Recurring concern

Unreliable resuscitation preparedness and response during cardiac arrest

Get email alerts

Request correction

First reported 3 Dec 2013•Latest report 26 May 2026

Definition

What this concern includes

Includes failures in the end-to-end cardiac-arrest resuscitation control: preparedness, trained response, equipment readiness or operation, recognition, and delivery of indicated CPR.

Not included

Generic clinical failings or avoidable deaths not explicitly tied to CPR or resuscitation.
Failures of unrelated equipment, measurement, staffing, governance, or communication that are not specifically dedicated to the CPR response.
DNACPR documentation or decision-making concerns unless they directly cause an unsafe CPR response during cardiac arrest.
Hazards involving self-harm, ligatures, poisoning, or other emergency processes unrelated to CPR.

Reports: 56
Individual concerns: 79
Date range: 2013–2026
Stated actions: 127

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.

Department of Health and Social Care7

HM Prison and Probation Service5

NHS England5

Pentonville Prison4

Care Quality Commission3

Care UK3

College of Policing3

Ministry of Justice3

East London NHS Foundation Trust2

Essex Partnership University NHS Foundation Trust2

Metropolitan Police Service2

South London and Maudsley NHS Foundation Trust2

Ardenlea Grove Care Home1

Aspray House1

Barking, Havering and Redbridge University Hospitals NHS Trust1

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.

26 May2026
West Sussex, Brighton and Hove
Concerns raised3
1. Delays in contacting 999 and the on-call doctor during cardiac arrests
2. Inability of staff to perform CPR properly
3. Failure to coordinate cardiac-arrest responses
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 4
1. Action
  Deliver regular unannounced emergency simulation training to strengthen staff confidence and response to cardiac arrest and opioid overdose.
  Stated by SPFTStated completed
2. Action
  Update the Resus policy to require monthly clinical and non-clinical emergency simulations across inpatient hospitals.
  Stated by SPFTStated completed
3. Action
  Introduce automated external defibrillators providing real-time CPR feedback and use them in staff training.
  Stated by SPFTStated completed
1. Action
  Develop a structured ward-level improvement plan to clarify responsibilities, improve documentation and track actions through to completion.
  Stated by SPFTStated in progress
Respondent positions 1
1. Position
  Existing Trust actions embedded in policy, training, governance and ward-level processes are considered sufficient; no further new actions are needed.
  Stated by SPFTExisting arrangements considered sufficient
AI-generated summary

Kristian Edward Allen · 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

Kristian Edward Allen, who had complex mental health issues and a history of drug and alcohol abuse, died at Millview Hospital on 16 February 2025 after taking heroin, cocaine and alcohol. The report identifies concerns about inappropriate authorisation of leave, inadequate searches and observations, poor communication, and a delayed and ineffective response to his cardiac arrest. The concerns also include staff being insufficiently trained to manage cardiac arrests and drug overdoses in acute mental health wards.

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
Delays in contacting 999 and the on-call doctor during cardiac arrests
Wider context from the report
“I am also concerned that staff are not properly able to deal with cardiac arrests in acute mental health wards. In Kristian’s inquest, evidence was heard that the response to Kristian’s arrest was chaotic and disorganised. Nobody appeared to be in charge, staff were unable to do CPR properly, the 999 call was of a poor standard, there were considerable delays in contacting 999 and the on call doctor and the staff did not have Naloxone training. I had the same issues in an Inquest I did nine months ago in the exact same ward, indeed in the neighbouring room. The fact that the same set of facts have repeated themselves in Kristian’s case leads me to a very real concern that future deaths will happen if action is not taken. ”
Source location
Kristian Edward Allen · 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
Inability of staff to perform CPR properly
Wider context from the report
“I am also concerned that staff are not properly able to deal with cardiac arrests in acute mental health wards. In Kristian’s inquest, evidence was heard that the response to Kristian’s arrest was chaotic and disorganised. Nobody appeared to be in charge, staff were unable to do CPR properly, the 999 call was of a poor standard, there were considerable delays in contacting 999 and the on call doctor and the staff did not have Naloxone training. I had the same issues in an Inquest I did nine months ago in the exact same ward, indeed in the neighbouring room. The fact that the same set of facts have repeated themselves in Kristian’s case leads me to a very real concern that future deaths will happen if action is not taken. ”
Source location
Kristian Edward Allen · 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 coordinate cardiac-arrest responses
Wider context from the report
“I am also concerned that staff are not properly able to deal with cardiac arrests in acute mental health wards. In Kristian’s inquest, evidence was heard that the response to Kristian’s arrest was chaotic and disorganised. Nobody appeared to be in charge, staff were unable to do CPR properly, the 999 call was of a poor standard, there were considerable delays in contacting 999 and the on call doctor and the staff did not have Naloxone training. I had the same issues in an Inquest I did nine months ago in the exact same ward, indeed in the neighbouring room. The fact that the same set of facts have repeated themselves in Kristian’s case leads me to a very real concern that future deaths will happen if action is not taken. ”
Source location
Kristian Edward Allen · 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
Deliver regular unannounced emergency simulation training to strengthen staff confidence and response to cardiac arrest and opioid overdose.

Verbatim wording from the response
“Response to cardiac arrest I appreciate your concern in relation to staff not being properly able to deal with cardiac arrests. You will have heard how this was recognised within the Trust's PSII and the need to strengthen preparedness and response to medical emergencies, including opioid overdose, resulted in recommended action. The identified action was the need to increase staff confidence in administering Immediate Life Support (ILS). I am informed that the Inquest heard of the impact upon staff of conducting ILS and how their confidence can be impacted by the rarity of having to conduct ILS. I confirm, as you heard, that as a direct action from the PSII into Kristian's death the Trust introduced regular simulation training ie: unannounced emergency simulations to which staff then have to respond.”

Source location
Response from Sussex Partnership Foundation Trust
Page 3 · response
Published 22 June 2026
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
Update the Resus policy to require monthly clinical and non-clinical emergency simulations across inpatient hospitals.

Verbatim wording from the response
“As you also heard in evidence the Trust's Resus policy has been updated to formalise the inclusion of simulation as standard in both clinical and non-clinical areas to enhance and embed medical emergency and cardiac arrest training, thereby ensuring staff remain competent and confident with emergency processes and procedures. The policy stipulates that simulations will be completed monthly throughout SPFT in inpatient hospitals. As ████████ informed you, the most recent simulation on Kristian's ward took place on 20th May, involving 8 staff and simulated a scenario of an opioid overdose leading to cardiac arrest. I am informed that feedback from the ILS team was that the ward-team's response was well led.”

Source location
Response from Sussex Partnership Foundation Trust
Page 3 · response
Published 22 June 2026
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 automated external defibrillators providing real-time CPR feedback and use them in staff training.

