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
Distinct published reports
Individual concerns
79
A report can raise multiple concerns
Date range
2013–2026
First to latest report issue date
Stated actions
127
Described in published responses
Reports over time
Reports over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
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
NHS trust24
Ministerial department10
Prison or young offender institution8
Executive non-departmental public body6
Private limited company6
Executive agency5
Police force5
Healthcare site4
Multi-service care provider4
Type not available4
Health and social care service regulator3
Health professional body3
National policing body3
Independent healthcare provider2
Nursing home2
Concerns and responses across reports
Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.
West Yorkshire Eastern
Concerns raised1
Insufficient national guidelines for identifying and treating reversible causes of cardiac arrest in newborn babies
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Include reversible causes of non-response in newborn resuscitation guidance, algorithms, course teaching and manuals.
Stated by Resuscitation Council UKStated completedThe respondent said that this action was complete when they made their response on 11 June 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.5
Position
The 4 H’s and 4 T’s guidance is owned by RCUK, so changes to it are outside the respondent’s authority.
Stated by Royal College of Paediatrics and Child HealthOutside remitThe respondent said that this matter was outside its role or authority.
Position
BAPM and RCUK should determine whether changes to neonatal use of the 4 H’s and 4 T’s guidance are required.
Stated by Royal College of Paediatrics and Child HealthRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Existing resuscitation guidance and mandatory and supplementary training adequately cover identifying and treating reversible causes of neonatal cardiac arrest.
Stated by Sheffield Children’s Hospital NHS Foundation Trust and Yorkshire & Humber Neonatal Operational Delivery Network (Y&H Neonatal ODNExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
The NLS approach and algorithm adequately address potential causes of non-response during newborn resuscitation.
Stated by Resuscitation Council UKExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
The national neonatal resuscitation algorithms' four Hs and five Ts cover the overwhelming majority of reversible causes of cardiac arrest.
Stated by British Association of Perinatal MedicineDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Inner North London
Concerns raised1
Failure to undertake CPR during cardiac arrest from a potentially reversible cause
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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Continue providing nursing and care staff with up-to-date CPR and emergency-situation training.
Stated by Acorn Lodge Care CentreStated in progressThe respondent said that this action was in progress when they made their response on 17 April 2025.
Action
Purchase Lifevac devices and train relevant staff in their use, alongside providing choking-response sessions.
Stated by Acorn Lodge Care CentreStated completedThe respondent said that this action was complete when they made their response on 17 April 2025.
West Yorkshire Eastern
Concerns raised2
Failure to appreciate the importance of early CPR
Delays in commencing CPR during a medical emergency in a cell
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Expand life-support training with custody-suite simulations and joint scenarios to improve coordination between healthcare professionals and detention officers.
Stated by Leeds Community Healthcare NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 26 March 2025.
Action
Incorporate recommendations from reflective discussions with incident staff into CPR training.
Stated by Leeds Community Healthcare NHS TrustStated completedThe respondent said that this action was complete when they made their response on 26 March 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing training and emergency procedures appropriately require Detention Officers to provide Basic Life Support and follow Healthcare Professional direction.
Stated by West Yorkshire PoliceExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
East London
Concerns raised1
Lack of nursing staff knowledge of criteria for commencing CPR on an unresponsive patient
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.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Operate the Resuscitation Service to review cardiac and emergency calls, mandate incident reporting and support teaching and deteriorating-patient review.
Stated by Barking, Havering and Redbridge University Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 31 October 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
BHRUT is responsible for responding fully to the concerns, so the Department will not duplicate its response.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Cumbria
Concerns raised2
Failure to perform and respond appropriately to basic checks and signs of life during resuscitation
Unavailability of a defibrillator for attempted resuscitation in the care home
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.6
Action
Provide basic life-support training for all senior staff and registered nurses.
Stated by WESTMORLAND HEALTHCARE LIMITEDStated completedThe respondent said that this action was complete when they made their response on 9 August 2024.
Action
Conduct daily walk-round audits that test staff knowledge of ABCDE assessment and recognition of cardiac arrest.
Stated by WESTMORLAND HEALTHCARE LIMITEDStated completedThe respondent said that this action was complete when they made their response on 9 August 2024.
Action
Followed up the provider’s actions addressing the CPR incident, including staff refresher training and action concerning the involved nurse.
