Recurring concern

Unreliable resuscitation preparedness and response during cardiac arrest

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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

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.

  1. Surrey

    AI-generated summary

    Henry Edward Hullin Doll · 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

    Henry Edward Hullin Doll, who had a learning disability, Down’s Syndrome and dementia and was at high risk of aspiration and choking, entered the kitchen of his residential care home alone on 21 February 2021, obtained a shortbread biscuit, choked and aspirated on it, and died the following day from aspiration pneumonia. The court found that the risks of him obtaining unsuitable food and eating it unsupervised had not been identified or appropriately prevented. Concerns also related to the way risk assessments were completed and the effectiveness of staff CPR training.

    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

    Insufficient staff capability to provide effective CPR

    Wider context from the report

    “2. The court found that the CPR provided by staff to Mr Doll on 21 February 2021 prior to the arrival of the paramedics was ineffective, albeit this did not contribute to his death. The Avenues Groups is invited to consider whether staff have received sufficient practical training so as to ensure that they are confident and capable of carrying out effective CPR. ”

    Source location

    Henry Edward Hullin Doll · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

  2. Milton Keynes

    AI-generated summary

    Glenda May Logsdail · 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

    Glenda May Logsdail was admitted with acute appendicitis and underwent emergency surgery. During induction of anaesthesia, an endotracheal tube was misplaced in the oesophagus and this was not recognised for a prolonged period, resulting in hypoxia, cardiac arrest, irreversible brain damage and her death. Concerns included failures to confirm tube placement, fixation on an incorrect diagnosis, inadequate team leadership and communication during the emergency, and inconsistent ventilator display configurations.

    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 awareness of the capnography safety campaign among anaesthesia staff

    Wider context from the report

    “(1) I was concerned to find that the anaesthetising Consultant Anaesthetist was not aware of the Royal College of Anaesthetists campaign video “Capnography in Cardiac Arrest: No Trace = Wrong Place”. (2) I became even more concerned when towards the end of the Inquest when I was hearing evidence on the Incident Investigation Report the author, told me he had not been aware of the campaign himself until this incident. ”

    Source location

    Glenda May Logsdail · 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

    Disseminate key lessons through Royal College, Association and Difficult Airway Society journals, newsletters and social media.

    Verbatim wording from the response

    “It is disappointing that both the anaesthetist involved in the case and the author of the incident investigation report were not aware of the “Capnography in Cardiac Arrest: No Trace = Wrong Place” video. This was published in 2018 and was widely promoted through the RCoA’s, the Association’s and DAS’s communication channels. We recognise that much of this promotional activity was concentrated in a relatively short period of time. We plan for the following coordinated actions to take place over the next year. We will:”

    Source location

    2021-0295-Response-from-Royal-College-of-Anaesthetists_Published
    Page 2 · response
    Published 9 September 2021

    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

    Present key lessons at specified anaesthesia, airway and perioperative educational conferences and meetings.

    Verbatim wording from the response

    “It is disappointing that both the anaesthetist involved in the case and the author of the incident investigation report were not aware of the “Capnography in Cardiac Arrest: No Trace = Wrong Place” video. This was published in 2018 and was widely promoted through the RCoA’s, the Association’s and DAS’s communication channels. We recognise that much of this promotional activity was concentrated in a relatively short period of time. We plan for the following coordinated actions to take place over the next year. We will:”

    Source location

    2021-0295-Response-from-Royal-College-of-Anaesthetists_Published
    Page 2 · response
    Published 9 September 2021

    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

    Work with operating department and perioperative stakeholders to ensure key messages reach the whole theatre team.

    Verbatim wording from the response

    “It is disappointing that both the anaesthetist involved in the case and the author of the incident investigation report were not aware of the “Capnography in Cardiac Arrest: No Trace = Wrong Place” video. This was published in 2018 and was widely promoted through the RCoA’s, the Association’s and DAS’s communication channels. We recognise that much of this promotional activity was concentrated in a relatively short period of time. We plan for the following coordinated actions to take place over the next year. We will:”

    Source location

    2021-0295-Response-from-Royal-College-of-Anaesthetists_Published
    Page 2 · response
    Published 9 September 2021

    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

    Work with other Royal Colleges to share key messages with all medical professionals undertaking intubation.