Verbatim wording from the response
“It is recognised that simulation training enables staff to develop their confidence beyond the basic level of skills and confidence achieved via the already existing mandatory ILS training. Additionally, as you heard, the Trust has now introduced new Automated External Defibrillators (AEDs) to support staff. These new AEDs give real-time information to the staff conducting CPR to inform them as to whether their rate and depth of CPR application is appropriate, thereby supporting staff to deliver high-quality CPR in line with guidelines. These new AEDs are also used in training to enable the nurses to see if those they are training are conducting CPR as optimally as possible.”

Source location
Response from Sussex Partnership Foundation Trust
Page 3 · response
Published 22 June 2026
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 a structured ward-level improvement plan to clarify responsibilities, improve documentation and track actions through to completion.

Verbatim wording from the response
“Additionally, Mill View Hospital, as a whole, have been subject to external review by recognised specialist consultants in organisational performance and service improvement. Their work has focused on strengthening ward-level processes and operational consistency, including clarifying roles and responsibilities, improving documentation standards, and ensuring that actions agreed in MDTs and reviews are clearly recorded, owned and followed through. This has supported the development of a structured ward-level improvement plan, enabling learning, including from PSIIs, to be translated into consistent day-to-day practice and more reliable delivery of care processes.”

Source location
Response from Sussex Partnership Foundation Trust
Page 4 · response
Published 22 June 2026
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 Trust actions embedded in policy, training, governance and ward-level processes are considered sufficient; no further new actions are needed.

Verbatim wording from the response
“In summary, given the comprehensive range of actions already taken by the Trust there are no further new actions that I consider the Trust needs to take. That said, as I recognised above, all improvement requires sustained, committed focus. So, whilst I can already say that the actions described above are now embedded within policy, training, governance and ward-level quality improvement processes, which are subject to ongoing monitoring to ensure improvements continue, I would like to assure you that the oversight and focus on”

Source location
Response from Sussex Partnership Foundation Trust
Page 4 · response
Published 22 June 2026
Open published response
17 Apr2026
Cumbria
Concerns raised1
1. Failure of advanced life support training to cover the need for a solid surface during CPR
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
  Reinforce CPR practice through resuscitation training.
  Stated by Lancashire & South Cumbria NHS Foundation TrustStated completed
Respondent positions 1
1. Position
  Current national guidance and aligned practice are considered sufficient; patients should not be moved from beds, with CPR mitigation used.
  Stated by Lancashire & South Cumbria NHS Foundation TrustExisting arrangements considered sufficient
AI-generated summary

Julie Ley · 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

Julie Ley, aged 71, died on 15 May 2025 at Westmorland General Hospital after her physical condition deteriorated while she was detained under the Mental Health Act. The inquest identified inadequate care, including failures in nutrition monitoring, physical health monitoring, transfer to a hospital able to provide appropriate treatment, and use of available legal powers to administer medication. A further concern was that CPR was performed on her bed, a soft surface, and a senior clinician was unaware that this could reduce its effectiveness.

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 advanced life support training to cover the need for a solid surface during CPR
Wider context from the report
“(1) The consultant who was involved in performing CPR on Mrs Ley agreed that she had been in bed at the time. When asked why he had not moved her to a solid surface he replied that he had attended many advanced life support training sessions and had never been told this was necessary. In their article "The impact of compliant surfaces on in-hospital chest compressions: Effects of common mattresses and a backboard" in the journal Resucitation (Vol 80, Issue 5, May 2009) the authors note that carrying out CPR in a hospital bed may be 50% less effective. I am concerned that despite receiving training a senior clinician was unaware of this and consider that it gives rise to a risk of future deaths. ”
Source location
Julie Ley · 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
Reinforce CPR practice through resuscitation training.

Verbatim wording from the response
“The Trust’s resuscitation practice is aligned with this current national guidance. In response to the matters raised in your report, the Trust has nevertheless taken steps to reinforce and assure this position through resuscitation training, policy review, equipment assurance and clinical governance processes, in order to minimise the risk of misunderstanding or inconsistent practice in the future.”

Source location
Response from Lancashire and South Cumbria NHS Foundation Trust
Page 2 · response
Published 21 August 2026
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
Current national guidance and aligned practice are considered sufficient; patients should not be moved from beds, with CPR mitigation used.

Verbatim wording from the response
“Since the publication of the article cited in your report, national and international resuscitation guidance has evolved. Current Resuscitation Council UK guidance recognises that, although a firm surface is optimal, rescuers should not move a person from a soft surface, such as a bed, to the floor in order to commence CPR. The guidance emphasises that CPR should be started without delay on the bed and that, where required, chest compressions should be delivered with increased depth to compensate for mattress compliance, alongside the use of appropriate mitigation such as backboards.”

Source location
Response from Lancashire and South Cumbria NHS Foundation Trust
Page 1 · response
Published 21 August 2026
Open published response
10 Apr2026
Shropshire, Telford and Wrekin
Concerns raised1
1. Inability of attending paramedics to comply with opioid-related respiratory-arrest and cardiac-arrest guidelines amid competing tasks
This report raised 2 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 7
1. Action
  Complete formal clinical reviews of ambulance Naloxone Hydrochloride quantities and confirm the current ten-ampoule load list remains appropriate.
  Stated by West Midlands Ambulance Service University NHS Foundation TrustStated completed
2. Action
  Raise the practical and evidential concerns about cardiac-arrest Naloxone Hydrochloride guidance with JRCALC for consideration in its guidance review.
  Stated by West Midlands Ambulance Service University NHS Foundation TrustStated completed
3. Action
  Review the naloxone monograph.
  Stated by Association of Ambulance Chief ExecutivesStated in progress
1. Action
  Approve changes to the naloxone monograph in response to the concerns raised.
  Stated by Association of Ambulance Chief ExecutivesStated completed
2. Action
  Remove naloxone use during cardiac arrest from the JRCALC guidance.
  Stated by Association of Ambulance Chief ExecutivesStated completed
3. Action
  Have the agreed naloxone changes reviewed by the national ambulance service medical directors group.
  Stated by Association of Ambulance Chief ExecutivesStated planned
4. Action
  Introduce the approved naloxone changes into ambulance service clinical practice guidelines, subject to approval.
  Stated by Association of Ambulance Chief ExecutivesStated planned
Respondent positions 3
1. Position
  Full adherence to repeated naloxone dosing during cardiac arrest is impracticable because of task saturation and competing life-saving interventions.
  Stated by West Midlands Ambulance Service University NHS Foundation TrustUnable to act
1. Position
  JRCALC and Class Publishing are responsible for resolving concerns about the naloxone cardiac-arrest guideline.
  Stated by West Midlands Ambulance Service University NHS Foundation TrustRedirects responsibility
2. Position
  Increasing naloxone stocks is unnecessary because naloxone will no longer be recommended during opioid-related cardiac arrest.
  Stated by Association of Ambulance Chief ExecutivesNo action considered necessary
AI-generated summary

Wayne AUSTIN · 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

Wayne Austin became unwell and collapsed at Shrewsbury Probation office on 10 October 2024 after reporting that he had consumed cider; paramedics were subsequently informed that he had consumed crack cocaine. He was treated with CPR, advanced life support and Naloxone, transferred to hospital, and died as a result of combined buprenorphine and alcohol toxicity. Concerns included difficulty locating and applying the appropriate Naloxone guidance, the practical difficulty of complying with dosing guidelines during cardiac arrest, and the number of Naloxone vials carried by ambulances.

