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.
Lancashire and Blackburn with Darwen
Concerns raised1
Lack of available mouth protection for resuscitation
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
Reissue the First Aid Policy Framework with face-shield requirements for prison first-aid kits and related CPR guidance.
Stated by HM Prison and Probation ServiceStated plannedThe respondent said that this action was planned when they made their response on 13 June 2023.
Action
Provide resuscitation face shields in first-aid boxes across all HMP Preston residential units.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 13 June 2023.
Action
Monitor HMP Preston face shields and replenish them when required.
Stated by HM Prison and Probation ServiceStatus unclearThe respondent did not make the status of this action clear when they made their response on 13 June 2023.
Action
Issue staff guidance explaining face-shield locations and the importance of using them during CPR.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 13 June 2023.
Essex
Concerns raised1
Failure of trained staff to provide basic life support assistance
This report raised 15 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
Action
Deliver drop-in refresher life-support training for clinical and administrative staff, emphasizing immediate help-seeking and pinpoint-alarm use.
Stated by Essex Partnership University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 7 March 2023.
Action
Conduct a medical-emergency simulation with Derwent Centre staff and share incident learning for incorporation into current training.
Stated by Essex Partnership University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 7 March 2023.
Action
Share emergency-response learning through basic-life-support and grab-bag training, including prompt notification of the Site Coordinator and Doctor.
Stated by Essex Partnership University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 7 March 2023.
Action
Review the business case for creating an in-house faculty to deliver Immediate Life Support training and consider faculty development system-wide.
Stated by Essex Partnership University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 7 March 2023.
Inner South London
Concerns raised1
Failure of nurses to provide effective resuscitation
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
Publish service specifications requiring prison healthcare providers to develop emergency-response protocols and CPR training.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 31 January 2023.
West Sussex
Concerns raised2
Delays in recognition of surgical emphysema during cardiac arrest
Failure to consider and exclude tension pneumothorax during PEA 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.
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
Include tension pneumothorax and surgical emphysema management in regular anaesthetic trainee simulation sessions.
Stated by University Hospitals Sussex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 23 January 2023.
Action
Develop and deliver simulation demonstrations of national anaesthetic Regulation 28 notices through teaching and clinical governance meetings.
Stated by University Hospitals Sussex NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 23 January 2023.
Action
Review guidance on managing increased airway pressure in ventilated patients, including its relevance to surgical emphysema and tension pneumothorax.
Stated by University Hospitals Sussex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 23 January 2023.
Action
Provide multidisciplinary training for obstetric, anaesthetic and midwifery staff covering obstetric emergencies, maternal collapse and the 4H’s and 4T’s.
Stated by University Hospitals Sussex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 23 January 2023.
Action
Share learning that non-traumatic bilateral pneumothoraces can cause failure to ventilate and cardiac arrest through safety updates, education and events.
Stated by Association Of Anaesthetists (Great Britain & Ireland) and Royal College of AnaesthetistsStated plannedThe respondent said that this action was planned when they made their response on 23 January 2023.
Action
Share learning that bilateral pneumothoraces can cause cardiac arrest without trauma or thoracic surgery through safety updates, education and events.
Stated by Association Of Anaesthetists (Great Britain & Ireland) and Royal College of AnaesthetistsStated plannedThe respondent said that this action was planned when they made their response on 23 January 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
The Trust disputes that the team unreasonably delayed identifying tension pneumothorax or surgical emphysema during the cardiac arrest.
Stated by University Hospitals Sussex NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
The identified care, evidence-handling, Duty of Candour and investigation concerns fall outside HEE’s current role and statutory responsibilities.
Stated by NHS EnglandOutside remitThe respondent said that this matter was outside its role or authority.
Position
The existing ALS course adequately covers the resuscitation algorithm and cardiac arrest in pregnancy, so no course change is required.
