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.

3 Dec2013
Inner North London
Concerns raised2
1. Failure to provide effective airway ventilation during resuscitation
2. Failure to maintain continuous responsibility for the airway during resuscitation
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 4
1. Action
  Approve and implement a revised Trust Resuscitation Policy aligned with national guidance and learning from the inquest.
  Stated by North London NHS Foundation TrustStated completed
2. Action
  Introduce six-monthly CPR simulation exercises across inpatient units, with committee monitoring.
  Stated by North London NHS Foundation TrustStated planned
3. Action
  Provide specialist oxygen-use training using live oxygen cylinders during training sessions.
  Stated by North London NHS Foundation TrustStated planned
1. Action
  Transfer resuscitation-scene coordination to the most senior nurse on duty until attending paramedics assume responsibility.
  Stated by North London NHS Foundation TrustStated planned
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 individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to maintain continuous responsibility for the airway 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 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
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
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
Transfer resuscitation-scene coordination to the most senior nurse on duty until attending paramedics assume responsibility.

Verbatim wording from the response
“e) Management of the resuscitation scene will no longer be with the attending doctor, but with the most senior nurse on duty at the time. This will be the duty nurse or site matron who will have responsibility for coordinating staff actions, and handing over information to attending paramedics. Until the paramedic lead accepts responsibility, the duty nurse or site matron will maintain the lead for managing the resuscitation.”

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

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised2

Failure to provide effective airway ventilation during resuscitation

Failure to maintain continuous responsibility for the airway 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.4

Actions described in response 4