Recurring concern
Unreliable resuscitation preparedness and response during cardiac arrest
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Request correctionFirst reported 3 Dec 2013•Latest report 26 May 2026
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
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
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.
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.
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Concerns raised2
Lack of clarity for untrained staff about what action to undertake during a suspected cardiac arrest
Lack of guidance for CPR-trained staff on when to commence CPR
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 concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
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Action
Provide all Grendon and Springhill staff with written advice on responding to a non-breathing person through a booklet, induction and the local intranet.
Stated by Governing Governor of HMP Grendon and Springhill -
Action
Issue interim First Aid Guidance for staff during consultation on the revised policy instruction.
Stated by Governing Governor of HMP Grendon and Springhill -
Action
Publish a revised First Aid at Work policy instruction after consultation.
Stated by Governing Governor of HMP Grendon and Springhill
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Concerns raised1
Lack of a process ensuring resuscitation during emergencies
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 concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
-
Action
Reissue resuscitation and choking policies to all staff.
Stated by Ardenlea Grove Nursing Home
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
Existing policies and procedures appropriately direct staff to commence CPR during emergencies; the incident resulted from those procedures not being followed.
Stated by Ardenlea Grove Nursing Home
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Concerns raised1
Failure to apply an available defibrillator promptly during resuscitation
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
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Action
Address resuscitation competency of staff involved in the incident through specific Trust competency processes.
Stated by North West Boroughs Healthcare NHS Foundation Trust -
Action
Conduct annual resuscitation practice drills including automated external defibrillator use and document competency outcomes.
Stated by North West Boroughs Healthcare NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Position
Staff involved in the resuscitation incident complied with mandatory training requirements; the failure concerned following approved procedures instead.
Stated by North West Boroughs Healthcare NHS Foundation Trust
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Concerns raised1
Lack of staff training in cardiopulmonary resuscitation and defibrillator use
This report raised 12 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
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Action
Implement monthly emergency incident drills to practise CPR and related emergency skills.
Stated by Partnerships in Care Group Limited -
Action
Deliver company-wide Immediate Life Support training, including defibrillator use, to qualified nurses and doctors.
Stated by Partnerships in Care Group Limited -
Action
Provide CPR and defibrillator training with competency sign-off and repeat training where staff do not meet the required standard.
Stated by Partnerships in Care Group Limited
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Concerns raised2
Failure to initiate resuscitation when a patient is not breathing normally
Misleading resuscitation aide memoires in staff resuscitation bags
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised2
Failure to provide effective airway ventilation during resuscitation
Failure to maintain continuous responsibility for the airway during resuscitation
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 concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
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Action
Approve and implement a revised Trust Resuscitation Policy aligned with national guidance and learning from the inquest.
Stated by North London NHS Foundation Trust -
Action
Introduce six-monthly CPR simulation exercises across inpatient units, with committee monitoring.
Stated by North London NHS Foundation Trust -
Action
Provide specialist oxygen-use training using live oxygen cylinders during training sessions.
Stated by North London NHS Foundation Trust
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Action
Transfer resuscitation-scene coordination to the most senior nurse on duty until attending paramedics assume responsibility.
Stated by North London NHS Foundation Trust
Data last updated 7 September 2026