    Verbatim wording from the response

    “It is disappointing that both the anaesthetist involved in the case and the author of the incident investigation report were not aware of the “Capnography in Cardiac Arrest: No Trace = Wrong Place” video. This was published in 2018 and was widely promoted through the RCoA’s, the Association’s and DAS’s communication channels. We recognise that much of this promotional activity was concentrated in a relatively short period of time. We plan for the following coordinated actions to take place over the next year. We will:”

    Source location

    2021-0295-Response-from-Royal-College-of-Anaesthetists_Published
    Page 2 · response
    Published 9 September 2021

    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 promote the “Capnography in Cardiac Arrest: No Trace = Wrong Place” video through professional communication channels.

    Verbatim wording from the response

    “It is disappointing that both the anaesthetist involved in the case and the author of the incident investigation report were not aware of the “Capnography in Cardiac Arrest: No Trace = Wrong Place” video. This was published in 2018 and was widely promoted through the RCoA’s, the Association’s and DAS’s communication channels. We recognise that much of this promotional activity was concentrated in a relatively short period of time. We plan for the following coordinated actions to take place over the next year. We will:”

    Source location

    2021-0295-Response-from-Royal-College-of-Anaesthetists_Published
    Page 2 · response
    Published 9 September 2021

    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

    Continue disseminating key lessons on preventing unrecognised oesophageal intubation through webpages, talks, publications, online resources and social media.

    Verbatim wording from the response

    “We launched a coordinated campaign to disseminate the key learning points from Mrs Logsdail’s case to our specialty. This included the following actions:”

    Source location

    2021-0295 - Response from Royal College of Anaesthetists
    Page 1 · response
    Published 9 September 2021

    Open published response

  3. Norfolk

    AI-generated summary

    Peggy COPEMAN · 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

    Mrs Peggy Copeman became unresponsive and was declared dead at the scene while being transported by ambulance on the M11. Concerns included delayed recognition of her deterioration, delay in calling emergency services, ineffective CPR because of her position, and inadequate CPR training among the transporting 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 enable effective CPR in the patient transport vehicle

    Wider context from the report

    “1. PRAS Response Policy provides that staff escorting patients “are to be fully trained in Basic Life Support (BLS) and are deemed to be competent to apply the techniques when needed. Staff can notice any changes or deteriorating patients and act appropriately in line with BLS training. Starting with Primary assessments followed by secondary assessment then commencing CardioPulmonary Resuscitation (CPR) while waiting for ambulance to arrive ... “ 2. The evidence so far is that during transit, Peggy did not respond when being called or when moving her head and on being noted as being unresponsive, emergency services were not called immediately but calls were initially made to Cygnet and then PRAS. CPR was started on being told to do so by emergency services 3. On attendance by Paramedics it was noted that due to the position of the patient in the back of the van, CPR was ineffective 4. A report has been obtained from a Consultant Cardiologist and General Physician as an expert witness who is of the firm view that the staff transporting Mrs Copeman did not recognise she was in respiratory distress and/or cardiac arrest and that she had effectively died whilst sat between them 5. Only one member of staff out of three had training in CPR 6. An internal investigation (undated) carried out shortly after the incident did not raise concern about these matters 7. A statement provided by the Compliance Manager, PRAS, dated 7 May 2021 concludes that “the ambulance was adequately staffed to enable the journey to be safely carried out”, despite only one member of staff being trained in CPR contrary to PRAS’s own Conveyance Policy ”

    Source location

    Peggy COPEMAN · Prevention of Future Deaths report
    Page 1 · 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 promptly recognise and respond to respiratory distress or cardiac arrest during patient transport

