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
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.

4 Sep2017
Manchester City
Concerns raised1
1. Inadequate training of airline staff to recognise cardiac arrest and administer first aid or prompt CPR
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 1
1. Action
  Provide initial and annual refresher first-aid and CPR training to cabin crew, including recognition of abnormal breathing as a cardiac-arrest sign.
  Stated by EmiratesStated completed
Respondent positions 1
1. Position
  Existing training, manuals and ongoing monitoring of resuscitation developments are considered sufficient; no additional cardiac-arrest training action is proposed.
  Stated by EmiratesExisting arrangements considered sufficient
AI-generated summary

Anthony William McCormack · 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

Anthony William McCormack became unwell and collapsed while an aircraft was taxiing at Manchester Airport, later suffering cardiac arrest and dying after resuscitation attempts at Wythenshawe Hospital. The report identified concerns about Emirates staff recognising cardiac arrest and agonal breathing, starting CPR promptly, and procedures when the Tempus system could not provide assistance. It also raised concerns about ambulance response targets and the availability of only one paramedic at Manchester Airport.

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
Inadequate training of airline staff to recognise cardiac arrest and administer first aid or prompt CPR
Wider context from the report
“• The adequacy of the training of Emirates staff in respect of the recognition of possible cardiac arrest and signs thereof including agonal breathing and the administration of appropriate first aid/prompt CPR ”
Source location
Anthony William McCormack · 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
Provide initial and annual refresher first-aid and CPR training to cabin crew, including recognition of abnormal breathing as a cardiac-arrest sign.

Verbatim wording from the response
“First Aid and CPR training is undertaken by all Emirates cabin crew both as part of their initial training and also on an annual basis as refresher training on medical procedures. The CPR training conducted by Emirates in each of these instances meets the rigorous standards set by leading international bodies, including the International Liaison Committee on Resuscitation (ILCOR), the American Heart Association (AHA) and the European Resuscitation Council. This training includes information on the recognition of abnormal breathing as a sign of cardiac arrest and this is reflected in the Emirates Operating Manuals and training materials covering this issue.”

Source location
2017-0241-Response-by-Emirates
Page 1 · response
Published 2 October 2017
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 training, manuals and ongoing monitoring of resuscitation developments are considered sufficient; no additional cardiac-arrest training action is proposed.

Verbatim wording from the response
“First Aid and CPR training is undertaken by all Emirates cabin crew both as part of their initial training and also on an annual basis as refresher training on medical procedures. The CPR training conducted by Emirates in each of these instances meets the rigorous standards set by leading international bodies, including the International Liaison Committee on Resuscitation (ILCOR), the American Heart Association (AHA) and the European Resuscitation Council. This training includes information on the recognition of abnormal breathing as a sign of cardiac arrest and this is reflected in the Emirates Operating Manuals and training materials covering this issue.”

Source location
2017-0241-Response-by-Emirates
Page 1 · response
Published 2 October 2017
Open published response
31 Jan2017
Nottinghamshire
Concerns raised1
1. Failure to use effective chest-compression technique
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.
Respondent positions 1
1. Position
  Existing training and annual resuscitation refreshers, alongside dynamic risk assessment, are considered sufficient for effective chest compressions despite technique varying by circumstances.
  Stated by East Midlands Ambulance Service NHS TrustExisting arrangements considered sufficient
AI-generated summary

Dipa Rameshchandra Lad · 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

Dipa Lad died after using an item of clothing to ligate on 4 March 2016; the medical cause of death was ligature pressure to the neck. The principal concerns related to differences between national guidance and the local ambulance protocol for stopping resuscitation, including the lack of guidance on when resuscitation was futile, staff awareness and training, and the clarity of the procedure. A further concern related to the technique used by one technician when giving chest compressions.

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 use effective chest-compression technique
Wider context from the report
“7. One of the technicians who attended gave chest compressions standing up – with both feet on the same side of the patient. The reason she gave for this was not wanting to get blood from the scene on her trousers. She was not in a confined space, and when challenged by her team leader subsequently, used a towel to protect her clothes and continued to give compressions kneeling down. I am concerned to ensure that staff are trained / reminded of the best technique to give effective compressions – for the patient and for staff resilience reasons. ”
Source location
Dipa Rameshchandra Lad · Prevention of Future Deaths report
Page 2 · 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
Existing training and annual resuscitation refreshers, alongside dynamic risk assessment, are considered sufficient for effective chest compressions despite technique varying by circumstances.