Stated by Care Quality CommissionStated completedThe respondent said that this action was complete when they made their response on 9 August 2024.
Action
Continue the fitness-to-practise investigation into the registered nurse and decide whether to progress or close the case for public-protection reasons.
Stated by Nursing and Midwifery CouncilStated in progressThe respondent said that this action was in progress when they made their response on 9 August 2024.
Action
Complete a risk assessment to determine whether urgent interim restrictions or suspension are required to protect the public.
Stated by Nursing and Midwifery CouncilStated completedThe respondent said that this action was complete when they made their response on 9 August 2024.
Action
Keep the decision not to impose an interim order under review pending new information.
Stated by Nursing and Midwifery CouncilStated in progressThe respondent said that this action was in progress when they made their response on 9 August 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
Position
An interim order restricting or suspending the nurse’s practice was not considered necessary for public protection or otherwise in the public interest.
Stated by Nursing and Midwifery CouncilNo action considered necessaryThe respondent said that no further action was needed.
Position
Requiring care homes to install defibrillators falls outside the regulator’s role and remit.
Stated by Care Quality CommissionOutside remitThe respondent said that this matter was outside its role or authority.
Position
Care providers are responsible for deciding how to deliver care safely and demonstrating compliance to the regulator.
Stated by Care Quality CommissionRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Without defibrillators, suitable resuscitation policies, procedures and trained staff are considered an appropriate alternative.
Stated by Care Quality CommissionExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Manchester North
Concerns raised1
Failure to provide training on recognising cardiac arrest
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Complete the FALP review and update learning outcomes to cover agonal gasps, cardiac arrest recognition and basic life support.
Stated by College of PolicingStated completedThe respondent said that this action was complete when they made their response on 28 June 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Individual forces are responsible for developing FALP learning materials, including video content, under local clinical governance procedures.
Stated by College of PolicingRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The reviewed FALP and new PPST are considered to provide policing with the necessary skills to preserve life and keep the public safe.
Stated by College of PolicingExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Essex
Concerns raised1
Delay in recording the first heart rhythm during resuscitation
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Concerns about care at Colchester General Hospital fall outside NHS England’s remit.
Stated by NHS EnglandOutside remitThe respondent said that this matter was outside its role or authority.
Position
East Suffolk & North Essex NHS Foundation Trust is responsible for responding to concerns about care at Colchester General Hospital.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Derby and Derbyshire
Concerns raised1
Inappropriate CPR guidance on rigor mortis exclusions in prisons without 24-hour healthcare staffing
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
Action
Revisit the guidance on recognising irreversible death and deciding when not to perform CPR.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 23 May 2024.
Action
Obtain advice from Resuscitation Council UK on diagnosing irreversible death from rigor mortis and starting CPR.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 23 May 2024.
Action
Review the guidance to address the risks concerning prison staff recognition of rigor mortis.
Stated by HM Prison and Probation ServiceStated plannedThe respondent said that this action was planned when they made their response on 23 May 2024.
Action
Issue a revised version of the guidance as soon as possible.
Stated by HM Prison and Probation ServiceStated plannedThe respondent said that this action was planned when they made their response on 23 May 2024.
Surrey
Concerns raised1
Failure to recognise cardiac arrest
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Provide sourced vital-signs training information to current clinical staff and new clinical starters.
Stated by Leonard Cheshire DisabilityStated plannedThe respondent said that this action was planned when they made their response on 6 September 2023.
Inner North London
Concerns raised1
Failure to recognise deterioration and commence CPR promptly
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
Action
Require all officers to complete digital training on recognising agonal breathing to support earlier CPR.
Stated by Metropolitan Police ServiceStated completedThe respondent said that this action was complete when they made their response on 10 July 2023.
Action
Standardise jaw-thrust airway management, retain casualties on their backs, limit recovery-position use to clearing fluids, and commence CPR when noisy breathing persists.
Stated by Metropolitan Police ServiceStated completedThe respondent said that this action was complete when they made their response on 10 July 2023.
Action
Deliver expanded Emergency Life Support Module 2 and refresher training, including additional practical scenario-based drills and techniques.
Stated by Metropolitan Police ServiceStated plannedThe respondent said that this action was planned when they made their response on 10 July 2023.
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Includes failures in the end-to-end cardiac-arrest resuscitation control: preparedness, trained response, equipment readiness or operation, recognition, and delivery of indicated CPR.