    Wider context from the report

    “1. PRAS Response Policy provides that staff escorting patients “are to be fully trained in Basic Life Support (BLS) and are deemed to be competent to apply the techniques when needed. Staff can notice any changes or deteriorating patients and act appropriately in line with BLS training. Starting with Primary assessments followed by secondary assessment then commencing CardioPulmonary Resuscitation (CPR) while waiting for ambulance to arrive ... “ 2. The evidence so far is that during transit, Peggy did not respond when being called or when moving her head and on being noted as being unresponsive, emergency services were not called immediately but calls were initially made to Cygnet and then PRAS. CPR was started on being told to do so by emergency services 3. On attendance by Paramedics it was noted that due to the position of the patient in the back of the van, CPR was ineffective 4. A report has been obtained from a Consultant Cardiologist and General Physician as an expert witness who is of the firm view that the staff transporting Mrs Copeman did not recognise she was in respiratory distress and/or cardiac arrest and that she had effectively died whilst sat between them 5. Only one member of staff out of three had training in CPR 6. An internal investigation (undated) carried out shortly after the incident did not raise concern about these matters 7. A statement provided by the Compliance Manager, PRAS, dated 7 May 2021 concludes that “the ambulance was adequately staffed to enable the journey to be safely carried out”, despite only one member of staff being trained in CPR contrary to PRAS’s own Conveyance Policy ”

    Source location

    Peggy COPEMAN · Prevention of Future Deaths report
    Page 1 · 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

    Provide basic life-support and CPR training to all patient-conveying staff, including drivers, completing internal training as external certificates expire.

    Verbatim wording from the response

    “1. In response to the concerns raised by the Coroner, Premier Rescue Ambulance Services Ltd., have made a decision that ALL members of staff, including drivers, are to have training in relation to CPR. As a consequence of this decision, ████████ has attended the following courses:”

    Source location

    2021-0182-Response-from-Premier-Rescue-Ambulance-Service-Ltd_Published
    Page 1 · response
    Published 2 June 2021

    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 a transport policy refusing patients who are not awake and responsive, requiring medical fitness confirmation and medication details for transfer risk assessment.

    Verbatim wording from the response

    “7. Premier Rescue Ambulance Service Ltd., have now implemented a Policy that they are no longer prepared to accept for transport, patients who are not awake and responsive at the commencement of the journey. This is so they can actually assess any changes in their behaviour on the journey. They will also require a signed document from a qualified Medical Practitioner confirming a patient’s fitness to travel and also require a detailed list of medications patients are receiving so as to enable them to carry out a risk assessment as to whether it is appropriate for those patients to be transferred by Premier Rescue Ambulance Service Ltd. The detailed list of medications will be reviewed by ████████ and ████████. Those Policies have been implemented immediately.”

    Source location

    2021-0182-Response-from-Premier-Rescue-Ambulance-Service-Ltd_Published
    Page 3 · response
    Published 2 June 2021

    Open published response

  4. Inner North London

    AI-generated summary

    Moses Victor Boardman · 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

    Moses Victor Boardman, an elderly and frail man, was mistakenly discharged to his home instead of sheltered accommodation, where he was found without heating, light or food and subsequently readmitted to hospital after a further cerebrovascular accident. While assessed as being at risk of aspiration and requiring supervised feeding, he was later found eating a whole fruit unsupervised, suffered a choking incident, and died at 04.48. The substantive concerns included discharge and transport safeguards, failure to escalate missed care visits, monitoring of patients fed at risk, and the response to a potential reversible cause of collapse when a DNACPR order was in place.

    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 when a reversible cause for collapse overrides a DNAR order

    Wider context from the report

    “6. The RLH failure to commence CPR when a potential reversible cause for collapse existed that would override the effect of the DNAR order. ”

    Source location

    Moses Victor Boardman · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    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

    The Trust disputes that an immediate reversible cause existed to override the DNAR order, concluding that no airway obstruction was present.

    Verbatim wording from the response

    “It’s clear from staff statements that Mr Boardman had taken a bite out of the kiwi fruit before it was removed at 2000. At 0200 he is heard coughing and when the nurse attends she finds him unresponsive. Although he has a DNR order the cardiac arrest team is called. They arrive and find him unresponsive with agonal breathing. This type of breathing would not occur with any form of upper airway obstruction; it was also six hours after he had taken a bite of the kiwi fruit. This related to poor blood flow to the brain, fitting with the description of him having an impalpable pulse. In view of no immediate reversible cause, such as an airway obstruction the DNR order was followed and the gentleman passed away peacefully two hours later.”

