let me have your thoughts as to how you propose to address this difficulty. ”
Source location
Karen Lesley Peters · Prevention of Future Deaths report
Page 4 · concerns
Open source report
15 Apr2014
Inner West London
Concerns raised2
1. Failure of airway-management training to ensure clinicians have the skills and confidence to perform emergency surgical tracheotomy
2. Insufficient A&E cover by clinicians able to secure airways via emergency surgical tracheotomy
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Provide and periodically repeat advanced airway training, including emergency tracheotomy and needle cricothyroidotomy, with practical training for relevant clinicians.
  Stated by NHS EnglandStated completed
2. Action
  Review Emergency Departments and senior-staff availability for emergency airway skills across London.
  Stated by NHS EnglandStated completed
3. Action
  Implement increased senior doctor presence in A&E departments, including 24/7 consultant cover in Major Trauma units and extended consultant or senior trainee cover elsewhere.
  Stated by NHS EnglandStated in progress
Respondent positions 3
1. Position
  Acute Trusts providing A&E are responsible for managing airway-cover risks through general training and timely access to specialist expertise.
  Stated by NHS EnglandRedirects responsibility
1. Position
  Existing airway training, recurring skills maintenance, guidelines and practical courses are considered sufficient for clinicians managing emergency airways.
  Stated by NHS EnglandExisting arrangements considered sufficient
2. Position
  Immediate resident ENT surgeon cover in every A&E is impractical because there are insufficient experienced ENT surgeons.
  Stated by NHS EnglandUnable to act
AI-generated summary

Desiree Harmony Falvo · 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

Desiree Harmony Falvo developed severe breathing difficulties after a procedure and was transferred to hospital in extremis. Difficulties securing her airway led to cardiac arrest and hypoxic brain injury, and she subsequently died in intensive care. The concerns were insufficient on-site emergency surgical tracheotomy expertise in some A&E departments and the adequacy of training and confidence of clinicians expected to secure airways.

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 airway-management training to ensure clinicians have the skills and confidence to perform emergency surgical tracheotomy
Wider context from the report
“(2) That the training planned and provided to those expected to manage and secure airways including the use as appropriate of surgical tracheotomy, is reviewed and upgraded such that those clinicians have both the skills and confidence to perform such procedures in an emergency situation. ”
Source location
Desiree Harmony Falvo · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Insufficient A&E cover by clinicians able to secure airways via emergency surgical tracheotomy
Wider context from the report
“(1) That A&E departments have insufficient cover to ensure that they have on site clinicians able to secure airways via emergency surgical tracheotomy, ”
Source location
Desiree Harmony Falvo · 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
Provide and periodically repeat advanced airway training, including emergency tracheotomy and needle cricothyroidotomy, with practical training for relevant clinicians.

Verbatim wording from the response
“There are insufficient experienced ENT surgeons to provide immediately available resident cover in all A&E departments at all times, and to do so would be impractical. Acute Trusts responsible for the provision of A&E are expected to recognise and manage this risk by ensuring that general training is available to the initial receiving staff in A&E, and that specialist expertise can be accessed in a timely way. A&E senior staff are trained as part of Advanced Trauma Life Support (ATLS) in both tracheotomies and needle cricothyroidotomy. This is repeated at least every four years to ensure skills and confidence are maintained.”

Source location
2014-0171-Response-by-NHS-England
Page 1 · response
Published 15 April 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
Review Emergency Departments and senior-staff availability for emergency airway skills across London.

Verbatim wording from the response
“Across London there has been a review of Emergency Departments and the availability of senior staff with these skills as part of a wider review of Quality Standards in Acute Trusts. It is clear that provision has varied, and a standard has been agreed whereby all Major Trauma units have consultants on site 24/7 and all A&Es will have increased consultant presence over 16 hours with senior training doctors (ST4s) on site and available for the other time. This is a substantial challenge as there is a shortage of A&E doctors, but already many Trusts have made strides to meet these standards and this has also been a drive behind the reconfiguration of some A&Es.”

