Recurring concern

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.

Reports and published responses 56 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Buckinghamshire

    AI-generated summary

    Peter Harry Mackie · 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

    Peter Harry Mackie, a prisoner at HMP Springhill, was found hanging in the prison chapel on 28 December 2013 and was declared deceased. The inquest concluded that he took his own life while the balance of his mind was disturbed. Concerns included the availability and deployment of first aiders and healthcare staff across the prison sites, and a lack of clarity about when CPR should be commenced and what action untrained staff should take.

    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 clarity for untrained staff about what action to undertake during a suspected cardiac arrest

    Wider context from the report

    “(3)It appears that there is not currently any guidance to staff as to when CPR should be commenced. This applies to CPR trained staff. For those without such training there is a lack of clarity as to what if any action they should undertake. ”

    Source location

    Peter Harry Mackie · 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

    Lack of guidance for CPR-trained staff on when to commence CPR

    Wider context from the report

    “(3)It appears that there is not currently any guidance to staff as to when CPR should be commenced. This applies to CPR trained staff. For those without such training there is a lack of clarity as to what if any action they should undertake. ”

    Source location

    Peter Harry Mackie · 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 all Grendon and Springhill staff with written advice on responding to a non-breathing person through a booklet, induction and the local intranet.

    Verbatim wording from the response

    “HMP Grendon and Springhill have sought additional advice from the Resuscitation Council UK on when CPR should be commenced and will be providing staff who work at HMP Grendon and Springhill with written advice on what to do should they find somebody not breathing. This will be provided to all staff in the form of a booklet by 31 January 2015, to ensure staff receive this information. The information will form part of the induction for new staff and will be made available on the local intranet at HMP Grendon and Springhill.”

    Source location

    2014-0528-Response-by-NOMS
    Page 2 · response
    Published 5 December 2014

    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

    Issue interim First Aid Guidance for staff during consultation on the revised policy instruction.

    Verbatim wording from the response

    “All first aid trained staff will be aware of how and when to apply CPR following the training they receive. A new First Aid at Work PSI is currently taking place. Once the period of consultation is complete, a revised PSI will be published. During the interim period, NOMS has issued the old First Aid Guidance for staff to use, as attached.”

    Source location

    2014-0528-Response-by-NOMS
    Page 2 · response
    Published 5 December 2014

    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 a revised First Aid at Work policy instruction after consultation.

    Verbatim wording from the response

    “All first aid trained staff will be aware of how and when to apply CPR following the training they receive. A new First Aid at Work PSI is currently taking place. Once the period of consultation is complete, a revised PSI will be published. During the interim period, NOMS has issued the old First Aid Guidance for staff to use, as attached.”

    Source location

    2014-0528-Response-by-NOMS
    Page 2 · response
    Published 5 December 2014

    Open published response

  2. Birmingham and Solihull

    AI-generated summary

    Noreen Porter · 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

    Noreen Porter, who had dementia and was at high risk of aspiration, died after aspirating food material while being fed tea at a nursing home on 18 September 2014. The concerns were that staff did not undertake CPR when she collapsed and that there appeared to be no process or procedure to ensure resuscitation during an emergency.

    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 a process ensuring resuscitation during emergencies

    Wider context from the report

    “(1) No CPR was undertaken by the staff when the deceased collapsed. (2) There appears to be no process or procedure in place to ensure resuscitation is undertaken when an emergency occurs ”

    Source location

    Noreen Porter · 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

    Reissue resuscitation and choking policies to all staff.

    Verbatim wording from the response

    “Since this incident, the home manager at Ardenlea Grove has carried out the following steps to ensure all staff are aware of Bupa's policy and the steps that they must take in a similar situation and to learn the lessons from this tragic incident:”

    Source location

    2014-0550-Response-by-Bupa
    Page 2 · response
    Published 22 December 2014

    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 policies and procedures appropriately direct staff to commence CPR during emergencies; the incident resulted from those procedures not being followed.

    Verbatim wording from the response

    “In the circumstances, in relation to your two areas of concern:”

    Source location

    2014-0550-Response-by-Bupa
    Page 2 · response
    Published 22 December 2014

    Open published response

  3. Manchester West

    AI-generated summary

    Margaret Walker · 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

    Margaret Walker, a detained patient at the Sephton Unit, was found unresponsive on 7 August 2012 and later diagnosed as having died from coronary artery disease. Concerns included inconsistent diabetes care, delays and omissions in obtaining and communicating medication and blood-test information, inadequate clinical-record documentation, and the defibrillator not being applied before ambulance personnel arrived.