    Source location

    2020-0160-Response-from-Barts-Health-NHS-Trust_Redacted.pdf
    Page 3 · response
    Published 22 October 2020

    Open published response

  5. Norfolk

    AI-generated summary

    Jake Edmund Lee · 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

    Jake Edmund Lee suffered a spinal cord infarction causing loss of feeling and immobility below the waist. After he collapsed at a rehabilitation unit, CPR was not commenced promptly, and the nurse in charge left him in the care of an untrained healthcare assistant while making another call. The principal concerns were the nurse’s lack of training and ability to respond to a collapse, her failure to remain with the patient, and her lack of knowledge about the bed and appropriate CPR and airway procedures.

    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 knowledge and failure to use a CPR-capable special bed correctly

    Wider context from the report

    “(1) Inability, lack of training/experience of nurse in charge to deal with an arrest/collapse of a patient. Clear panic in the face of an emergency. (2) Nurse leaving collapsed patient in care of untrained HCA whilst she made an unnecessary second phone call, she denied that there was a phone she could have used in his room. (3) Her lack of knowledge about the special bed which Mr Lee had, which allowed CPR on the bed and her stating that she put Mr Lee into the recovery position when he was semi recumbent, she did not flatten the bed and she did not do a mouth sweep to see if his airway was occluded by his tongue. ”

    Source location

    Jake Edmund Lee · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  6. Inner North London

    AI-generated summary

    Robert Thomas GINN · 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

    Robert Thomas Ginn hanged himself in his cell at HM Prison Pentonville and was discovered at around 1.05am on 29 November 2018. Concerns were raised about the quality of the nurse-led resuscitation attempt, including failure to check breathing, inadequate oxygenation, variable chest compressions, lack of coaching, and incorrectly applied defibrillator pads.

    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 coach non-clinical staff to improve chest compressions

    Wider context from the report

    “7. No attempt was made by either of the nurses to coach the prison officer to improve the quality of chest compressions. ”

    Source location

    Robert Thomas GINN · 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 of a nurse to administer chest compressions

    Wider context from the report

    “8. One of the nurses (Hotel 7) did not administer chest compressions at all. She did not give evidence at inquest and so the reason for this is unclear. ”

    Source location

    Robert Thomas GINN · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to maintain oxygenation throughout nurse-led resuscitation

    Wider context from the report

    “4. After the first two minutes of footage, the oxygen mask that had been in place was taken off and no further efforts were made to oxygenate Mr Ginn. 5. Given that Mr Ginn’s heart had stopped beating, he must have stopped breathing as well. A full, effective, nurse led resuscitation attempt should have included an attempt to oxygenate throughout. Hotel 12 said that she did not do this because Mr Ginn’s jaw was too stiff to insert an airway, but the LAS did so without any difficulty. And if he had been cold and stiff when they arrived, the LAS paramedics would not have commenced resuscitation. In any event, an oxygen mask can be applied even if there is stiffness (as it was here, but then it was removed two minutes into the resuscitation and nearly nine minutes before LAS took over). ”

    Source location

    Robert Thomas GINN · 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 provide consistently effective chest compressions

    Wider context from the report

    “6. Chest compressions given by different members of staff were variable and some, including those of one of the nurses, were sub optimal. At one point, chest compressions were given by a staff member sandwiched between Mr Ginn and the wall, where there was not enough space to be effective. ”

    Source location

    Robert Thomas GINN · 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

    Require annual Immediate Life Support training for employed resuscitation staff and monitor compliance through monthly dashboards and the Resuscitation Committee.

    Verbatim wording from the response

    “Our policy for the standards of training for employed staff within our Health in Justice service who respond to resuscitation is Immediate Life Support (ILS) training, provided by Resuscitation Council accredited trainers. Although the requirement from the Resuscitation Council is that attendee’s repeat this on a 3 yearly cycle, we mandate that all Care UK employed staff complete this annually. Assurance around the compliance of this training is monitored via monthly performance dashboards and reported to Care UK’s Resuscitation Committee.”

    Source location

    Response from Care UK
    Page 2 · response
    Published 13 December 2019

    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

    Contract for additional prison-scenario Immediate Life Support training sessions beyond annual recertification across Care UK sites.