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
Inability of attending paramedics to comply with opioid-related respiratory-arrest and cardiac-arrest guidelines amid competing tasks
Wider context from the report
“(2) Inability of attending paramedics to comply with the guidelines for Respiratory arrest/depression due to other competing tasks and therefore certainly a complete inability to comply with the guidelines for cardiac arrest (where opioid toxicity is the likely cause) making them potentially unrealistic. ”
Source location
Wayne AUSTIN · 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
Complete formal clinical reviews of ambulance Naloxone Hydrochloride quantities and confirm the current ten-ampoule load list remains appropriate.

Verbatim wording from the response
“WMAS has undertaken formal clinical review of this issue. An initial review of Naloxone Hydrochloride quantities was completed in May 2025 by the WMAS Consultant Paramedic for Emergency Care, followed by a further review in September 2025 by the senior clinical team. The latter specifically considering the cardiac arrest guidance where opioid overdose is suspected. The consensus from the latest review was that the current Naloxone Hydrochloride quantities carried on the WMAS Load List were appropriate.”

Source location
Response from West Midlands Ambulance Service
Page 4 · response
Published 17 April 2026
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 the practical and evidential concerns about cardiac-arrest Naloxone Hydrochloride guidance with JRCALC for consideration in its guidance review.

Verbatim wording from the response
“Overall, this issue reflects a disconnect between guideline intent and what is operationally achievable during cardiac arrest resuscitation, rather than an unreasonable failure to follow guidance. WMAS considers that, in this context, the guideline may not be fully realistic for frontline application and should be interpreted pragmatically, with patient-centred prioritisation of core life-saving interventions. The WMAS Medical Director has raised these points with JRCALC, and it is our understanding that the Naloxone Hydrochloride guidance will be reviewed.”

Source location
Response from West Midlands Ambulance Service
Page 3 · response
Published 17 April 2026
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 the naloxone monograph.

Verbatim wording from the response
“We are currently working on standardising all drug monographs through our Medicines Governance Group to ensure that all medicines monographs within JRCALC meet legal, regulatory, and good practice requirements. The naloxone monograph is currently under review, and we have shared the matters of concern with the lead person for the drug monograph and the JRCALC committee who have approved changes in response to your concerns.”

Source location
Response from Association of Ambulance Chief Executives (on behalf of the Joint Royal Colleges Ambulance Liaison Committee)
Page 1 · response
Published 17 April 2026
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
Approve changes to the naloxone monograph in response to the concerns raised.

Verbatim wording from the response
“We are currently working on standardising all drug monographs through our Medicines Governance Group to ensure that all medicines monographs within JRCALC meet legal, regulatory, and good practice requirements. The naloxone monograph is currently under review, and we have shared the matters of concern with the lead person for the drug monograph and the JRCALC committee who have approved changes in response to your concerns.”

Source location
Response from Association of Ambulance Chief Executives (on behalf of the Joint Royal Colleges Ambulance Liaison Committee)
Page 1 · response
Published 17 April 2026
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
Remove naloxone use during cardiac arrest from the JRCALC guidance.

Verbatim wording from the response
“The JRCALC committee has approved the removal of the use of naloxone during cardiac arrest. The evidence that naloxone improves survival once cardiac arrest has occurred is limited. Furthermore, it may distract the attending clinicians from more important tasks such as early defibrillation, high quality chest compressions and effective ventilation. The use of naloxone will remain indicated for the reversal of acute opioid or opiate toxicity for respiratory arrest or respiratory depression; this is detailed in several of our clinical guidelines. We have also contacted the UK National Poisons Information Service to discuss the recommended cardiac arrest management for opioid poisoning.”

Source location
Response from Association of Ambulance Chief Executives (on behalf of the Joint Royal Colleges Ambulance Liaison Committee)
Page 2 · response
Published 17 April 2026
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
Have the agreed naloxone changes reviewed by the national ambulance service medical directors group.

Verbatim wording from the response
“The changes agreed to the use of naloxone by the JRCALC committee will be reviewed by the national ambulance service medical directors group (NASMeD) and, subject to approval, will subsequently be introduced into ambulance service clinical practice guidelines.”

Source location
Response from Association of Ambulance Chief Executives (on behalf of the Joint Royal Colleges Ambulance Liaison Committee)
Page 2 · response
Published 17 April 2026
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 the approved naloxone changes into ambulance service clinical practice guidelines, subject to approval.

Verbatim wording from the response
“The changes agreed to the use of naloxone by the JRCALC committee will be reviewed by the national ambulance service medical directors group (NASMeD) and, subject to approval, will subsequently be introduced into ambulance service clinical practice guidelines.”

Source location
Response from Association of Ambulance Chief Executives (on behalf of the Joint Royal Colleges Ambulance Liaison Committee)
Page 2 · response
Published 17 April 2026
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
Full adherence to repeated naloxone dosing during cardiac arrest is impracticable because of task saturation and competing life-saving interventions.

Verbatim wording from the response
“WMAS recognises that, in the context of an active cardiac arrest, achieving this dosing regimen is not realistically achievable. Cardiac arrest management requires the simultaneous delivery of multiple time-critical interventions, including high-quality CPR, airway management, ventilation, rhythm recognition, defibrillation where appropriate, vascular access, drug preparation and administration, and team leadership. Unless multiple additional clinicians are present with a designated role focused exclusively on the repeated preparation, checking, and administration of Naloxone Hydrochloride, compliance with this aspect of the guideline is not practicable during resuscitation.”

Source location
Response from West Midlands Ambulance Service
Page 3 · response
Published 17 April 2026
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
JRCALC and Class Publishing are responsible for resolving concerns about the naloxone cardiac-arrest guideline.

Verbatim wording from the response
“Overall, this issue reflects a disconnect between guideline intent and what is operationally achievable during cardiac arrest resuscitation, rather than an unreasonable failure to follow guidance. WMAS considers that, in this context, the guideline may not be fully realistic for frontline application and should be interpreted pragmatically, with patient-centred prioritisation of core life-saving interventions. The WMAS Medical Director has raised these points with JRCALC, and it is our understanding that the Naloxone Hydrochloride guidance will be reviewed.”

Source location
Response from West Midlands Ambulance Service
Page 3 · response
Published 17 April 2026
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
Increasing naloxone stocks is unnecessary because naloxone will no longer be recommended during opioid-related cardiac arrest.