    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 apply an available defibrillator promptly during resuscitation

    Wider context from the report

    “(3) When Mrs Walker was found unresponsive at approximately 6.00am on the morning of the 7th August 2012, cardio-pulmonary resuscitation was appropriately commenced and continued and a defibrillator was obtained. However the defibrillator was not applied prior to the arrival of ambulance personnel who then applied their own defibrillator, which did not reveal a heart rhythm suitable for a shock to be given. ”

    Source location

    Margaret Walker · 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

    Address resuscitation competency of staff involved in the incident through specific Trust competency processes.

    Verbatim wording from the response

    “In this case, while the staff involved in the incident were compliant with their mandatory training requirements they had not appropriately followed the Trust approved Resuscitation policy and procedures in relation to the use of the automated external defibrillator. I would like to reassure you that this has been addressed with the staff in question who has undergone specific Trust processes in relation to their competency.”

    Source location

    2014-0134-Response-by-5-Boroughs-Partnership-NHS-Foundation-Trust
    Page 3 · response
    Published 25 March 2014

    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

    Conduct annual resuscitation practice drills including automated external defibrillator use and document competency outcomes.

    Verbatim wording from the response

    “In line with NPSA and RCUK guidelines, it is recommended that services undertake practice drills to support further learning within the clinical environment. The Trust operates an annual practice drill schedule that includes use of an automated external defibrillator. Practice drills are undertaken by the Trust resuscitation trainers to ensure correct standards of practice are demonstrated. Staff are assessed against the RCUK competency framework during practice drills; the outcomes of practice drills are documented to identify areas of good practice and areas requiring improvement. Local actions plans are agreed to address any areas of concern. Records are available which evidence that Sephton Ward have had 4 practice drills completed between November 2012 and January 2014.”

    Source location

    2014-0134-Response-by-5-Boroughs-Partnership-NHS-Foundation-Trust
    Page 3 · response
    Published 25 March 2014

    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

    Staff involved in the resuscitation incident complied with mandatory training requirements; the failure concerned following approved procedures instead.

    Verbatim wording from the response

    “In line with National Patient Safety Agency (NPSA) RRO10 “Resuscitation in Mental Health and Learning Disability inpatient settings” (November 2008) and Resuscitation Council UK (RCUK) requirements, all medical staff and registered nurses working within inpatient settings are expected to be competent to the standard of Immediate Life Support (ILS). All support workers are expected to be competent to the standard of Basic Life Support (BLS).”

    Source location

    2014-0134-Response-by-5-Boroughs-Partnership-NHS-Foundation-Trust
    Page 3 · response
    Published 25 March 2014

    Open published response

  4. West Sussex

    AI-generated summary

    Natasha Raghoo · 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

    Natasha Raghoo was admitted to The Dene Hospital in April 2012 for treatment related to bipolar disorder and was later detained under section 2 of the Mental Health Act. She was found unresponsive in bed on 5 May 2012 and died from anaphylactic shock caused by an unknown allergen. Concerns included inconsistent physical observations, lack of ECG assessment, staff training in resuscitation and defibrillator use, and communication and handover problems.

    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 staff training in cardiopulmonary resuscitation and defibrillator use

    Wider context from the report

    “1. During the course of the evidence, concern was expressed concerning the training that staff had received in the techniques of cardio pulmonary resuscitation and the use of the defibrillator. The latter was reported not to have been used by hospital staff although available on the ward. ”

    Source location

    Natasha Raghoo · 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

    Implement monthly emergency incident drills to practise CPR and related emergency skills.

    Verbatim wording from the response

    “Lessons Learned and changes made”

    Source location

    2014-0100-Response-by-Partnership-in-Care
    Page 2 · response
    Published 6 March 2014

    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

    Deliver company-wide Immediate Life Support training, including defibrillator use, to qualified nurses and doctors.

    Verbatim wording from the response

    “In 2013, and subsequent to the death, PiC implemented a company-wide training programme to move from the provision of Basic Life Support to Immediate Life Support. This training has been delivered to all qualified nurses and doctors across PiC. This training specifically includes the use of the defibrillator.”

    Source location

    2014-0100-Response-by-Partnership-in-Care
    Page 2 · response
    Published 6 March 2014

    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 CPR and defibrillator training with competency sign-off and repeat training where staff do not meet the required standard.