    Verbatim wording from the response

    “Going forwards, we will contract with our ILS training provider to deliver additional training sessions, including some prison scenario based training. These will be in addition to the annual re-certification sessions. We anticipate that this will be rolled out across our sites nationally over 2020. In addition our intention is to film some of these scenario-based training exercises for use at in-house training events and induction.”

    Source location

    Response from Care UK
    Page 2 · response
    Published 13 December 2019

    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

    Film selected scenario-based resuscitation exercises for use in in-house training and induction.

    Verbatim wording from the response

    “Going forwards, we will contract with our ILS training provider to deliver additional training sessions, including some prison scenario based training. These will be in addition to the annual re-certification sessions. We anticipate that this will be rolled out across our sites nationally over 2020. In addition our intention is to film some of these scenario-based training exercises for use at in-house training events and induction.”

    Source location

    Response from Care UK
    Page 2 · response
    Published 13 December 2019

    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

    Request CCTV or body-worn-camera footage after on-site custody deaths involving resuscitation and review it through immediate and internal learning reviews.

    Verbatim wording from the response

    “Following a death in custody where resuscitation has taken place on site, a request is made to the prison for the opportunity to view or receive a copy of any CCTV or body worn camera footage so that this can be reviewed as part of Care UK’s 72hr immediate review process and Internal Learning Review. This is to enable us to identify issues or concerns and to assist in improving clinical care and identifying training needs.”

    Source location

    Response from Care UK
    Page 2 · response
    Published 13 December 2019

    Open published response

  7. Inner North London

    AI-generated summary

    César Cuauhtémoc González Barrón · 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

    César Cuauhtémoc González Barrón died while performing as a Mexican wrestler at a Lucha Libre event. After he lost consciousness and suffered cardiac arrest, there were delays in recognising the emergency, summoning assistance, starting CPR and providing effective resuscitation. The report also identified inadequate event briefing, unclear emergency roles and procedures, communication difficulties, delayed ambulance access, and a confused handover to ambulance 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 when cardiac arrest is identified

    Wider context from the report

    “5. When the first aider arrived at Mr González Barrón's side, she cut off his face mask. Though she was told immediately by someone she thought to be a doctor that Mr González Barrón was not breathing and had no pulse, she did not start cardiopulmonary resuscitation (CPR). She did hand over her pocket mask and oropharyngeal airways, and she did go to retrieve emergency equipment from the first aid room 15-20 seconds away, but she could not remember in court if she fetched the defibrillator on her first or second return to the first aid room. ”

    Source location

    César Cuauhtémoc González Barrón · 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

    Ineffective delivery of chest compressions

    Wider context from the report

    “7. The chest compressions in progress when the London Ambulance Service (LAS) arrived were ineffective. ”

    Source location

    César Cuauhtémoc González Barrón · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  8. West Sussex

    AI-generated summary

    Duncan Tomlin · 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

    Duncan Tomlin died on 29 July 2014 after cardiac arrest following the use of drugs and police prone restraint, including handcuffs, leg restraints and incapacitant spray. The report identified concerns about insufficient emphasis on the heightened breathing risks of multiple factors, delayed opportunities to assess and reposition him, inadequate guidance on monitoring, the timing of CPR, and understanding atypical or post-seizure behaviour.

    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

    Inconsistent understanding of when to commence CPR for abnormal or distressed breathing

    Wider context from the report

    “Commencing CPR 4. The evidence relating to current training and training at the time of the death concerned in this inquest indicates that CPR should commence when a person is not breathing normally (described as in 2-3 breaths in 10 seconds for an adult and 3-5 in 10 seconds for small children) or if breathing is distressed (snoring, rasping) known as agonal breathing. The evidence in the inquest was that individual officers of some experience understood CPR should commence when breathing had stopped. Whilst that may be a misunderstanding on the part of individual officers, owing to the importance of commencing CPR at the earliest opportunity when time is critically of the essence, the timing of when CPR should start should be a central point of when training CPR and when reacting to situations akin to that seen in this inquest. ”

    Source location

    Duncan Tomlin · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

    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

    Changes to nationally agreed police training packages require approval through national policing bodies rather than unilateral force action.