Verbatim wording from the response
“Although the most appropriate technique to perform CPR is to be kneeling close to the patient or standing over the patient this cannot always be possible and staff will conduct their own dynamic risk assessment when performing chest compressions. All clinical staff are trained in delivering effective chest compressions and undergo an annual statutory and mandatory refresher training course which includes updates and an assessment on resuscitation in one of our education centres.”

Source location
2017-0019-Response-by-East-Midlands-Ambulance-Service-NHS-Trust
Page 6 · response
Published 19 February 2017
Open published response
6 Dec2016
Inner North London
Concerns raised4
1. Ineffective chest compressions during CPR
2. Unavailability of a serviceable oxygen cylinder during resuscitation
3. Delay in providing substantive resuscitation care after nurse arrival
1. Failure to check pulse during resuscitation
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 2
1. Action
  Check that all Care UK clinical staff receive mandatory intermediate life-support training.
  Stated by Care UKStated completed
2. Action
  Develop and circulate a standard operating procedure for emergency response.
  Stated by Care UKStated in progress
AI-generated summary

Tedros Habtom KAHSSAY · 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

Tedros Kahssay killed himself by hanging in HM Prison Pentonville about a month after being admitted on a charge of murdering his pregnant partner. Concerns included incomplete transfer and recording of information, shortcomings in reception screening, and significantly deficient and chaotic resuscitation procedures. The report states that he was already dead when resuscitation commenced, while expressing concern for other prisoners requiring 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
Ineffective chest compressions during CPR
Wider context from the report
“7. The resuscitation led by the two nurses occupying the positions of primary (Hotel 7) and secondary (Hotel 12) leads for emergency healthcare in the prison that night, was significantly lacking in the following ways. • The nurse with primary responsibility for emergency care in the prison did not have a proper understanding of the nature of a code red and a code blue prison medical emergency. (I have raised this issue in the past.) • One minute and twelve seconds elapsed after nurse arrival before any substantive care was given. The action during that one minute and twelve seconds did not appear to progress the resuscitation attempt. • There seemed no clear demarcation of roles and responsibilities during the resuscitation. Of course these may change as those giving resuscitation tire, but the changes seemed haphazard. • There was no checking for breath or airway manoeuvre at the outset or at any time during the resuscitation. • There was no checking for pulse at the outset, before commencing chest compressions, or at any time during the resuscitation. The lead nurse attempted to justify this by saying that she had not wanted to waste time. This was despite the first action upon finding the casualty being to apply a blood pressure cuff, on the basis that this was part of the nurse assessment. • When giving evidence, the lead nurse appeared to conflate the casualty who is in cardiorespiratory arrest with the casualty who is merely unconscious. She repeatedly talked about the need to give cardiopulmonary resuscitation (CPR) to an unconscious casualty. She said that, at the time she started chest compressions, she did not know whether Mr Kahssay was breathing or not breathing. • When CPR was given, chest compressions were ineffective, being too quick and too shallow. • There was only one brief attempt to use an ambubag, the majority of the resuscitation taking place without airway assistance or with a non rebreathe oxygen mask. • It appeared that one oxygen cylinder was empty, as it had to be changed for another. The nurse leading the resuscitation described it as chaotic. That is indeed how it appeared to me from her description and from viewing the bodycam footage. I was and remain very gravely concerned, not in this respect for Mr Kahssay who was in fact already dead when resuscitation commenced, but for anyone else in the prison in need of first aid. ”
Source location
Tedros Habtom KAHSSAY · Prevention of Future Deaths report
Page 4 · 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
Unavailability of a serviceable oxygen cylinder during resuscitation
Wider context from the report
“7. The resuscitation led by the two nurses occupying the positions of primary (Hotel 7) and secondary (Hotel 12) leads for emergency healthcare in the prison that night, was significantly lacking in the following ways. • The nurse with primary responsibility for emergency care in the prison did not have a proper understanding of the nature of a code red and a code blue prison medical emergency. (I have raised this issue in the past.) • One minute and twelve seconds elapsed after nurse arrival before any substantive care was given. The action during that one minute and twelve seconds did not appear to progress the resuscitation attempt. • There seemed no clear demarcation of roles and responsibilities during the resuscitation. Of course these may change as those giving resuscitation tire, but the changes seemed haphazard. • There was no checking for breath or airway manoeuvre at the outset or at any time during the resuscitation. • There was no checking for pulse at the outset, before commencing chest compressions, or at any time during the resuscitation. The lead nurse attempted to justify this by saying that she had not wanted to waste time. This was despite the first action upon finding the casualty being to apply a blood pressure cuff, on the basis that this was part of the nurse assessment. • When giving evidence, the lead nurse appeared to conflate the casualty who is in cardiorespiratory arrest with the casualty who is merely unconscious. She repeatedly talked about the need to give cardiopulmonary resuscitation (CPR) to an unconscious casualty. She said that, at the time she started chest compressions, she did not know whether Mr Kahssay was breathing or not breathing. • When CPR was given, chest compressions were ineffective, being too quick and too shallow. • There was only one brief attempt to use an ambubag, the majority of the resuscitation taking place without airway assistance or with a non rebreathe oxygen mask. • It appeared that one oxygen cylinder was empty, as it had to be changed for another. The nurse leading the resuscitation described it as chaotic. That is indeed how it appeared to me from her description and from viewing the bodycam footage. I was and remain very gravely concerned, not in this respect for Mr Kahssay who was in fact already dead when resuscitation commenced, but for anyone else in the prison in need of first aid. ”