    Verbatim wording from the response

    “Cardio Pulmonary Resuscitation (CPR) and Defibrillator Training”

    Source location

    2014-0100-Response-by-Partnership-in-Care
    Page 1 · response
    Published 6 March 2014

    Open published response

  5. Surrey

    AI-generated summary

    Sarah Anne Shepherd · 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

    Sarah Anne Shepherd, a patient detained under the Mental Health Act, was found in her room with a plastic bin liner over her head on 12 September 2011 and died in hospital the following day. The report identified concerns about unclear referral processes to the Psychiatric Intensive Care Unit, failures to attempt resuscitation in accordance with guidance, and uncertainty and misleading materials concerning resuscitation 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

    Failure to initiate resuscitation when a patient is not breathing normally

    Wider context from the report

    “(2) It was apparent from the evidence that the nursing staff who found the Deceased in an unresponsive state on the 12th September 2011 did not attempt to resuscitate her in accordance with the guidelines of the Resuscitation Council. They understood that resuscitation should be started if the patient was not “breathing” whereas the Council states that it should be started if the patient is not “breathing normally”. The evidence heard as to what training the nursing staff had been given concerning when resuscitation should be started was unclear and confusing. It remains unclear whether the resuscitation training now being given to clinical staff (a) is fully and clearly in accordance with the current guidance of the Resuscitation Council and (b) includes training as to what observations should be taken and recorded. Further, it was apparent from the evidence that the resuscitation bags used by staff contain a laminated aide memoire which is itself misleading as it refers to the use of resuscitation when the patient is not “breathing” rather than “breathing normally”. ”

    Source location

    Sarah Anne Shepherd · 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

    Misleading resuscitation aide memoires in staff resuscitation bags

    Wider context from the report

    “(2) It was apparent from the evidence that the nursing staff who found the Deceased in an unresponsive state on the 12th September 2011 did not attempt to resuscitate her in accordance with the guidelines of the Resuscitation Council. They understood that resuscitation should be started if the patient was not “breathing” whereas the Council states that it should be started if the patient is not “breathing normally”. The evidence heard as to what training the nursing staff had been given concerning when resuscitation should be started was unclear and confusing. It remains unclear whether the resuscitation training now being given to clinical staff (a) is fully and clearly in accordance with the current guidance of the Resuscitation Council and (b) includes training as to what observations should be taken and recorded. Further, it was apparent from the evidence that the resuscitation bags used by staff contain a laminated aide memoire which is itself misleading as it refers to the use of resuscitation when the patient is not “breathing” rather than “breathing normally”. ”

    Source location

    Sarah Anne Shepherd · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  6. Inner North London

    AI-generated summary

    Abdullahi Sharif ABOKAR · 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

    Abdullahi Sharif Abokar, a 22-year-old patient detained under section 3 of the Mental Health Act, was found hanging from smoke alarm wires on a secure mental health ward on 16 June 2012 and died five days after being taken to hospital. Concerns included staff not asking him about suicidal thoughts and significant shortcomings in the conduct of resuscitation, including compromised ventilatory support and uncertainty about airway management.

    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 provide effective airway ventilation during resuscitation

    Wider context from the report

    “2. Resuscitation The psychiatry doctor who attended the resuscitation in progress (approximately seven minutes after Mr Abokar was discovered), found an ambubag mask on Mr Abokar’s face, but no ambubag connected and no person holding the mask. The nurse who had been in charge of Mr Abokar’s airway said that she had been giving him mouth to mouth resuscitation, though no other witness in the room saw this. No explanation was provided as to why she would have given mouth to mouth rather than use the ambubag present (even if the ambubag was not connected to a flow of oxygen). The nurse had left Mr Abokar in the middle of resuscitation, simply to go out into the corridor and ascertain the whereabouts of the paramedic. She said that she had left Mr Abokar’s airway in the care of another member of staff, but she did not know who that person was, and all other members of staff in the room denied that his airway was ever left in their charge. She was out of the room for 50 seconds. The paramedic attending Mr Abokar after resuscitation had been ongoing for quite some minutes, said that Mr Abokar’s head was not tilted back sufficiently, and the ambubag reservoir was not inflated because the oxygen cylinder, whilst connected, was not switched on. Neither of the paramedic’s observations was accepted by the nurse with control of the airway, though he clearly has a great deal more experience of resuscitation than she. The nurse also said that a colleague, though she did not know who, had connected the ambubag to the first oxygen cylinder; and then a colleague, either the same colleague or a different one, she did not know, had connected the ambubag to a second cylinder; though all other members of staff in the room denied that they had done this. It appears that Mr Abokar’s ventilatory support was significantly compromised by the way in which it was conducted. It was entirely unclear what impact, if any, this had on Mr Abokar’s potential recovery, though that would not necessarily be the case for another patient in a similar position. ”