    Verbatim wording from the response

    “We are currently delivering nationally agreed training packages and any alteration to these should be agreed nationally with approval of all parties. The benefit in delivering training packages (for all mandatory training, not just Personal Safety Training) is they are consistent across the UK, all police officers are trained in the most current, relevant and up to date thinking which is designed using the latest research and learning from all Forces. We are aware this is currently being reviewed by NPCC and any alterations passed onto Forces in order for them to include in their training. It would be expected these alterations would be completed by the end of 2020.”

    Source location

    2019-0135-Response-by-Sussex-Police
    Page 2 · response
    Published 14 June 2019

    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

    Basic first-aid training provides officers with knowledge and skills suitable for their policing role.

    Verbatim wording from the response

    “Police officers are not trained to the level of medical practitioners. All police officers have basic first aid training (First Aid – Module 2 of the College of Policing curriculum which includes conducting CPR and managing a casualty who is convulsing) which gives them the knowledge and skills suitable for their role. It is the expectation that they recognise signs and symptoms of a wide variety of medical conditions. It is unrealistic to expect officers to have the knowledge of medical professionals, as the risks posed to themselves and others in trying to take action in which they are not trained is too great. Officers will carry out a dynamic risk assessment of any risk posed by a violent individual – whether the violence is caused by a medical condition or otherwise – and make a decision based on that risk assessment at that time”

    Source location

    2019-0135-Response-by-Sussex-Police
    Page 3 · response
    Published 14 June 2019

    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

    Officers cannot reasonably be expected to possess medical professionals’ knowledge because attempting untrained interventions could pose excessive risks.

    Verbatim wording from the response

    “Police officers are not trained to the level of medical practitioners. All police officers have basic first aid training (First Aid – Module 2 of the College of Policing curriculum which includes conducting CPR and managing a casualty who is convulsing) which gives them the knowledge and skills suitable for their role. It is the expectation that they recognise signs and symptoms of a wide variety of medical conditions. It is unrealistic to expect officers to have the knowledge of medical professionals, as the risks posed to themselves and others in trying to take action in which they are not trained is too great. Officers will carry out a dynamic risk assessment of any risk posed by a violent individual – whether the violence is caused by a medical condition or otherwise – and make a decision based on that risk assessment at that time”

    Source location

    2019-0135-Response-by-Sussex-Police
    Page 3 · response
    Published 14 June 2019

    Open published response

  9. Cumbria

    AI-generated summary

    Sharon Rose Grierson · 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

    Sharon Rose Grierson, aged 44, underwent elective surgery to remove a benign vocal cord polyp and developed laryngospasm during extubation. Endotracheal tubes were twice placed in the oesophagus rather than the trachea, leading to oxygen deprivation, hypoxic brain injury and her death. Concerns included failure to appreciate capnography readings, lack of coordination and situational awareness, and limited experience of senior staff in crisis situations.

    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 understanding of capnography interpretation during CPR

    Wider context from the report

    “(1) There was a lack of appreciation of what the capnography was indicating and some lack of understanding of the trace one might expect to see during CPR. ”

    Source location

    Sharon Rose Grierson · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  10. Preston and West Lancashire

    AI-generated summary

    Christopher Talbot · 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

    Christopher Talbot, a prisoner at Preston Prison, was found with a plastic bag over his head after being identified as vulnerable and at risk of suicide. Resuscitation initially restored breathing and cardiac output, but he later died in hospital. Concerns included inadequate reception training, the absence of a breathing guard during resuscitation, insufficient sharing of information about similar deaths, and failures to request immediate assistance and maintain constant observation.

    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

    Unavailability of breathing guards for senior officers during resuscitation

    Wider context from the report

    “(2) A Senior Officer gave mouth to mouth resuscitation to Mr Talbot without the use of a guard. It is understood that although mandatory for more junior officers at HMP Preston, carrying a breathing guard at all times is discretionary for certain senior grades. Lack of such a guard might put an officer in personal danger when attempting to revive a prisoner or dissuade that officer from intervening, with potential adverse consequences for the prisoner. ”

    Source location

    Christopher Talbot · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026