Source location
Tedros Habtom KAHSSAY · Prevention of Future Deaths report
Page 4 · 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
Delay in providing substantive resuscitation care after nurse arrival
Wider context from the report
“7. The resuscitation led by the two nurses occupying the positions of primary (Hotel 7) and secondary (Hotel 12) leads for emergency healthcare in the prison that night, was significantly lacking in the following ways. • The nurse with primary responsibility for emergency care in the prison did not have a proper understanding of the nature of a code red and a code blue prison medical emergency. (I have raised this issue in the past.) • One minute and twelve seconds elapsed after nurse arrival before any substantive care was given. The action during that one minute and twelve seconds did not appear to progress the resuscitation attempt. • There seemed no clear demarcation of roles and responsibilities during the resuscitation. Of course these may change as those giving resuscitation tire, but the changes seemed haphazard. • There was no checking for breath or airway manoeuvre at the outset or at any time during the resuscitation. • There was no checking for pulse at the outset, before commencing chest compressions, or at any time during the resuscitation. The lead nurse attempted to justify this by saying that she had not wanted to waste time. This was despite the first action upon finding the casualty being to apply a blood pressure cuff, on the basis that this was part of the nurse assessment. • When giving evidence, the lead nurse appeared to conflate the casualty who is in cardiorespiratory arrest with the casualty who is merely unconscious. She repeatedly talked about the need to give cardiopulmonary resuscitation (CPR) to an unconscious casualty. She said that, at the time she started chest compressions, she did not know whether Mr Kahssay was breathing or not breathing. • When CPR was given, chest compressions were ineffective, being too quick and too shallow. • There was only one brief attempt to use an ambubag, the majority of the resuscitation taking place without airway assistance or with a non rebreathe oxygen mask. • It appeared that one oxygen cylinder was empty, as it had to be changed for another. The nurse leading the resuscitation described it as chaotic. That is indeed how it appeared to me from her description and from viewing the bodycam footage. I was and remain very gravely concerned, not in this respect for Mr Kahssay who was in fact already dead when resuscitation commenced, but for anyone else in the prison in need of first aid. ”
Source location
Tedros Habtom KAHSSAY · Prevention of Future Deaths report
Page 3 · 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 check pulse during resuscitation
Wider context from the report
“7. The resuscitation led by the two nurses occupying the positions of primary (Hotel 7) and secondary (Hotel 12) leads for emergency healthcare in the prison that night, was significantly lacking in the following ways. • The nurse with primary responsibility for emergency care in the prison did not have a proper understanding of the nature of a code red and a code blue prison medical emergency. (I have raised this issue in the past.) • One minute and twelve seconds elapsed after nurse arrival before any substantive care was given. The action during that one minute and twelve seconds did not appear to progress the resuscitation attempt. • There seemed no clear demarcation of roles and responsibilities during the resuscitation. Of course these may change as those giving resuscitation tire, but the changes seemed haphazard. • There was no checking for breath or airway manoeuvre at the outset or at any time during the resuscitation. • There was no checking for pulse at the outset, before commencing chest compressions, or at any time during the resuscitation. The lead nurse attempted to justify this by saying that she had not wanted to waste time. This was despite the first action upon finding the casualty being to apply a blood pressure cuff, on the basis that this was part of the nurse assessment. • When giving evidence, the lead nurse appeared to conflate the casualty who is in cardiorespiratory arrest with the casualty who is merely unconscious. She repeatedly talked about the need to give cardiopulmonary resuscitation (CPR) to an unconscious casualty. She said that, at the time she started chest compressions, she did not know whether Mr Kahssay was breathing or not breathing. • When CPR was given, chest compressions were ineffective, being too quick and too shallow. • There was only one brief attempt to use an ambubag, the majority of the resuscitation taking place without airway assistance or with a non rebreathe oxygen mask. • It appeared that one oxygen cylinder was empty, as it had to be changed for another. The nurse leading the resuscitation described it as chaotic. That is indeed how it appeared to me from her description and from viewing the bodycam footage. I was and remain very gravely concerned, not in this respect for Mr Kahssay who was in fact already dead when resuscitation commenced, but for anyone else in the prison in need of first aid. ”
Source location
Tedros Habtom KAHSSAY · 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
Check that all Care UK clinical staff receive mandatory intermediate life-support training.

