Recurring concern

Unreliable airway management during emergency care

First to latest report 3 Dec 2013 — 31 Mar 2026

Reports that mention this concern
21
Times this concern has been raised
28
Stated actions linked to this concern
42

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.

What is 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 and published responses 21 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Inner North London

    AI-generated summary

    Abdullahi Sharif ABOKAR · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

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

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to provide effective airway ventilation during resuscitation

    Wider context from the report

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

    Source location

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

    Open source report

    Source evidence

    How this 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

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026