Unreliable resuscitation preparedness and response during cardiac arrest
First to latest report 3 Dec 2013 — 26 May 2026
Reports that mention this concern
56
Times this concern has been raised
79
Stated actions linked to this concern
127
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.
What is 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.
Trends
Reports over time
Reports mentioning this concern, over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
Department of Health and Social Care7
HM Prison and Probation Service5
NHS England5
Pentonville Prison4
Care Quality Commission3
Care UK3
College of Policing3
Ministry of Justice3
East London NHS Foundation Trust2
Essex Partnership University NHS Foundation Trust2
Metropolitan Police Service2
South London and Maudsley NHS Foundation Trust2
Ardenlea Grove Care Home1
Aspray House1
Barking, Havering and Redbridge University Hospitals NHS Trust1
NHS trust24
Ministerial department10
Prison or young offender institution8
Executive non-departmental public body6
Private limited company6
Executive agency5
Police force5
Healthcare site4
Multi-service care provider4
Type not available4
Health and social care service regulator3
Health professional body3
National policing body3
Independent healthcare provider2
Nursing home2
Reports and published responses 56 reports
See individual reports that have raised this concern, and the actions taken in response
West Yorkshire Eastern
Concerns raised1
Insufficient national guidelines for identifying and treating reversible causes of cardiac arrest in newborn babies
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
British Association of Perinatal Medicine
Resuscitation Council UK
Royal College of Paediatrics and Child Health
Sheffield Children’s Hospital NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Resuscitation Council UK
Include reversible causes of non-response in newborn resuscitation guidance, algorithms, course teaching and manuals.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.5
Royal College of Paediatrics and Child Health
The 4 H’s and 4 T’s guidance is owned by RCUK, so changes to it are outside the respondent’s authority.
Outside remitThe respondent said that this matter was outside its role or authority.
Royal College of Paediatrics and Child Health
BAPM and RCUK should determine whether changes to neonatal use of the 4 H’s and 4 T’s guidance are required.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Sheffield Children’s Hospital NHS Foundation Trust and Yorkshire & Humber Neonatal Operational Delivery Network (Y&H Neonatal ODN
Existing resuscitation guidance and mandatory and supplementary training adequately cover identifying and treating reversible causes of neonatal cardiac arrest.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Resuscitation Council UK
The NLS approach and algorithm adequately address potential causes of non-response during newborn resuscitation.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
British Association of Perinatal Medicine
The national neonatal resuscitation algorithms' four Hs and five Ts cover the overwhelming majority of reversible causes of cardiac arrest.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
Inner North London
Concerns raised1
Failure to undertake CPR during cardiac arrest from a potentially reversible cause
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Acorn Lodge Care Centre
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Acorn Lodge Care Centre
Continue providing nursing and care staff with up-to-date CPR and emergency-situation training.
Acorn Lodge Care Centre
Purchase Lifevac devices and train relevant staff in their use, alongside providing choking-response sessions.
West Yorkshire Eastern
Concerns raised2
Failure to appreciate the importance of early CPR
Delays in commencing CPR during a medical emergency in a cell
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Leeds Community Healthcare NHS Trust
West Yorkshire Police
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Leeds Community Healthcare NHS Trust
Expand life-support training with custody-suite simulations and joint scenarios to improve coordination between healthcare professionals and detention officers.
Leeds Community Healthcare NHS Trust
Incorporate recommendations from reflective discussions with incident staff into CPR training.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
West Yorkshire Police
Existing training and emergency procedures appropriately require Detention Officers to provide Basic Life Support and follow Healthcare Professional direction.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
East London
Concerns raised1
Lack of nursing staff knowledge of criteria for commencing CPR on an unresponsive patient
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Barking, Havering and Redbridge University Hospitals NHS Trust
Department of Health and Social Care
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Barking, Havering and Redbridge University Hospitals NHS Trust
Operate the Resuscitation Service to review cardiac and emergency calls, mandate incident reporting and support teaching and deteriorating-patient review.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Department of Health and Social Care
BHRUT is responsible for responding fully to the concerns, so the Department will not duplicate its response.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Cumbria
Concerns raised2
Failure to perform and respond appropriately to basic checks and signs of life during resuscitation
Unavailability of a defibrillator for attempted resuscitation in the care home
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Care Quality Commission
Nursing and Midwifery Council
WESTMORLAND HEALTHCARE LIMITED
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.6
WESTMORLAND HEALTHCARE LIMITED
Provide basic life-support training for all senior staff and registered nurses.