Verbatim wording from the response
“All clinical staff that are employed by Care UK have ILS as a mandatory training requirement. A check has been undertaken to ensure that all Care UK clinical staff are receiving the ILS training. This has been confirmed to be the case.”

Source location
2016-0437-Response-by-Care-UK.pdf
Page 3 · response
Published 6 December 2016
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 and circulate a standard operating procedure for emergency response.

Verbatim wording from the response
“In addition to this, the healthcare team plan to discuss issues relating to resuscitation and use of emergency bags regularly in their Friday afternoon training sessions. A SOP for emergency response is in development by the national team and is due for circulation shortly.”

Source location
2016-0437-Response-by-Care-UK.pdf
Page 3 · response
Published 6 December 2016
Open published response
15 Jul2016
Birmingham and Solihull
Concerns raised3
1. Inadequate ventilation during resuscitation in GP practices
2. Failure to provide oxygen during resuscitation in GP practices
3. Failure to use suction during resuscitation in GP practices
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 5
1. Action
  Assist the practice involved in the incident to identify and address issues highlighted by the incident.
  Stated by Birmingham South Central CCGStated in progress
2. Action
  Circulate learning from the incident to all commissioned GP practices.
  Stated by Birmingham South Central CCGStated planned
3. Action
  Circulate incident learning to surrounding clinical commissioning groups for dissemination to their practices.
  Stated by Birmingham South Central CCGStated planned
1. Action
  Ask the CQC to ensure inspections check that primary care services have equipment and skills to address respiratory emergencies.
  Stated by NHS EnglandStated completed
2. Action
  Provide defibrillator, oxygen, oximeter and recommended CPR equipment for managing medical emergencies in the practice.
  Stated by Wychall Lane SurgeryStated completed
Respondent positions 6
1. Position
  The CQC is responsible for using its inspection regime to ensure primary care services carry necessary equipment and skills for respiratory emergencies.
  Stated by NHS EnglandRedirects responsibility
1. Position
  General practice is not an emergency service and is not contracted, equipped or organised to deliver team-based emergency care.
  Stated by Wychall Lane SurgeryOutside remit
2. Position
  Except in remote or inaccessible locations, practices may rely on rapid access to emergency services when determining appropriate equipment and training.
  Stated by NHS EnglandExisting arrangements considered sufficient
3. Position
  Suction facilities should not be mandated nationally because training should prioritise recognising emergencies rather than maintaining suction skills.
  Stated by NHS EnglandNo action considered necessary
4. Position
  GP practices do not need to maintain suction equipment because its use is extremely rare and competence would be difficult to maintain.
  Stated by Wychall Lane SurgeryNo action considered necessary
5. Position
  Regular GP practices need not maintain suction equipment because its use is extremely rare and competence would be difficult to maintain.
  Stated by Birmingham South Central CCGNo action considered necessary
AI-generated summary

Sydney Mya Neil · 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

Sydney Mya Neil suffered from severe brittle asthma and died at Birmingham Children's Hospital after collapsing at a GP surgery following breathing difficulties. The report raised concerns about inadequate ventilation, lack of suction and lack of oxygen during resuscitation, and whether GP practices have sufficient expertise and equipment for emergencies.

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
Inadequate ventilation during resuscitation in GP practices
Wider context from the report
“Once Sydney collapsed in the GP surgery there was inadequate ventilation for 8 minutes. No suction was used nor was oxygen provided. I am concerned about the level of expertise in GP practices when resuscitation is required and whether they have sufficient equipment to deal with emergency situations. ”
Source location
Sydney Mya Neil · 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 provide oxygen during resuscitation in GP practices
Wider context from the report
“Once Sydney collapsed in the GP surgery there was inadequate ventilation for 8 minutes. No suction was used nor was oxygen provided. I am concerned about the level of expertise in GP practices when resuscitation is required and whether they have sufficient equipment to deal with emergency situations. ”
Source location
Sydney Mya Neil · 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 use suction during resuscitation in GP practices
Wider context from the report
“Once Sydney collapsed in the GP surgery there was inadequate ventilation for 8 minutes. No suction was used nor was oxygen provided. I am concerned about the level of expertise in GP practices when resuscitation is required and whether they have sufficient equipment to deal with emergency situations. ”
Source location
Sydney Mya Neil · 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
Assist the practice involved in the incident to identify and address issues highlighted by the incident.