Verbatim wording from the response
“3) WMAS ambulances only carry a box of 10 Naloxone 400mg vials per ambulance which means that one ambulance attending a situation such as Wayne’s would be insufficient to deal with the circumstances, as would two ambulances. It would mean that three ambulances are required to comply with cardiac arrest (where opioid toxicity is the likely cause).”

Source location
Response from Association of Ambulance Chief Executives (on behalf of the Joint Royal Colleges Ambulance Liaison Committee)
Page 2 · response
Published 17 April 2026
Open published response
30 Mar2026
Inner North London
Concerns raised1
1. Less-than-fully-competent CPR attempts
This report raised 11 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 5
1. Action
  Deliver annual RCUK-accredited ILS training including ROLE, audit compliance, and restrict emergency-radio assignment for staff whose training is out of date.
  Stated by Practice Plus GroupStated completed
2. Action
  Deliver the booked ILS training session to increase current training compliance above 90%.
  Stated by Practice Plus GroupStated planned
3. Action
  Publish and implement the purple-alert guidance clarifying BLS, ILS, ROLE, and CPR expectations, and remind staff of its application.
  Stated by Practice Plus GroupStated completed
1. Action
  Hold a June 2026 meeting with regional and nursing directors to review guidance, consider further scoping, and assess safe ILS/ROLE staffing levels.
  Stated by Practice Plus GroupStated planned
2. Action
  Introduce multidisciplinary, scenario-based resuscitation training for healthcare, prison, and prison-officer staff by July 2026.
  Stated by Practice Plus GroupStated in progress
Respondent positions 1
1. Position
  Responsibility for the concerns about HMPPS and HMP Pentonville rests with separate organisations, so no response is proposed.
  Stated by Practice Plus GroupRedirects responsibility
AI-generated summary

Rickie Wai Kee POON · 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

Rickie Poon, a dismissed police officer detained under the Mental Health Act and later remanded in custody at HMP Pentonville, was found hanging in his cell one month after arriving at the prison. The jury found failures in the prison’s ACCT process contributed to his death, including inadequate management, accountability, training, implementation of actions and the early closure of the ACCT; concerns were also raised about inappropriate CPR after he had died.

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
Less-than-fully-competent CPR attempts
Wider context from the report
“The nurse’s actions could not have had an impact on the outcome because Mr Poon was already dead when she arrived. However, conducting CPR on a person who had clearly died was not professional or appropriate, it did not afford Mr Poon dignity or privacy, it was neither acceptable nor kind. What concerns me particularly for the future is that there might be an occasion when a CPR attempt that is less than fully competent does have the potential to impact on the outcome. I sent PFD reports to PPG’s earlier incarnation, Care UK, and/or HMP Pentonville about the nature of attempts at resuscitation in respect of the following deceased: • William Davies (2014) • Adil Habib (2015) • Samuel Blair (2016) • Tedros Kahssay (2016) • Amir Faizi (2018) • Robert Ginn (2019) I recognise that I made the last of these reports over six years ago and I have heard descriptions of many changes since then, but I consider that I would be failing in my duty if I were not to flag up this issue now. I hope that by doing so, such a situation will be less likely to arise in the future. ”
Source location
Rickie Wai Kee POON · 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
Deliver annual RCUK-accredited ILS training including ROLE, audit compliance, and restrict emergency-radio assignment for staff whose training is out of date.

Verbatim wording from the response
“It is important to note that all clinical staff are trained to ILS (Immediate Life Support) standards. This is a RCUK accredited course for healthcare professionals to manage patients in cardiac arrest before the ambulance team arrives. It focuses on the ABCDE approach, airway management, and safe defibrillation. All staff are expected to complete this training which is done yearly to ensure ongoing competence. This is also subject to audit, which currently shows a 74% compliance rate. Anyone who does not have the training in date would not be assigned to an emergency radio and would be expected to book and complete the training as soon as possible. There is a session booked on the week commencing 25th June 2026 which will raise the compliance to over 90%.”

Source location
Response from Practice Plus Group
Page 3 · response
Published 10 April 2026
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
Deliver the booked ILS training session to increase current training compliance above 90%.

Verbatim wording from the response
“It is important to note that all clinical staff are trained to ILS (Immediate Life Support) standards. This is a RCUK accredited course for healthcare professionals to manage patients in cardiac arrest before the ambulance team arrives. It focuses on the ABCDE approach, airway management, and safe defibrillation. All staff are expected to complete this training which is done yearly to ensure ongoing competence. This is also subject to audit, which currently shows a 74% compliance rate. Anyone who does not have the training in date would not be assigned to an emergency radio and would be expected to book and complete the training as soon as possible. There is a session booked on the week commencing 25th June 2026 which will raise the compliance to over 90%.”

Source location
Response from Practice Plus Group
Page 3 · response
Published 10 April 2026
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
Publish and implement the purple-alert guidance clarifying BLS, ILS, ROLE, and CPR expectations, and remind staff of its application.

Verbatim wording from the response
“A purple alert (which is a companywide safety notification) was published for all Heads of Healthcare to action, which clarified the organisational position on cardiopulmonary resuscitation following updated guidance by NHSE on 19 March 2026, which is being actioned in line with the deadline given in the alert. A copy of this alert is attached to this response for ease of reference. The purple alert highlights to all services within Practice Plus Group (PPG) that we fully support the national HMPPS/NHS England guidance that cardiopulmonary resuscitation (CPR) should begin immediately when an individual is unresponsive, not breathing and/or has no pulse, unless there are unmistakable signs of irreversible death. However, it recognises that PPG’s clinical training model differs from the national assumption that prison healthcare staff are trained only to Basic Life Support (BLS) level.”

Source location
Response from Practice Plus Group
Page 4 · response
Published 10 April 2026
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
Hold a June 2026 meeting with regional and nursing directors to review guidance, consider further scoping, and assess safe ILS/ROLE staffing levels.

Verbatim wording from the response
“In light of the Prevention of Future Deaths (PFD) report, the site has also requested a meeting with the Regional Director and the Director of Nursing, due to be held in June 2026. The purpose of this meeting is to:”

Source location
Response from Practice Plus Group
Page 4 · response
Published 10 April 2026
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 multidisciplinary, scenario-based resuscitation training for healthcare, prison, and prison-officer staff by July 2026.

Verbatim wording from the response
“As a service, we are committed to further strengthening our resuscitation response following the issues highlighted in the PFD. To support this, we are introducing multidisciplinary, scenario-based training by July 2026. This programme will involve healthcare staff, prison staff, and prison officers where appropriate, ensuring that learning is shared across the whole custodial environment and that all parties understand their roles during a medical”

Source location
Response from Practice Plus Group
Page 4 · response
Published 10 April 2026
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
Responsibility for the concerns about HMPPS and HMP Pentonville rests with separate organisations, so no response is proposed.