Stated by NHS EnglandExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
West Yorkshire Eastern
Concerns raised3
Failure to consider defibrillator use during a cardiac emergency
Delays in providing CPR after cardiac arrest
Failure to provide annual refresher training in CPR and defibrillator use for night patrol staff
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.
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
Update the emergency-response training video and distribute it to training centres and prisons for staff training.
Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 19 December 2022.
Action
Resume local FAW and EFAW training, prioritising night-group staff and extending training to Custodial Managers and other officers.
Stated by HM Prison and Probation ServiceStated plannedThe respondent said that this action was planned when they made their response on 19 December 2022.
Action
Review first-aid policy and collaborate on updated guidance covering CPR commencement and signposting safer-custody guidance.
Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 19 December 2022.
East London
Concerns raised1
Failure of nursing cardiac-arrest response to follow resuscitation guidelines
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.8
Action
Conduct monthly physical-health simulation training across inpatient units and continue emergency simulations on Cazaubon Ward.
Stated by East London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 5 October 2022.
Action
Add a weekly ward-managers agenda item to plan East Ham Care Centre simulation exercises.
Stated by East London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 5 October 2022.
Action
Provide further Immediate Life Support training to the two staff members involved in the incident.
Stated by East London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 5 October 2022.
Action
Discuss resuscitation policy and emergency-management topics during Cazaubon Ward staff away days.
Stated by East London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 5 October 2022.
Action
Advise Cazaubon Ward staff to use the DNACPR forms red folder as the first emergency reference.
Stated by East London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 5 October 2022.
Action
Provide an electronic DNACPR alert in RiO as a secondary aid.
Stated by East London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 5 October 2022.
Action
Include CPR status formally in every Cazaubon Ward nursing-shift handover.
Stated by East London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 5 October 2022.
Action
Amend resuscitation policy to emphasise RiO recording, CPR communication and early defibrillator use.
Stated by East London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 5 October 2022.
South Yorkshire (Western)
Concerns raised1
Failure to provide clear CPR leadership and task structure
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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
Action
Provide monthly unannounced resuscitation drills, assess response times, record responders and retrain staff where issues are identified.
Stated by Cygnet Health Care LimitedStated completedThe respondent said that this action was complete when they made their response on 3 October 2022.
Action
Provide nurse drop-in sessions with the ILS lead, including practical refresher training on emergency equipment.
Stated by Cygnet Health Care LimitedStated completedThe respondent said that this action was complete when they made their response on 3 October 2022.
Action
Complete ILS train-the-trainer qualification for the resuscitation lead.
Stated by Cygnet Health Care LimitedStated plannedThe respondent said that this action was planned when they made their response on 3 October 2022.
Inner North London
Concerns raised3
Failure to attempt CPR when cardiac arrest occurs
Failure to deliver effective chest compressions during resuscitation
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.4
Action
Provide and competency-assess Basic Life Support and DNACPR training, including practical choking and CPR assessment.
Stated by BupaStated completedThe respondent said that this action was complete when they made their response on 12 May 2022.
Action
Retrain remaining Highgate staff and ensure they are competent and confident to manage future choking, cardiac arrest and CPR incidents.
Stated by BupaStated plannedThe respondent said that this action was planned when they made their response on 12 May 2022.
Action
Have the Internal Lead Inspector attend Basic Life Support training to assess its quality and efficacy.
Stated by BupaStated plannedThe respondent said that this action was planned when they made their response on 12 May 2022.
Action
Consider implementing more frequent competency checks or opportunities to practise chest compressions.
Stated by BupaStated plannedThe respondent said that this action was planned when they made their response on 12 May 2022.
Inner North London
Concerns raised1
Failure to perform chest compressions on the chest during resuscitation
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.
Birmingham and Solihull
Concerns raised1
Failure of officers to understand the need for rescue breaths during resuscitation
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The existing APP-AP provides appropriate operational guidance for armed-policing medical assistance and does not require amendment.
Stated by College of PolicingExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
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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.