Verbatim wording from the response
“The CCG has been assisting the practice involved in this incident to identify and address issues that have been highlighted by this unfortunate incident and it is the intention of the CCG to circulate any learning from this incident across all GP practices that we are responsible for commissioning. We will also circulate this learning to surrounding CCGs so that they may also disseminate these lessons to their practices.”

Source location
2016-0256-Response-by-Birmingham-South-Central-Clinical-Commissioning-Group
Page 2 · response
Published 15 July 2016
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
Circulate learning from the incident to all commissioned GP practices.

Verbatim wording from the response
“The CCG has been assisting the practice involved in this incident to identify and address issues that have been highlighted by this unfortunate incident and it is the intention of the CCG to circulate any learning from this incident across all GP practices that we are responsible for commissioning. We will also circulate this learning to surrounding CCGs so that they may also disseminate these lessons to their practices.”

Source location
2016-0256-Response-by-Birmingham-South-Central-Clinical-Commissioning-Group
Page 2 · response
Published 15 July 2016
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
Circulate incident learning to surrounding clinical commissioning groups for dissemination to their practices.

Verbatim wording from the response
“The CCG has been assisting the practice involved in this incident to identify and address issues that have been highlighted by this unfortunate incident and it is the intention of the CCG to circulate any learning from this incident across all GP practices that we are responsible for commissioning. We will also circulate this learning to surrounding CCGs so that they may also disseminate these lessons to their practices.”

Source location
2016-0256-Response-by-Birmingham-South-Central-Clinical-Commissioning-Group
Page 2 · response
Published 15 July 2016
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
Ask the CQC to ensure inspections check that primary care services have equipment and skills to address respiratory emergencies.

Verbatim wording from the response
“I have asked ████████ Head of Primary Care Commissioning, NHS”

Source location
2016-0256-Response-by-NHS-England
Page 3 · response
Published 15 July 2016
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 defibrillator, oxygen, oximeter and recommended CPR equipment for managing medical emergencies in the practice.

Verbatim wording from the response
“It suggests agreed principles for defibrillators, oxygen and oximeters (attachment 3). We have these at the practice.”

Source location
2016-0256-Response-by-Wychall-Lane-Surgery
Page 2 · response
Published 15 July 2016
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
The CQC is responsible for using its inspection regime to ensure primary care services carry necessary equipment and skills for respiratory emergencies.

Verbatim wording from the response
“The Care Quality Commission (CQC) as the regulator of general practice needs to be assured that practices are able to immediately respond to the needs of a person who becomes seriously ill. The CQC does not have explicit guidance around emergency equipment; however does state that if the practice does not have oxygen they are unlikely to be able to demonstrate they are equipped for dealing with emergencies.²”

Source location
2016-0256-Response-by-NHS-England
Page 3 · response
Published 15 July 2016
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
General practice is not an emergency service and is not contracted, equipped or organised to deliver team-based emergency care.

Verbatim wording from the response
“We have taken advice from the Local Medical Committee and General Practice Committee (GPC) of the BMA who commissioned ████████ who is a senior GP who has held roles including provision of and teaching of immediate care, now known as Pre-Hospital Emergency Medicine and is chair of BASICS Education Ltd, who aim to improve emergency care outside hospital, to comment on the care the Practice provided to Miss Neil and provide his general thoughts on this incident. He states general practice and general practitioners are not an emergency service…… General practitioners who very, very infrequently have to deal with life threatening emergencies and are neither equipped, contracted nor organised to deliver such team based emergency care.”

Source location
2016-0256-Response-by-Wychall-Lane-Surgery
Page 2 · response
Published 15 July 2016
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
Except in remote or inaccessible locations, practices may rely on rapid access to emergency services when determining appropriate equipment and training.

Verbatim wording from the response
“The Care Quality Commission (CQC) as the regulator of general practice needs to be assured that practices are able to immediately respond to the needs of a person who becomes seriously ill. The CQC does not have explicit guidance around emergency equipment; however does state that if the practice does not have oxygen they are unlikely to be able to demonstrate they are equipped for dealing with emergencies.²”

Source location
2016-0256-Response-by-NHS-England
Page 3 · response
Published 15 July 2016
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
Suction facilities should not be mandated nationally because training should prioritise recognising emergencies rather than maintaining suction skills.