Verbatim wording from the response
“We do not propose to respond to the points raised above in respect of HMPPS and HMP Pentonville as these matters are for separate organisation.”

Source location
Response from Practice Plus Group
Page 3 · response
Published 10 April 2026
Open published response
20 Feb2026
Inner North London
Concerns raised1
1. Failure of first aid staff to provide complete resuscitation measures
This report raised 11 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
  Create and require staff to complete a separate online medical-emergency vehicle course covering emergency response, basic life support and related vehicle incidents, with an 80% pass threshold.
  Stated by Serco Group plcStated completed
AI-generated summary

Sean Perry WILLIAMS · 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

Sean Williams died in the back of a Serco van outside Thames Magistrates’ Court after suffering a fit during transport and then a cardiac arrest. Concerns included gaps in his custody healthcare assessment and treatment, inadequate Serco first-aid training and competence assessment, failure to provide timely first aid, unclear emergency procedures, and insufficient emphasis on preserving life.

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 first aid staff to provide complete resuscitation measures
Wider context from the report
“For the MPS The MPS had already recognised before inquest that, following Mr Williams’ detention, he was not seen by a custody nurse for 23 hours. However, there was another sub optimal element of his care that did not appear to have been identified. The custody nurse who reviewed Mr Williams on two separate occasions in the twelve hours immediately before he attended court, did not on the second occasion take any observations of Mr Williams’ vital signs before (or after) prescribing dihydrocodeine, and did not record any part of Mr Williams’ clinical picture. Despite having prescribed dihydrocodeine for drug withdrawal, when giving evidence in court the nurse was unable to describe the signs and symptoms of withdrawal. For Serco By 18.11 hours, the Serco van that was transporting Mr Williams had returned to the court car park entrance and the driver had got out of the cab and into the back of the van. At that point, neither the escort nor the driver opened the door to Mr Williams’ cell to administer first aid - at the very least to relieve his slumped, squashed position to try to deal with any potential airway obstruction. At 18.15 hours when he stopped showing any signs of life, they still did not open his door. They only opened his door at 18.23 hours, removing him from the cell at 18.24 hours, and administering chest compressions at 18.25 hours. The driver did not press the emergency button in the cab to alert the operations control centre of the situation. The Serco crew did call the London Ambulance Service from the van, but were unable to give the postcode of their location. I put it to the Serco driver that the focus of the two Serco crew members seemed to be on talking to the three other prisoners in their cells, on phone calls, in fact on anything except getting Mr Williams out of his cell to see if the crew could help him. The driver agreed. The Serco driver eventually administered chest compressions but could not face giving rescue breaths. He seemed to have forgotten that he had a face guard hanging from his belt. Despite evidence from Serco that they were satisfied with the first aid training that was given to the two officers, the jury found that: - the Serco first aid training was inadequate; - it did not include a video of a seizure; - it did not sufficiently emphasise the urgency of potentially life saving measures such as use of the recovery position; - the Serco assessment of the first aid knowledge and competence of its staff was inadequate; - Serco failed to provide clear guidance on the emergency button procedures; - Serco’s policy appeared to conflict with its training slides about whether staff should or are even permitted to drive a casualty direct to hospital; - Serco gave insufficient emphasis on urgency and the paramount importance of preserving life. ”
Source location
Sean Perry WILLIAMS · 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
Create and require staff to complete a separate online medical-emergency vehicle course covering emergency response, basic life support and related vehicle incidents, with an 80% pass threshold.

Verbatim wording from the response
“In addition, in order to remind staff of the required process and aid their retention of the information provided during the training, in March 2025 we created a new online course on Serco’s LMS. This is a mandatory course for all staff members and includes what to do in an emergency medical incident, basic life support, self-harm incidents, vehicle breakdown, fire and anything deemed a vehicle emergency. The content provides a refresher of the training covered in the ITC course, to reinforce learning and gives additional prominence by being a separate module and links together the concepts that staff have learned during their Highfield First Aid training.”

Source location
Response from Serco
Page 3 · response
Published 24 February 2026
Open published response
8 Feb2026
Essex
Concerns raised1
1. Incorrect operation of the defibrillator during initial analysis
This report raised 30 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
  Deliver annual face-to-face Immediate Life Support training to registered inpatient nurses and annual Basic Life Support training to non-registered CAMHS inpatient staff.
  Stated by Essex Partnership University NHS Foundation TrustStated completed
2. Action
  Facilitate life-support refresher sessions for CAMHS staff between mandatory training sessions.
  Stated by Essex Partnership University NHS Foundation TrustStated completed
3. Action
  Undertake medical-emergency simulations every three months in inpatient settings and record them using the approved report.
  Stated by Essex Partnership University NHS Foundation TrustStated completed
1. Action
  Introduce Resus Link Practitioners across inpatient wards to support simulations, equipment readiness, life-support training, audit and dissemination of updates.
  Stated by Essex Partnership University NHS Foundation TrustStated completed
AI-generated summary

Elise Kay Louise Sebastian · 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

Elise Kay Louise Sebastian tied a fatal ligature in her room on Longview Ward on 17 April 2021 and died two days later in hospital. The principal concerns included inadequate and falsified observations, insufficiently trained and staffed ward personnel, poor communication about ligaturing and self-harm, medication-recording errors, failures involving Oxevision, and other care and record-keeping deficiencies.

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
Incorrect operation of the defibrillator during initial analysis
Wider context from the report
“10. Whilst this did not directly cause Elise’s death, there were plenty of staff who responded quickly to the emergency when Elise was found unresponsive but there was a delay: a. bringing the grab bag to this emergency b. obtaining and attaching the defibrillator. c. In notifying the duty doctor who was not contacted for over 40 minutes. d. The expert witness was of the opinion once the defibrillator was attached, it was being switched on and off in the first few minutes. When looking at the machine analysis there appeared to be 3 analysis checks on the machine within the first few minutes when the machine is set to conduct analysis at set intervals which is inconsistent with this. ”
Source location
Elise Kay Louise Sebastian · Prevention of Future Deaths report
Page 5 · 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
Deliver annual face-to-face Immediate Life Support training to registered inpatient nurses and annual Basic Life Support training to non-registered CAMHS inpatient staff.

Verbatim wording from the response
“The Trust has made the decision to deliver the ‘gold standard’ Resuscitation Council UK Immediate Life Support (RCUK ILS) training to all registered nursing staff working within an inpatient setting. RCUK ILS training was rolled out from September 2022. The one day face to face training is accompanied by a RCUK ILS ‘hard copy’ training manual and is delivered on an annual basis.”

Source location
2026-0078 - Response from Essex University Partnership Trust
Page 12 · response
Published 13 February 2026
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
Facilitate life-support refresher sessions for CAMHS staff between mandatory training sessions.