    Source location

    Abdullahi Sharif ABOKAR · 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 continuous responsibility for the airway during resuscitation

    Wider context from the report

    “2. Resuscitation The psychiatry doctor who attended the resuscitation in progress (approximately seven minutes after Mr Abokar was discovered), found an ambubag mask on Mr Abokar’s face, but no ambubag connected and no person holding the mask. The nurse who had been in charge of Mr Abokar’s airway said that she had been giving him mouth to mouth resuscitation, though no other witness in the room saw this. No explanation was provided as to why she would have given mouth to mouth rather than use the ambubag present (even if the ambubag was not connected to a flow of oxygen). The nurse had left Mr Abokar in the middle of resuscitation, simply to go out into the corridor and ascertain the whereabouts of the paramedic. She said that she had left Mr Abokar’s airway in the care of another member of staff, but she did not know who that person was, and all other members of staff in the room denied that his airway was ever left in their charge. She was out of the room for 50 seconds. The paramedic attending Mr Abokar after resuscitation had been ongoing for quite some minutes, said that Mr Abokar’s head was not tilted back sufficiently, and the ambubag reservoir was not inflated because the oxygen cylinder, whilst connected, was not switched on. Neither of the paramedic’s observations was accepted by the nurse with control of the airway, though he clearly has a great deal more experience of resuscitation than she. The nurse also said that a colleague, though she did not know who, had connected the ambubag to the first oxygen cylinder; and then a colleague, either the same colleague or a different one, she did not know, had connected the ambubag to a second cylinder; though all other members of staff in the room denied that they had done this. It appears that Mr Abokar’s ventilatory support was significantly compromised by the way in which it was conducted. It was entirely unclear what impact, if any, this had on Mr Abokar’s potential recovery, though that would not necessarily be the case for another patient in a similar position. ”

    Source location

    Abdullahi Sharif ABOKAR · 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

    Approve and implement a revised Trust Resuscitation Policy aligned with national guidance and learning from the inquest.

    Verbatim wording from the response

    “a) A revised Trust Resuscitation Policy was approved by the Trust’s Quality Committee in November 2013, containing changes in line with national guidance and also directly related to learning from this inquest’s findings.”

    Source location

    2013-0323-Response-by-Camden-Islington-NHS-Foundation-Trust
    Page 4 · response
    Published 23 February 2014

    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

    Introduce six-monthly CPR simulation exercises across inpatient units, with committee monitoring.

    Verbatim wording from the response

    “d) Due to the infrequent occurrences of CPR within mental health hospital settings, our inpatient units will now perform simulation exercises every 6 months to ensure staff get practice in performing CPR. The matron from each unit has responsibility for organising these, under the guidance of the Deputy Director of Nursing. The first such exercises will take place in April 2014. The exercises will be monitored through our committee structure.”

    Source location

    2013-0323-Response-by-Camden-Islington-NHS-Foundation-Trust
    Page 5 · response
    Published 23 February 2014

    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 specialist oxygen-use training using live oxygen cylinders during training sessions.

    Verbatim wording from the response

    “f) Training in use of oxygen will now be provided by an independent company contracted to provide this for the Trust. This is a specialist Health and Safety firm. The Trust will ensure that live oxygen cylinders are provided for each training session for this purpose, which will enable staff undergoing training to familiarise themselves fully with the cylinder and how it functions, including the sound it makes when activated. The Deputy Director of Nursing has responsibility for organising this. The Trust will also recommend to the National Resuscitation Council that this should be a component of in-hospital Life support training, as it is not currently stipulated as”

    Source location

    2013-0323-Response-by-Camden-Islington-NHS-Foundation-Trust
    Page 5 · response
    Published 23 February 2014

    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

    Transfer resuscitation-scene coordination to the most senior nurse on duty until attending paramedics assume responsibility.

    Verbatim wording from the response

    “e) Management of the resuscitation scene will no longer be with the attending doctor, but with the most senior nurse on duty at the time. This will be the duty nurse or site matron who will have responsibility for coordinating staff actions, and handing over information to attending paramedics. Until the paramedic lead accepts responsibility, the duty nurse or site matron will maintain the lead for managing the resuscitation.”

    Source location

    2013-0323-Response-by-Camden-Islington-NHS-Foundation-Trust
    Page 5 · response
    Published 23 February 2014

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026