Verbatim wording from the response
“In relation to the requirement for suction facilities to facilitate ventilator support, I have sought the views of NHS England’s National Clinical Directors. Whilst a number of practices will have some access to suction facilities, it was not felt that this should become a national requirement of primary care. BTS guidance highlights the risks associated with ventilatory support and non-invasive ventilation, (NIV) in severe asthma. It is the view of my Clinical Directors therefore better to target training in primary care on recognising an emerging emergency situation rather than to attempt to train and maintain skills in using suction equipment in challenging emergency situations. As a result, I do not feel it appropriate to mandate all general practices to purchase and maintain suction facilities which would necessarily include ensuring all relevant staff are appropriately trained.”

Source location
2016-0256-Response-by-NHS-England
Page 3 · response
Published 15 July 2016
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
GP practices do not need to maintain suction equipment because its use is extremely rare and competence would be difficult to maintain.

Verbatim wording from the response
“We have met with Birmingham South Central CCG and after a detailed significant event analysis they have stated:- “All organisations providing primary care should also have appropriate equipment and drugs for managing other life-threatening emergencies (e.g. anaphylaxis). The CCG would expect all staff to be trained to deliver basic CPR to patients, to have this training updated on a regular basis and have appropriate protocols in place to deal with such emergencies. In respect of suction being available, the CCG view would be that there would be no requirement for GP practices to have suction available on a regular basis as the use of such equipment would be extremely rare and it would be difficult for GPs to maintain their competence in using this type of equipment.”

Source location
2016-0256-Response-by-Wychall-Lane-Surgery
Page 2 · response
Published 15 July 2016
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
Regular GP practices need not maintain suction equipment because its use is extremely rare and competence would be difficult to maintain.

Verbatim wording from the response
“In respect of suction being available, the CCG view would be that there would be no requirement for GP practices to have suction available on a regular basis since the use of such equipment would be extremely rare and it would be difficult for GPs to maintain their competence in using this type of equipment. Similarly the CCG would not expect a GP to be able to intubate a patient or to have the equipment available to undertake this procedure as this would not be within the regular skill set of a GP. This view is based on the Resuscitation Council (UK) guidance that identifies these equipment and competencies are required for GPs having an extended role in aspects such as urgent and emergency care rather than generic general practice.”

Source location
2016-0256-Response-by-Birmingham-South-Central-Clinical-Commissioning-Group
Page 2 · response
Published 15 July 2016
Open published response
19 May2016
Inner North London
Concerns raised1
1. Failure to re-check the pulse during resuscitation
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 1
1. Action
  Deliver an ILS training plan for most healthcare staff by December 2016 and provide annual refresher training.
  Stated by Care UKStated in progress
Respondent positions 1
1. Position
  The nurse acted within his competence because BLS-trained staff were not expected to check a pulse under applicable guidance.
  Stated by Care UKDisputes the concern
AI-generated summary

Samuel Rodney Darren BLAIR · 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

Rodney Blair, who had a history of paranoid schizophrenia, alcohol dependency, multiple drug use and depression, was remanded in custody at HM Prison Pentonville and was found hanging in his cell on 2 August 2015. The inquest concluded that his death was suicide, with several contributing factors. Concerns included gaps in assessment and management of his mental health and antidepressant treatment, and delays and procedural issues in the prison emergency response.

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 re-check the pulse during resuscitation
Wider context from the report
“8. That nurse (a mental health, rather than general nurse) began resuscitation. He gave evidence that he started chest compressions and continued these for two minutes until a custodial manager arrived, without any intention of ever stopping to re-check Mr Blair’s pulse. He said that, whilst his basic life support certification was current at the time of Mr Blair’s death, his intermediate life support certification was not, and is still not; it is currently at least three years out of date. ”
Source location
Samuel Rodney Darren BLAIR · 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 an ILS training plan for most healthcare staff by December 2016 and provide annual refresher training.

Verbatim wording from the response
“Care UK Cardiopulmonary (CPR) Resuscitation Policy in the Training section (section 7) states:”

Source location
2016-0196-Response-by-Care-Uk
Page 4 · response
Published 19 May 2016
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
The nurse acted within his competence because BLS-trained staff were not expected to check a pulse under applicable guidance.

Verbatim wording from the response
“The nurse concerned was trained in Basic Life Support (BLS) but not Intermediate Life Support (ILS). As such, staff trained to BLS level are not expected to check a pulse as per the Resuscitation Council UK 2015 guideline. The nurse was therefore acting within the scope of his practice and competence. However, as detailed in the table below, we have implemented a training plan to ensure that, by December 2016, most healthcare staff will be ILS trained and that refresher trainings will occur yearly.”