Verbatim wording from the response
“The Head of Deteriorating Patient Pathways and Resuscitation Training Officer and The Head of Clinical Transformation have facilitated life support drop in refreshers sessions for EPUT staff working within a CAMHS setting. These sessions are an opportunity for staff to refresh their knowledge of BLS/ILS in small groups, in between their mandatory training sessions, including refreshers on topics such as chest compressions and airway management.”

Source location
2026-0078 - Response from Essex University Partnership Trust
Page 12 · response
Published 13 February 2026
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
Undertake medical-emergency simulations every three months in inpatient settings and record them using the approved report.

Verbatim wording from the response
“The Essex Partnership NHS Foundation Trust’s CPR procedure document (CLPG14A) states the Ward Manager, Matron or Service Manager/Clinical lead for each inpatient setting, will be responsible for ensuring that medical emergency simulations are undertaken every three months in the clinical environment. Each inpatient setting must record when a medical emergency simulation is facilitated, using the approved ‘Medical Emergency Simulation Practice Report’”

Source location
2026-0078 - Response from Essex University Partnership Trust
Page 12 · response
Published 13 February 2026
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 Resus Link Practitioners across inpatient wards to support simulations, equipment readiness, life-support training, audit and dissemination of updates.

Verbatim wording from the response
“The Trust has also introduced the role of Resus Link Practitioners (RLP) to all inpatient ward settings. These volunteers will play a key role in strengthening the response to medical emergency situations within the wards. The role is open to all nurses and HCAs/support workers and the RLP will act as a link between the Resuscitation and Deteriorating Patient Group and their ward, promoting best practice and raising awareness. The RLP will:”

Source location
2026-0078 - Response from Essex University Partnership Trust
Page 13 · response
Published 13 February 2026
Open published response
25 Nov2025
Nottinghamshire
Concerns raised1
1. Lack of evidence of improvement in Emergency Assessment Unit staff ability to respond effectively to cardiac arrest
This report raised 2 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 9
1. Action
  Deliver and continue in-situ cardiac-arrest simulation sessions for Emergency Assessment Unit nursing and medical staff.
  Stated by Sherwood Forest Hospitals NHS Foundation TrustStated in progress
2. Action
  Implement the revised Advanced Life Support course format, including AED demonstrations and practical skills assessment.
  Stated by Sherwood Forest Hospitals NHS Foundation TrustStated planned
3. Action
  Provide prompt Advanced Life Support training for newly appointed Band 6 nurses.
  Stated by Sherwood Forest Hospitals NHS Foundation TrustStated completed
1. Action
  Monitor Advanced Life Support compliance through monthly service-line performance meetings and escalate issues as required.
  Stated by Sherwood Forest Hospitals NHS Foundation TrustStated planned
2. Action
  Book new Emergency Assessment Unit staff onto the next available Immediate Life Support course.
  Stated by Sherwood Forest Hospitals NHS Foundation TrustStated planned
3. Action
  Procure additional AEDs for practical mandatory resuscitation training.
  Stated by Sherwood Forest Hospitals NHS Foundation TrustStated planned
4. Action
  Introduce practical AED training into mandatory resuscitation sessions for nursing, midwifery, allied health professional and medical staff.
  Stated by Sherwood Forest Hospitals NHS Foundation TrustStated planned
5. Action
  Include resuscitation-service teaching on equipment and defibrillator operation in doctor induction programmes.
  Stated by Sherwood Forest Hospitals NHS Foundation TrustStated completed
6. Action
  Review reported cardiac arrests trust-wide through the resuscitation team and provide feedback to relevant area leads.
  Stated by Sherwood Forest Hospitals NHS Foundation TrustStated completed
Respondent positions 1
1. Position
  Three planned Emergency Assessment Unit simulation sessions were cancelled because staffing and operational constraints prevented their delivery.
  Stated by Sherwood Forest Hospitals NHS Foundation TrustUnable to act
AI-generated summary

Connor Nelson · 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

Connor Nelson died at Kings Mill Hospital on 30 November 2024 from hypoxic ischaemic encephalopathy following a prolonged cardiac arrest on 10 November 2024. The report describes an undiagnosed congenital prolonged QT syndrome, a nine-minute delay in administering a necessary shock, and concerns about cardiac-arrest response and processes for identifying and investigating prolonged QTc syndrome.

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 evidence of improvement in Emergency Assessment Unit staff ability to respond effectively to cardiac arrest
Wider context from the report
“1. The lack of evidence of any improvement in the ability of Emergency Assessment Unit staff to respond effectively to a cardiac arrest ”
Source location
Connor Nelson · 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
Deliver and continue in-situ cardiac-arrest simulation sessions for Emergency Assessment Unit nursing and medical staff.

Verbatim wording from the response
“In situ skills and drills simulation sessions: During December 2025, a total of nine simulation sessions were scheduled to be undertaken on EAU with both nursing and medical staff, with additional sessions continuing into subsequent months. These sessions were being led by the resus team and were set to include the following key topics:”

Source location
Response from Sherwood Forest Hospitals NHS Foundation Trust
Page 1 · response
Published 3 December 2025
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 the revised Advanced Life Support course format, including AED demonstrations and practical skills assessment.

Verbatim wording from the response
“Advanced Life Support Training: Since the inquest was held the Resuscitation Council UK (RCUK) has introduced a revision to training protocols, now permitting the use of an Automated External Defibrillator (AED) during cardiac arrest demonstrations, as well as the discussion of AED usage within the CPR and defibrillation skill station as part of the Advanced Life Support (ALS) course. This updated course format became effective as of 1st January 2026 nationally, and its implementation will commence with the ALS courses, consisting of 1-day online learning plus 1 day of hands-on training with a comprehensive skill station assessment, scheduled for 21st and 22nd January at Sherwood Forest Hospitals (SFH).”

Source location
Response from Sherwood Forest Hospitals NHS Foundation Trust
Page 2 · response
Published 3 December 2025
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 prompt Advanced Life Support training for newly appointed Band 6 nurses.

Verbatim wording from the response
“It is recognised, that the rotation of new staff within EAU has the potential to affect training compliance rates, particularly for training such as ALS. To address this, a comprehensive plan has been implemented to ensure that all new Band 6 staff promptly receive the necessary training upon appointment. Furthermore, measures are being explored to provide existing Band 5 registered nurses looking for development opportunity therefore supporting both ongoing professional development and the maintenance of a highly skilled workforce.”

Source location
Response from Sherwood Forest Hospitals NHS Foundation Trust
Page 2 · response
Published 3 December 2025
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
Monitor Advanced Life Support compliance through monthly service-line performance meetings and escalate issues as required.

Verbatim wording from the response
“ALS training compliance will now be included in the service line performance meetings monthly commencing February 2026 to enable consistent monitoring and escalation as required.”

Source location
Response from Sherwood Forest Hospitals NHS Foundation Trust
Page 2 · response
Published 3 December 2025
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
Book new Emergency Assessment Unit staff onto the next available Immediate Life Support course.

