First reported 19 Jul 2016•Latest report 18 Mar 2026
Definition
What this concern includes
Includes failures of staff training, refresher training, simulation, drills or competence assurance specifically intended to prepare staff to recognise, coordinate or respond to unexpected emergencies in the setting where they work.
Not included
Excludes training for a separately named emergency system, hazard or professional function where that narrower concern is the supported boundary.
Excludes generic staffing, equipment, policy or communication deficiencies where inadequate emergency-response training is not itself identified.
Excludes failures limited to the performance of a particular emergency response after staff preparation was adequate.
Excludes first-aid, CPR, defibrillator, ambulance-call or other specific emergency competencies unless the assertion also supports the broader staff emergency-response training condition.
Reports
15
Distinct published reports
Individual concerns
16
A report can raise multiple concerns
Date range
2016–2026
First to latest report issue date
Stated actions
57
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.
Bow School1
Bromley by Bow Health Centre1
Care Quality Commission1
Central and North West London NHS Foundation Trust1
Compass Wellbeing Tower Hamlets1
Cygnet Behavioural Health Limited1
Daughter of the deceased1
Department of Health and Social Care1
Goals Soccer Centres PLC1
HM Prison and Probation Service1
London Ambulance Service NHS Trust1
Lukka Care Homes Limited1
Mandeville Grange Nursing Home1
Meadow House1
Ministry of Justice1
Healthcare site3
NHS trust3
Type not available3
Ministerial department2
Prison or young offender institution2
Private limited company2
Residential care home2
Company limited by guarantee1
Coronial office1
Domiciliary care provider1
English county council1
Executive agency1
Health and social care service regulator1
Integrated care board1
Maintained school1
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.
Essex
Concerns raised1
Insufficient staff understanding of emergency protocols
This report raised 5 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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
Action
Maintain recurring major-haemorrhage and emergency scenario training, including escalation, blood-supply, role-clarity, documentation and transfer exercises.
Stated by Nuffield HealthStated completedThe respondent said that this action was complete when they made their response on 26 March 2026.
Action
Further develop the major-haemorrhage training module to clarify end-to-end processes and differences from NHS pathways.
Stated by Nuffield HealthStated plannedThe respondent said that this action was planned when they made their response on 26 March 2026.
Action
Roll out mandatory emergency-protocol induction for site leaders, night coordinators and senior nursing staff, including role responsibilities.
Stated by Nuffield HealthStated plannedThe respondent said that this action was planned when they made their response on 26 March 2026.
Action
Monitor emergency training compliance, emergency-document availability, MyStaff policy access and scenario outcomes through audit and governance processes.
Stated by Nuffield HealthStated in progressThe respondent said that this action was in progress when they made their response on 26 March 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
All staff, including the site manager, had received training on the transfusion and major haemorrhage policies in force at the time.
Stated by Nuffield HealthDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
The Regulation 28 concerns did not contribute to the patient’s death.
Stated by Nuffield HealthDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Liverpool and the Wirral
Concerns raised1
Insufficient training of non-clinical staff in responding to urgent health concerns
This report raised 5 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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Supervise senior care assistants on obtaining clinical support, including contacting 111 or 999 when residents are unwell and a GP is unavailable.
Stated by Riversdale (Northwest) LimitedStated completedThe respondent said that this action was complete when they made their response on 5 November 2025.
Devon, Plymouth and Torbay
Concerns raised1
Lack of training on rapid escalation of emergency events
This report raised 7 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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Embed the Escalating Clinical Concerns Charter through staff engagement, training amendments and bi-monthly safety walkabouts.
Stated by Somerset NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 6 August 2025.
Inner North London
Concerns raised1
Lack of healthcare assistant and nursing staff training and clinical skills or knowledge for emergency care
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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Continue providing nursing and care staff with up-to-date CPR and emergency-situation training.
Stated by Acorn Lodge Care CentreStated in progressThe respondent said that this action was in progress when they made their response on 17 April 2025.
Action
Purchase Lifevac devices and train relevant staff in their use, alongside providing choking-response sessions.
Stated by Acorn Lodge Care CentreStated completedThe respondent said that this action was complete when they made their response on 17 April 2025.
Buckinghamshire
Concerns raised2
Failure to provide and embed effective life-support training for emergency response
Failure to maintain emergency-response training through drills and expiry awareness
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.
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
Action
Deliver emergency-response training through eLearning, recorded face-to-face sessions, expiry reminders, a maintained training matrix and weekly compliance review.
Stated by Chiltern Care ServicesStated completedThe respondent said that this action was complete when they made their response on 13 January 2025.
Action
Engage four additional trainers to maintain consistency and capacity in face-to-face training.
Stated by Chiltern Care ServicesStated completedThe respondent said that this action was complete when they made their response on 13 January 2025.
Action
Finalise the process document governing emergency CPR drills.
Stated by Chiltern Care ServicesStated completedThe respondent said that this action was complete when they made their response on 13 January 2025.
Action
Assess the competency of staff who will deliver emergency CPR training within one month.
Stated by Chiltern Care ServicesStated plannedThe respondent said that this action was planned when they made their response on 13 January 2025.