Source location
2016-0196-Response-by-Care-Uk
Page 4 · response
Published 19 May 2016
Open published response
15 May2016
Mid Kent and Medway
Concerns raised1
1. Failure to consider or use an available defibrillator when appropriate
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 3
1. Action
  Issue emergency-response policy guidance and brief staff on responsibilities, code use, ambulance summoning, and defibrillator deployment.
  Stated by HM Prison and Probation ServiceStated completed
2. Action
  Provide defibrillator-use demonstrations and guidance on defibrillator deployment and location.
  Stated by HM Prison and Probation ServiceStated completed
3. Action
  Follow up with staff to ensure they know when and how to use defibrillators.
  Stated by HM Prison and Probation ServiceStated planned
AI-generated summary

Ronnie Olliffe · 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

Ronnie Olliffe collapsed in his cell at HMP Rochester on 1 October 2014 and was later confirmed dead at the scene; the medical cause of death was anabolic steroid-related cardiac hypertrophy. Concerns included failures to issue a required Code Blue, inadequate understanding that this would summon an ambulance, and failure to consider or use an available defibrillator.

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 consider or use an available defibrillator when appropriate
Wider context from the report
“1) there was a failure to issue a Code Blue pursuant to both a local and national policy in circumstances where it was appropriate to do so 2) there was a lack of understanding as to what consequences flowed from the issuing of a Code Blue, namely that an ambulance would be summoned immediately 3) there was a failure to consider or use a defibrillator when it was appropriate to do so and when one was available ”
Source location
Ronnie Olliffe · 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
Issue emergency-response policy guidance and brief staff on responsibilities, code use, ambulance summoning, and defibrillator deployment.

Verbatim wording from the response
“All night staff have been issued with a personal copy of Prison Service Instruction (PSI) 03/2013 Medical Emergency Response Codes and have each signed to say they understand the PSI and are fully aware of their responsibilities. A Notice to Staff setting out the policy has been issued and the remaining staff have been briefed at staff engagement sessions.”

Source location
2016-0224-Response-by-NOMS
Page 1 · response
Published 15 May 2016
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 defibrillator-use demonstrations and guidance on defibrillator deployment and location.

Verbatim wording from the response
“The Notice to Staff described above also explains the process for the deployment of defibrillators and their location within the prison. A demonstration of the use of a defibrillator was provided during the July 2016 staff engagement session, and the Safer Custody team will follow this up so that all staff know when and how to use them.”

Source location
2016-0224-Response-by-NOMS
Page 1 · response
Published 15 May 2016
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
Follow up with staff to ensure they know when and how to use defibrillators.

Verbatim wording from the response
“The Notice to Staff described above also explains the process for the deployment of defibrillators and their location within the prison. A demonstration of the use of a defibrillator was provided during the July 2016 staff engagement session, and the Safer Custody team will follow this up so that all staff know when and how to use them.”

Source location
2016-0224-Response-by-NOMS
Page 1 · response
Published 15 May 2016
Open published response
21 Apr2016
Berkshire
Concerns raised1
1. Delays in commencing CPR for unresponsive patients
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 1
1. Action
  Redesign basic life support and automated defibrillator training around realistic ward-based emergencies and required resuscitation procedures.
  Stated by West London NHS TrustStated completed
AI-generated summary

Christopher Harold Brand · 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 Harold Brand, a 53-year-old patient at Broadmoor Hospital, became unresponsive after returning from treatment at Frimley Park Hospital and could not be revived despite resuscitation attempts. Concerns included failures to follow observation procedures, failure to check that he was alive when his room was unlocked, and a delay in starting CPR.

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 commencing CPR for unresponsive patients
Wider context from the report
“(1) There were periods during the observation of Mr Brand by nursing staff where the hospital observation policy was not followed correctly. In particular, one nurse gave evidence that he saw no movement from Mr Brand after 06.50 hours for some 40-50 minutes. His view of Mr Brand was obscured by poor lighting in the room, scratches to the observation window through which he was observing Mr Brand and by the position in which Mr Brand was lying under heavy bedding. He made no effort to ensure that Mr Brand was safe and well, in line with the policy. (2) When the door to Mr Brand’s room was unlocked at 07.15 on 1st July 2015, no attempt was made to check that he was alive and well in breach of the policy at the time. At least a further 10 minutes passed before it was realised that Mr Brand had not moved and checks revealed him to be unresponsive. (3) Having found Mr Brand to be unresponsive, nursing staff did not immediately begin CPR. The evidence shows that it was only the 4th member of staff attending Mr Brand who commenced CPR and there was a delay while the first staff on the scene called for more senior assistance. (4) While the failure to follow hospital policy may not have directly impacted upon the circumstances of Mr Brand’s death, the nature of the breaches are so fundamental that they could be the difference between life and death of a patient on future occasions. ”
Source location
Christopher Harold Brand · 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
Redesign basic life support and automated defibrillator training around realistic ward-based emergencies and required resuscitation procedures.