Verbatim wording from the response
“Immediate Life Support Training: As of 23rd January 2026 91% of registered nurses working on EAU had undergone Immediate Life Support Training and the remaining 9% of staff are booked onto courses.”

Source location
Response from Sherwood Forest Hospitals NHS Foundation Trust
Page 3 · response
Published 3 December 2025
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
Procure additional AEDs for practical mandatory resuscitation training.

Verbatim wording from the response
“Mandatory resuscitation training: In addition, further measures have been implemented to enhance resuscitation training across all staff at SFH. Additional AEDs have been procured to facilitate the inclusion of AEDs as a practical, hands-on component within mandatory resuscitation training sessions. The introduction of this practical element will commence in April 2026, following the conclusion of the winter pause in mandatory training. This initiative will be delivered in conjunction with the E-Learning for Healthcare (E-LfH) content, which will be utilised by nursing, midwifery, and allied health professional (N.M&AHP) staff to fulfil Resuscitation Level 1 and 2 theoretical requirements, in alignment with the broader NHS training transferability plan. Simultaneously, mandatory sessions for medical staff will also be adapted to incorporate practical AED training from April 2026 onwards.”

Source location
Response from Sherwood Forest Hospitals NHS Foundation Trust
Page 3 · response
Published 3 December 2025
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 practical AED training into mandatory resuscitation sessions for nursing, midwifery, allied health professional and medical staff.

Verbatim wording from the response
“Mandatory resuscitation training: In addition, further measures have been implemented to enhance resuscitation training across all staff at SFH. Additional AEDs have been procured to facilitate the inclusion of AEDs as a practical, hands-on component within mandatory resuscitation training sessions. The introduction of this practical element will commence in April 2026, following the conclusion of the winter pause in mandatory training. This initiative will be delivered in conjunction with the E-Learning for Healthcare (E-LfH) content, which will be utilised by nursing, midwifery, and allied health professional (N.M&AHP) staff to fulfil Resuscitation Level 1 and 2 theoretical requirements, in alignment with the broader NHS training transferability plan. Simultaneously, mandatory sessions for medical staff will also be adapted to incorporate practical AED training from April 2026 onwards.”

Source location
Response from Sherwood Forest Hospitals NHS Foundation Trust
Page 3 · response
Published 3 December 2025
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
Include resuscitation-service teaching on equipment and defibrillator operation in doctor induction programmes.

Verbatim wording from the response
“Changes to Doctor induction: Effective from 3rd December 2025, the doctor induction programme now incorporates a dedicated session delivered by the trust resuscitation service. This session provides an overview of the adult resuscitation trolley and its contents, as well as instruction on the two defibrillator models used at SFHFT and their operational functions. The session is made available to Foundation Year 2 (FY2) doctors and higher at each entry point throughout the training year. Foundation Year 1 (FY1) doctors receive a separate induction covering the same material in July.”

Source location
Response from Sherwood Forest Hospitals NHS Foundation Trust
Page 3 · response
Published 3 December 2025
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 reported cardiac arrests trust-wide through the resuscitation team and provide feedback to relevant area leads.

Verbatim wording from the response
“Review of cardiac arrests on EAU in December 2025: To provide further assurance regarding improvements in the management of a cardiac arrest, all cardiac arrests on EAU during the period from 1st December to 30th December 2025 were reviewed by the trust resus team. It was confirmed that EAU initiated three 2222 calls (emergency calls), of these, one was categorised as a medical emergency for which cardiopulmonary resuscitation (CPR) was not required. The remaining two incidents were audited in accordance with the cardiac arrest governance process. One case raised no concerns, while the other identified issues related to Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) documentation—specifically, that although the DNACPR decision appeared to have”

Source location
Response from Sherwood Forest Hospitals NHS Foundation Trust
Page 3 · response
Published 3 December 2025
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
Three planned Emergency Assessment Unit simulation sessions were cancelled because staffing and operational constraints prevented their delivery.

Verbatim wording from the response
“Of the planned sessions, six were successfully delivered, attended by 18 staff members, resulting in an average attendance of three participants per session. Three sessions were cancelled due to staffing and operational constraints. Furthermore, nine additional sessions are scheduled for January 2026. It should be noted that, owing to the small group sizes and the restricted nature of the space utilised for "in situ" training, these sessions are not directly comparable to previous simulation events. Within the limitations of the skills practised, staff performance was assessed by the trust resuscitation team to be of a satisfactory standard.”

Source location
Response from Sherwood Forest Hospitals NHS Foundation Trust
Page 2 · response
Published 3 December 2025
Open published response
19 Sep2025
South London
Concerns raised1
1. Delays in accessing advanced life support resuscitation for detained patients
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.
AI-generated summary

Mr Luke John Chatterton · 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

Mr Luke John Chatterton had a history of Clozapine-related constipation and developed vomiting, severe pain and suspected intestinal obstruction. He was discharged from the emergency department after an X-ray, later deteriorated and suffered a cardiac arrest, with delays in advanced life support before he died. The principal concerns were the safety and timeliness of resuscitation for detained mental health patients and the identification and escalation of risks associated with suspected obstruction in patients taking Clozapine.

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
Delays in accessing advanced life support resuscitation for detained patients
Wider context from the report
“1. The delays in accessing advanced life support (ALS) resuscitation in the MH hospital were worse than expected in the community. London Ambulance Service target for Category 1 calls is 7 minutes and yet it took 37 minutes before the paramedics arrived. Despite concerns that resuscitation skills were better to maintain in a MH Trust, Adrenaline and IV lines were part of the system at the time. Initially no IV line could be found, then none could be inserted. 25 minutes of asystole elapsed before Adrenaline was administered. Evidence was heard that MH Trusts cannot safely provide advanced life support resuscitation unless they are co-located with an acute hospital site. The National Quality Standards in mental health in patient care requires calling 999 immediately and strongly recommends provision of IV-line insertion and drug administration and a team leader with ALS skills, but the Resuscitation Council has apparently approved the Trust policy. Thus, the safety of a patient detained by the State, who has a cardio-respiratory arrest, would seem to vary according to post code, some not being close to acute hospital standards, and might even be worse than in the community. Given that those who suffer psychosis have increased risks of premature death, including suicide and cardiovascular deaths, in part related to treatment, the State would seem to have a responsibility to mitigate these risks, when compulsorily detaining them. It raises the question as to whether patients with high risk should have the right to choose a site where there is co-location of acute services and whether units with high concentration of detained psychotics should and can be safely equipped to provide Advanced Life Support. ”
Source location
Mr Luke John Chatterton · Prevention of Future Deaths report
Page 2 · concerns
Open source report
26 Aug2025
Inner North London
Concerns raised1
1. Failure to initiate CPR or retrieve a store defibrillator during cardiac arrest
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

Gabriella Omolabake Torisheju JAYIESIMI · 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

Gabriella Omolabake Torisheju Jayiesimi suffered seizures and a cardiac arrest at a Tesco supermarket on 24 January 2025 and died a month later from the hypoxic brain injury sustained during the arrest. The concerns included the absence of effective first aid and CPR, failure to recognise that she had stopped breathing, failure to check her pulse or use a defibrillator, and inadequate first-aid training and preparedness among relevant Tesco and security staff.