WESTMORLAND HEALTHCARE LIMITED
Conduct daily walk-round audits that test staff knowledge of ABCDE assessment and recognition of cardiac arrest.
Care Quality Commission
Followed up the provider’s actions addressing the CPR incident, including staff refresher training and action concerning the involved nurse.
Nursing and Midwifery Council
Continue the fitness-to-practise investigation into the registered nurse and decide whether to progress or close the case for public-protection reasons.
Nursing and Midwifery Council
Complete a risk assessment to determine whether urgent interim restrictions or suspension are required to protect the public.
Nursing and Midwifery Council
Keep the decision not to impose an interim order under review pending new information.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
Nursing and Midwifery Council
An interim order restricting or suspending the nurse’s practice was not considered necessary for public protection or otherwise in the public interest.
No action considered necessaryThe respondent said that no further action was needed.
Care Quality Commission
Requiring care homes to install defibrillators falls outside the regulator’s role and remit.
Outside remitThe respondent said that this matter was outside its role or authority.
Care Quality Commission
Care providers are responsible for deciding how to deliver care safely and demonstrating compliance to the regulator.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Care Quality Commission
Without defibrillators, suitable resuscitation policies, procedures and trained staff are considered an appropriate alternative.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Manchester North
Concerns raised1
Failure to provide training on recognising cardiac arrest
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
College of Policing
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
College of Policing
Complete the FALP review and update learning outcomes to cover agonal gasps, cardiac arrest recognition and basic life support.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
College of Policing
Individual forces are responsible for developing FALP learning materials, including video content, under local clinical governance procedures.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
College of Policing
The reviewed FALP and new PPST are considered to provide policing with the necessary skills to preserve life and keep the public safe.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Essex
Concerns raised1
Delay in recording the first heart rhythm during resuscitation
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
NHS England
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
NHS England
Concerns about care at Colchester General Hospital fall outside NHS England’s remit.
Outside remitThe respondent said that this matter was outside its role or authority.
NHS England
East Suffolk & North Essex NHS Foundation Trust is responsible for responding to concerns about care at Colchester General Hospital.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Derby and Derbyshire
Concerns raised1
Inappropriate CPR guidance on rigor mortis exclusions in prisons without 24-hour healthcare staffing
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
HM Prison and Probation Service
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
HM Prison and Probation Service
Revisit the guidance on recognising irreversible death and deciding when not to perform CPR.
HM Prison and Probation Service
Obtain advice from Resuscitation Council UK on diagnosing irreversible death from rigor mortis and starting CPR.
HM Prison and Probation Service
Review the guidance to address the risks concerning prison staff recognition of rigor mortis.
HM Prison and Probation Service
Issue a revised version of the guidance as soon as possible.
Surrey
Concerns raised1
Failure to recognise cardiac arrest
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Leonard Cheshire Disability
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Leonard Cheshire Disability
Provide sourced vital-signs training information to current clinical staff and new clinical starters.
Inner North London
Concerns raised1
Failure to recognise deterioration and commence CPR promptly
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
Metropolitan Police Service
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
Metropolitan Police Service
Require all officers to complete digital training on recognising agonal breathing to support earlier CPR.
Metropolitan Police Service
Standardise jaw-thrust airway management, retain casualties on their backs, limit recovery-position use to clearing fluids, and commence CPR when noisy breathing persists.
Metropolitan Police Service
Deliver expanded Emergency Life Support Module 2 and refresher training, including additional practical scenario-based drills and techniques.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.