Action
Obtain a PractiMan adult/child CPR training manikin for the home.
Stated by Chiltern Care ServicesStated in progressThe respondent said that this action was in progress when they made their response on 13 January 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Emergency CPR drills have not started because trainer competency assessment is pending; drills are expected to begin within one month.
Stated by Chiltern Care ServicesUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Inner West London
Concerns raised1
Lack of official training for Operational Support Grades
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.
Cheshire
Concerns raised1
Inability of training to fully prepare first-on-scene staff for 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 concerns
Each 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
Action
Launch and disseminate a medical-emergency response video through HMPPS, including delivery to new officers and sharing with Governing Governors.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 23 May 2024.
Action
Show the medical-emergency response video to all current operational staff at HMP Styal by November 2024.
Stated by HM Prison and Probation ServiceStated plannedThe respondent said that this action was planned when they made their response on 23 May 2024.
Coventry
Concerns raised1
Failure to provide sufficiently frequent and effective emergency response training for care home staff
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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
Action
Provide face-to-face basic life-support and Level 1 first-aid training covering choking recognition, immediate response and escalation; training has reached 82% of staff.
Stated by J&K PartnershipStatus at responseThe respondent said that this action was partly complete when they made their response on 29 April 2024.
Action
Give the two staff members without face-to-face training choking-response guidance and e-learning training.
Stated by J&K PartnershipStated completedThe respondent said that this action was complete when they made their response on 29 April 2024.
Action
Deliver a face-to-face three-day Level 3 first-aid qualification to all service shift leaders.
Stated by J&K PartnershipStated plannedThe respondent said that this action was planned when they made their response on 29 April 2024.
Action
Introduce tabletop emergency exercises alongside face-to-face training and continuing e-learning.
Stated by J&K PartnershipStated completedThe respondent said that this action was complete when they made their response on 29 April 2024.
West London
Concerns raised1
Failure to provide adequate unexpected simulation training for ward staff
Responses linked to these concerns
Each 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.5
Action
Provide nationally accredited RCUK Level 3 Immediate Life Support training annually to substantive inpatient nurses and doctors, with compliance monitored through governance structures.
Stated by Central and North West London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 April 2024.
Action
Deliver a Trust-wide in-situ simulation programme using standardised planning, facilitation, debriefing and recording processes for resuscitation and other emergencies.
Stated by Central and North West London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 April 2024.
Action
Continue rolling in-situ simulation delivery across inpatient wards, adding sessions for areas identified as needing greater support.
Stated by Central and North West London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 3 April 2024.
Action
Train staff who facilitate simulations and provide local facilitator update training.
Stated by Central and North West London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 3 April 2024.
Action
Build a simulation room for staff identified as needing refresher training to attend planned sessions.
Stated by Central and North West London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 3 April 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing resuscitation and in-situ simulation arrangements provide sufficient assurance that the identified training concerns are being addressed.
Stated by Central and North West London NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Norfolk
Concerns raised1
Failure to organise a multi-disciplinary learning event on emergency non-technical skills
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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.9
Action
Attend a fixed multi-agency meeting with partner organisations to plan the recommended non-technical-skills learning event.
Stated by Norfolk and Suffolk NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 1 November 2019.
Action
Participate in the multidisciplinary meeting planning the learning event.
Stated by the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 1 November 2019.
Action
Support and contribute to the multidisciplinary learning event scheduled for February 2020.
Stated by the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 1 November 2019.
Action
Arrange and chair a multidisciplinary task-and-finish group meeting to develop the learning event.
Stated by NHS Norfolk and Suffolk Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 1 November 2019.
Action
Request QEH’s Risk and Safety team to compile investigation learning for consideration by the task-and-finish group.
Stated by NHS Norfolk and Suffolk Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 1 November 2019.
Action
Arrange the multidisciplinary learning event for mid-February 2020.
Stated by NHS Norfolk and Suffolk Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 1 November 2019.
Action
Identify and secure an external facilitator for the proposed learning event.
Stated by NHS Norfolk and Suffolk Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 1 November 2019.
Action
Develop learning-event materials covering the incident, organisational changes, staff messages and relevant lessons learned.
Stated by NHS Norfolk and Suffolk Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 1 November 2019.
Action
Invite senior operational staff from NNUH and James Paget University Hospitals to disseminate incident and investigation learning.
Stated by NHS Norfolk and Suffolk Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 1 November 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
Position
West Norfolk CCG will lead organising and facilitating the multi-disciplinary learning event, with other participants providing support and contributions.
Stated by the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The CCG did not agree to lead or take over responsibility for Recommendation 2 or the learning event.
Stated by NHS Norfolk and Suffolk Integrated Care BoardDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
QEH and its Deputy Director of Patient Safety are the organisational and individual leads for Recommendation 2 and the learning event.
Stated by NHS Norfolk and Suffolk Integrated Care BoardRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The review’s learning themes are already being addressed through existing work and approaches for working with children and families.
Stated by Norfolk County CouncilExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
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Includes failures of staff training, refresher training, simulation, drills or competence assurance specifically intended to prepare staff to recognise, coordinate or respond to unexpected emergencies in the setting where they work.