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 initiate CPR or retrieve a store defibrillator during cardiac arrest
Wider context from the report
“When Ms Jaiyesimi was on the floor having suffered several fits, no person put her in the recovery position. They were apparently unaware that her present position could be causing an airway obstruction preventing her breathing. Then when Ms Jaiyesimi stopped breathing, nobody recognised this, though they were looking at her and made one inadequate attempt to feel for breathing (by placing a single finger somewhere near her nose). No person ever attempted to check Ms Jaiyesimi’s pulse to see if her heart was still beating. Even if they had identified her cardiac arrest, there was nobody present who would have started CPR. Nobody thought of fetching one of the store defibrillators. Lack of CPR notwithstanding, the failure to understand the situation properly meant that nobody relayed the crucial information of the arrest to the ambulance service. ”
Source location
Gabriella Omolabake Torisheju JAYIESIMI · Prevention of Future Deaths report
Page 2 · concerns
Open source report
21 Jul2025
East London
Concerns raised2
1. Failure to commence CPR promptly when indicated despite a DNACPR order
2. Failure to commence chest compressions promptly after breathing stops
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 4
1. Action
  Deliver lessons-learned, anti-choking, first-aid and competency training to permanent, agency, care and non-care staff, including refresher training.
  Stated by Aspray HouseStated completed
2. Action
  Review the Swallowing Difficulties and Basic Life Support, Resuscitation and DNARCPR policies for compliance with relevant guidance.
  Stated by Aspray HouseStated completed
3. Action
  Display a colour-coded choking flow chart in nursing stations and pictorial choking first-aid posters in dining areas.
  Stated by Aspray HouseStated completed
1. Action
  Add dementia-related choking-risk and CPR warnings to the Care Notes of every resident with a dementia diagnosis.
  Stated by Aspray HouseStated completed
AI-generated summary

Madeline Reding · 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

Madeline Reding, a 79-year-old nursing-home resident with advanced vascular dementia, became unwell after lunch on 17 May 2024, regurgitated food, developed an upper-airway obstruction and respiratory arrest, and died that afternoon. The inquest identified delayed and disorganised staff responses, including a failure to sound the emergency alarm or make an immediate 999 call, delayed CPR, and ineffective 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 commence CPR promptly when indicated despite a DNACPR order
Wider context from the report
“4. Despite specific instructions to commence CPR being given on three separate occasions by a London Ambulance Service call dispatch handler, resuscitation was not commenced by a registered nurse as she did not appreciate that a “Do not attempt cardio-pulmonary resuscitation order” would not apply to the patient in the event that the cardiac arrest was due to a reversible cause, such as choking. ”
Source location
Madeline Reding · 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 commence chest compressions promptly after breathing stops
Wider context from the report
“5. First aid that was administered was ineffective. a. Back slaps were weak b. Abdominal thrusts were not attempted c. Chest compressions were only commenced over ten minutes after Mrs Reding was found to have stopped breathing. ”
Source location
Madeline Reding · 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
Deliver lessons-learned, anti-choking, first-aid and competency training to permanent, agency, care and non-care staff, including refresher training.

Verbatim wording from the response
“Immediately following the incident, an urgent flash Lessons Learnt training session was held with all nursing staff (including the management nurses present at the incident) on 23 May 2025 to reinforce the existing Swallowing Difficulties policy and Basic Life support, Resuscitation and DNARCPR policies and the procedures to be followed in the event of a choking incident. Both policies were subsequently reviewed on 31 July 2024 and noted to be compliant with Resuscitation Council, Royal College of Nursing and CQC guidance.”

Source location
2025-0368 Response from Aspray House Nursing Home
Page 2 · response
Published 23 July 2025
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 the Swallowing Difficulties and Basic Life Support, Resuscitation and DNARCPR policies for compliance with relevant guidance.

Verbatim wording from the response
“Immediately following the incident, an urgent flash Lessons Learnt training session was held with all nursing staff (including the management nurses present at the incident) on 23 May 2025 to reinforce the existing Swallowing Difficulties policy and Basic Life support, Resuscitation and DNARCPR policies and the procedures to be followed in the event of a choking incident. Both policies were subsequently reviewed on 31 July 2024 and noted to be compliant with Resuscitation Council, Royal College of Nursing and CQC guidance.”

Source location
2025-0368 Response from Aspray House Nursing Home
Page 2 · response
Published 23 July 2025
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
Display a colour-coded choking flow chart in nursing stations and pictorial choking first-aid posters in dining areas.

Verbatim wording from the response
“Senior management designed a simple to follow colour coded Choking Flow Chart in October 2024 which is compliant with current guidance and which has been placed on display in all nursing stations throughout Aspray House reinforcing the policy, procedure and expectations of how all staff should deal with choking situations – including highlighting that CPR must be attempted if suitable even on residents with a DNAR in place. This has been supplemented with a pictorial Choking First Aid poster for universal understanding which has been displayed in all dining areas.”

Source location
2025-0368 Response from Aspray House Nursing Home
Page 2 · response
Published 23 July 2025
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
Add dementia-related choking-risk and CPR warnings to the Care Notes of every resident with a dementia diagnosis.

Verbatim wording from the response
“Aspray House noted the Coroner’s concerns at the Inquest that even where a choking risk assessment had been carried out and a resident not identified as having a choking risk, that a diagnosis of dementia could cause a risk of choking. Immediately after the inquest concluded, Aspray House implemented warnings being added to the Care Plans for every resident with a dementia diagnosis the following day. This new warning is displayed on the first page of a patient’s Care Notes on the hand-held PCS devices used by all staff and highlights a risk of choking (regardless of the score achieved against a standard choking risk assessment) due to dementia and that choking is a potentially reversible situation and that CPR should be commenced if suitable.”

Source location
2025-0368 Response from Aspray House Nursing Home
Page 3 · response
Published 23 July 2025
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised3

Delays in contacting 999 and the on-call doctor during cardiac arrests

Inability of staff to perform CPR properly

Failure to coordinate cardiac-arrest responses

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.1

Concerns raised1

Failure of advanced life support training to cover the need for a solid surface during CPR

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 raised1

Inability of attending paramedics to comply with opioid-related respiratory-arrest and cardiac-arrest guidelines amid competing tasks

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3

Concerns raised1

Less-than-fully-competent CPR attempts

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.5

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

Actions described in response 4

Respondent positions 1

Actions described in response 1

Respondent positions 1

Actions described in response 7

Respondent positions 3

Actions described in response 5

Respondent positions 1