Source location
2014-0171-Response-by-NHS-England
Page 1 · response
Published 15 April 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
Implement increased senior doctor presence in A&E departments, including 24/7 consultant cover in Major Trauma units and extended consultant or senior trainee cover elsewhere.

Verbatim wording from the response
“Across London there has been a review of Emergency Departments and the availability of senior staff with these skills as part of a wider review of Quality Standards in Acute Trusts. It is clear that provision has varied, and a standard has been agreed whereby all Major Trauma units have consultants on site 24/7 and all A&Es will have increased consultant presence over 16 hours with senior training doctors (ST4s) on site and available for the other time. This is a substantial challenge as there is a shortage of A&E doctors, but already many Trusts have made strides to meet these standards and this has also been a drive behind the reconfiguration of some A&Es.”

Source location
2014-0171-Response-by-NHS-England
Page 1 · response
Published 15 April 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
Acute Trusts providing A&E are responsible for managing airway-cover risks through general training and timely access to specialist expertise.

Verbatim wording from the response
“There are insufficient experienced ENT surgeons to provide immediately available resident cover in all A&E departments at all times, and to do so would be impractical. Acute Trusts responsible for the provision of A&E are expected to recognise and manage this risk by ensuring that general training is available to the initial receiving staff in A&E, and that specialist expertise can be accessed in a timely way. A&E senior staff are trained as part of Advanced Trauma Life Support (ATLS) in both tracheotomies and needle cricothyroidotomy. This is repeated at least every four years to ensure skills and confidence are maintained.”

Source location
2014-0171-Response-by-NHS-England
Page 1 · response
Published 15 April 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
Existing airway training, recurring skills maintenance, guidelines and practical courses are considered sufficient for clinicians managing emergency airways.

Verbatim wording from the response
“There are insufficient experienced ENT surgeons to provide immediately available resident cover in all A&E departments at all times, and to do so would be impractical. Acute Trusts responsible for the provision of A&E are expected to recognise and manage this risk by ensuring that general training is available to the initial receiving staff in A&E, and that specialist expertise can be accessed in a timely way. A&E senior staff are trained as part of Advanced Trauma Life Support (ATLS) in both tracheotomies and needle cricothyroidotomy. This is repeated at least every four years to ensure skills and confidence are maintained.”

Source location
2014-0171-Response-by-NHS-England
Page 1 · response
Published 15 April 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
Immediate resident ENT surgeon cover in every A&E is impractical because there are insufficient experienced ENT surgeons.

Verbatim wording from the response
“There are insufficient experienced ENT surgeons to provide immediately available resident cover in all A&E departments at all times, and to do so would be impractical. Acute Trusts responsible for the provision of A&E are expected to recognise and manage this risk by ensuring that general training is available to the initial receiving staff in A&E, and that specialist expertise can be accessed in a timely way. A&E senior staff are trained as part of Advanced Trauma Life Support (ATLS) in both tracheotomies and needle cricothyroidotomy. This is repeated at least every four years to ensure skills and confidence are maintained.”

Source location
2014-0171-Response-by-NHS-England
Page 1 · response
Published 15 April 2014
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to provide first aid and airway-clearing assistance during choking

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised2

Failure to assess breathing and perform airway manoeuvres during resuscitation

Insufficient airway ventilation assistance during resuscitation

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

Concerns raised1

Lack of an action plan for obtaining assistance during airway loss or difficulty placing a pacemaker wire

Concerns raised1

Failure to make SGA use conditional on laryngoscopy to detect foreign body airway obstruction

Concerns raised2

Inadequate ventilation during resuscitation in GP practices

Failure to use suction during resuscitation in GP practices

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.5

Concerns raised1

Lack of suction equipment for clearing airways

Concerns raised1

Lack of joint guidance for front-of-neck access during a “Can’t Intubate Can’t Oxygenate” emergency involving anaesthetists and ENT surgeons

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

Actions described in response 1

Respondent positions 1

Actions described in response 3

Actions described in response 4

Respondent positions 5

Actions described in response 2