Verbatim wording from the response
“Following Mr Brand’s death, the basic life support and automated defibrillator training course was redesigned. It now takes place on ward environments where emergencies are recreated to mimic realistic ward situations, enabling staff to better transfer their skills. It incorporates the in-hospital resuscitation procedures designed by the Resuscitation Council (UK), which in turn is accredited by NICE. Each attendee has the opportunity to perform all stages of the sequences of action required to support the collapsed patient. In keeping with the inquest findings (and recommendations of the Resuscitation Council) the requirement for immediate action and subsequent medical and managerial leadership of the resuscitation process is emphasised. Positive feedback has been obtained from course attendees. For staff expected to complete this course, there is currently 87% compliance.”

Source location
2016-0154-Response-by-West-London-Mental-Health-NHS-Trust
Page 3 · response
Published 21 April 2016
Open published response
15 Feb2016
Portsmouth and South East Hampshire
Concerns raised1
1. Unavailability of useful equipment in nursing home emergency resuscitation packs
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

James Robertson · 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

James Robertson died on 22 July 2015 while resident at Cams Ridge Care Home, after he was last checked at around 13.00 hours and found apparently deceased at around 15.30 hours. Concerns included inaccurate recording of care-check times, delayed recognition of his DNACPR status, and inadequate equipment in the emergency resuscitation pack, particularly the lack of a suction unit.

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 useful equipment in nursing home emergency resuscitation packs
Wider context from the report
“3) I was also told that there are no national standards for what should be included in emergency resuscitation packs kept at nursing homes and in consequence, the pack brought to assist Mr Robertson was lacking useful equipment, particularly a suction unit. ”
Source location
James Robertson · Prevention of Future Deaths report
Page 1 · concerns
Open source report
8 Jan2016
Cornwall
Concerns raised1
1. Lack of appropriate care-home resuscitation policies and staff preparation to preserve life
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.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Norman Dorn · 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

Norman Dorn was found presumed dead in an armchair at a residential home after eating a jam sandwich, with food in his mouth. He was known to have swallowing problems, and staff did not remove the food or attempt resuscitation; the report also states that the GP and other emergency services did not attend in a timely manner. The concerns included whether care homes had adequate policies and staff training for recognising or confirming death and for resuscitation.

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 appropriate care-home resuscitation policies and staff preparation to preserve life
Wider context from the report
“2. That some care home in Cornwall may not have an appropriate resuscitation policy in place to ensure that all attempts have been made to preserve life (when appropriate). If such policies are in place that they are regularly updated and staff are made aware of them and given the appropriate training. ”
Source location
Norman Dorn · Prevention of Future Deaths report
Page 1 · concerns
Open source report
27 Aug2015
Manchester South
Concerns raised1
1. Lack of nursing and medical staff understanding of cardiac-arrest response
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.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Frederick Sutton · 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

Frederick Sutton fell and broke his hip at home on 3 February 2015, may have suffered a myocardial infarction, and died approximately 12 hours after admission to hospital. The concerns included hospital staffing levels, escalation procedures, failures to read nursing notes, incompatible computerised record systems, inadequate staff training, response to cardiac arrest, medication administration, and inaccurate next-of-kin information.

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 nursing and medical staff understanding of cardiac-arrest response
Wider context from the report
“(5) The patient required the administration of cyclizane and there was an obvious problem with the (lack of) training of the staff in this regard. (6) The patient suffered a cardiac arrest and there was a lack of understanding amongst nursing and medical staff as to how this ought to have been responded to. (7) There seemed to be a lack of training amongst the staff as to the administration of certain prescribed drugs, both as to the appropriate amount thereof and the method of delivery. ”
Source location
Frederick Sutton · Prevention of Future Deaths report
Page 1 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Inadequate training of airline staff to recognise cardiac arrest and administer first aid or prompt 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

Failure to use effective chest-compression technique

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

Concerns raised4

Ineffective chest compressions during CPR

Unavailability of a serviceable oxygen cylinder during resuscitation

Delay in providing substantive resuscitation care after nurse arrival

Failure to check pulse during resuscitation

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

Concerns raised3

Inadequate ventilation during resuscitation in GP practices

Failure to provide oxygen during resuscitation in GP practices

Failure to use suction during resuscitation in GP practices

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.6

Concerns raised1

Failure to re-check the pulse during resuscitation

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

Actions described in response 1

Respondent positions 1

Respondent positions 1

Actions described in response 2

Actions described in response 5

Respondent positions 6

Actions described in response 1

Respondent positions 1