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
Distinct published reports
Individual concerns
28
A report can raise multiple concerns
Date range
2013–2026
First to latest report issue date
Stated actions
42
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.
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
NHS trust7
Multi-service care provider4
Executive non-departmental public body3
Private limited company3
Health professional body2
Prison or young offender institution2
Aviation regulator1
Coronial office1
Executive agency1
Health and social care service regulator1
Healthcare site1
Health-sector membership body1
Integrated care board1
Local authority1
Ministerial department1
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.
West Yorkshire Western
Concerns raised1
Lack of trained support for paediatric emergency intubation
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.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Implement regular multidisciplinary simulation training for escalation, communication, deterioration management and paediatric airway scenarios.
Stated by Mid Yorkshire Teaching NHS TrustStated completedThe respondent said that this action was complete when they made their response on 7 April 2026.
Action
Introduce an enhanced out-of-hours paediatric rapid-response model through ongoing recruitment.
Stated by Mid Yorkshire Teaching NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 7 April 2026.
Manchester South
Concerns raised1
Lack of compulsory direct observed training for paediatric middle grades performing neonatal intubation
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
Action
Provide neonatal airway management training through Progress+ neonatology placements.
Stated by Royal College of Paediatrics and Child HealthStated completedThe respondent said that this action was complete when they made their response on 14 February 2025.
Action
Strengthen the Progress+ curriculum's neonatal airway capabilities, emphasizing non-invasive airway management and specialty-level safe intubation and difficult-airway management.
Stated by Royal College of Paediatrics and Child HealthStated completedThe respondent said that this action was complete when they made their response on 14 February 2025.
Action
Develop a neonatal airway safety standard with BAPM addressing skills maintenance and ongoing training.
Stated by Royal College of Paediatrics and Child HealthStated completedThe respondent said that this action was complete when they made their response on 14 February 2025.
Action
Signpost members to the neonatal airway safety standard and its skills-maintenance resources.
Stated by Royal College of Paediatrics and Child HealthStated plannedThe respondent said that this action was planned when they made their response on 14 February 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Removing mandatory neonatal intubation DOPS does not necessarily increase risk because non-invasive airway management is safer and the former DOPS provided false reassurance.
Stated by Royal College of Paediatrics and Child HealthDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Operational delivery networks are responsible for supporting airway and resuscitation skill maintenance across neonatal units, particularly where skills are infrequently used.
Stated by Royal College of Paediatrics and Child HealthRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Essex
Concerns raised3
Failure to provide guidance on inflation pressure when securing a paediatric airway adjunct in life-threatening asthma
Lack of clear ambulance guidance for recognising and managing life-threatening childhood asthma and failed airway management
Limited availability of trained paediatric endotracheal intubation capability
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.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
Action
Review JRCALC guidance against the concerns raised about asthma and airway management.
Stated by Association of Ambulance Chief ExecutivesStated completedThe respondent said that this action was complete when they made their response on 12 December 2023.
Action
Review the asthma guideline and assess whether its severity assessment and management algorithm require clearer detail or greater emphasis on adrenaline.
Stated by Association of Ambulance Chief ExecutivesStated plannedThe respondent said that this action was planned when they made their response on 12 December 2023.
Action
Authorise specialist-qualified paramedics in the relevant cohort to perform endotracheal intubation, including under-12 patients through specified critical-care roles.
Stated by East of England Ambulance Service NHS TrustStated completedThe respondent said that this action was complete when they made their response on 12 December 2023.
Action
Introduce Advanced Paramedics in Critical Care cars across the region, one per Integrated Care Board area, through the advanced-practice programme.
Stated by East of England Ambulance Service NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 12 December 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
Position
AACE is not constituted to mandate or instruct ambulance services on responsive safety measures.
Stated by Association of Ambulance Chief ExecutivesOutside remitThe respondent said that this matter was outside its role or authority.
Position
Individual clinicians and employing organisations must ensure airway competency and determine advanced airway skills and adjuncts used.
Stated by Association of Ambulance Chief ExecutivesRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Mandating regular airway training and practice is beyond JRCALC’s scope.
Stated by Association of Ambulance Chief ExecutivesOutside remitThe respondent said that this matter was outside its role or authority.
Position
Broader paramedic intubation is not undertaken because infrequent exposure prevents maintaining competency and creates patient-safety risks.
Stated by East of England Ambulance Service NHS TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Nottinghamshire
Concerns raised2
Limited use of comprehensive difficult-airway strategies with structured planning and preparation
Unavailability of equipment and skills to carry out difficult-airway plans
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.7
Action
Use a Critical Care Airway Plan to classify airways and document, display, review, and hand over management plans for patients with difficult airways.
Stated by UHDBStated completedThe respondent said that this action was complete when they made their response on 27 April 2023.
Action
Circulate and reinforce procedures for airway care plans, NAP4 algorithms, emergency intubation checklists, and airway management.
Stated by UHDBStated completedThe respondent said that this action was complete when they made their response on 27 April 2023.
Action
Repeat the airway study day with theory and simulation training on airway management, trolley orientation, intubation checklists, and dislodged tracheostomy management.
Stated by UHDBStated plannedThe respondent said that this action was planned when they made their response on 27 April 2023.
Action
Maintain airway trolleys with required equipment, NAP4 algorithms, and intubation checklists, supported by daily checks, restocking, and documented compliance.
Stated by UHDBStated completedThe respondent said that this action was complete when they made their response on 27 April 2023.
Action
Add airway management to the junior doctor induction programme.
Stated by UHDBStated in progressThe respondent said that this action was in progress when they made their response on 27 April 2023.
Action
Provide practical airway training for Band 6 and 7 nursing teams and display airway education materials within the unit.
Stated by UHDBStated completedThe respondent said that this action was complete when they made their response on 27 April 2023.
Action
Purchase a new intubating bronchoscope and order an additional machine to provide two bronchoscope options in intensive care.
Stated by UHDBStatus at responseThe respondent said that this action was partly complete when they made their response on 27 April 2023.
Northamptonshire
Concerns raised1
Failure to attempt suction
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Develop a clinical bulletin reinforcing systematic seizure management, aspiration assessment and maintenance of oxygenation during patient transfer.
Stated by East Midlands Ambulance Service NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 20 January 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Suction was not required because the child did not vomit while the crew was present.
Stated by East Midlands Ambulance Service NHS TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Birmingham and Solihull
Concerns raised1
Failure of officers to understand the need for rescue breaths during resuscitation
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The existing APP-AP provides appropriate operational guidance for armed-policing medical assistance and does not require amendment.
Stated by College of PolicingExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Norfolk
Concerns raised1
Failure to position the patient correctly and assess airway obstruction during an emergency
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Black Country
Concerns raised1
Failure to manage the newborn airway during transfer from ambulance to hospital
This report raised 5 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.
Inner North London
Concerns raised1
Failure to check breathing during resuscitation
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
Action
Require annual Immediate Life Support training for employed resuscitation staff and monitor compliance through monthly dashboards and the Resuscitation Committee.
Stated by Care UKStated completedThe respondent said that this action was complete when they made their response on 13 December 2019.
Action
Contract for additional prison-scenario Immediate Life Support training sessions beyond annual recertification across Care UK sites.
Stated by Care UKStated plannedThe respondent said that this action was planned when they made their response on 13 December 2019.
Action
Film selected scenario-based resuscitation exercises for use in in-house training and induction.
Stated by Care UKStated plannedThe respondent said that this action was planned when they made their response on 13 December 2019.
Action
Request CCTV or body-worn-camera footage after on-site custody deaths involving resuscitation and review it through immediate and internal learning reviews.
Stated by Care UKStated completedThe respondent said that this action was complete when they made their response on 13 December 2019.
West Sussex
Concerns raised1
Failure to place an incapacitated patient in a position that protects the airway
This report raised 13 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Increase and maintain staff safety training, competency assessment, mandatory-training tracking and first-aider coverage on every shift.
Stated by Shaw Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 23 August 2019.
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Includes failures of controls 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.
