Recurring concern

Inadequate staff training for emergency response

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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

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.

  1. Liverpool and the Wirral

    AI-generated summary

    Jack Riding · 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

    Jack Riding collapsed while playing football after a genetic heart condition caused his heart to stop, and he was declared dead in hospital on 15 August 2018. The report raised concerns about delays in deploying a defibrillator and directing ambulance personnel to the pitch, as well as the adequacy of emergency medical risk assessments, first-aid training, and related procedures. The report stated that these delays could not be said to have contributed to Mr Riding’s death but presented a risk of future death.

    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 training and drills for directing emergency services

    Wider context from the report

    “(2) I heard evidence that there was a significant delay in the ambulance personnel getting to the pitch after arriving at the front gates of the Goals Soccer Centres Plc premises. I saw some CCTV evidence that there was no one in the car park to meet and direct the paramedic crew. I have read the representations, from Goals Soccer Centres Plc, in particular appendix 13 for dealing with the arrival of emergency services, but it remains a concern to me how it is ensured the policy in place is followed to ensure that in the case of an emergency that valuable moments are not lost by paramedics not being directed appropriately. I have seen Appendix 2 of the response of Goals Soccer Centres Plc which sets out that the personnel at Goals, Liverpool North have been made aware of the new policy but I have seen insufficient evidence of programmes of training to be carried out in the future, or of training drills, or the like. I am concerned that whilst it could not be said on the evidential balance to have contributed to Mr Riding’s death, any delay of this kind presents a risk of future death. ”

    Source location

    Jack Riding · 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

    Circulate the Emergency First Aid Incident Procedure to all clubs to reinforce emergency roles and responsibilities.

    Verbatim wording from the response

    “In addition to First Aid training, all staff are trained in ‘situational awareness’. This training includes medical emergencies. In particular, the training includes directing a member of staff to go and wait for an ambulance at the nearest accessible entry point to the incident location and to accompany the paramedic crew to the casualty. In the case of Jack Riding this didn’t happen and we acknowledge that this part of the emergency was not handled in line with what Goals training. Since the incident, we have immediately circulated the Emergency First Aid Incident Procedure (appendix 13 in our response dated 18th November) to reaffirm the”

    Source location

    2018-0303-Responses
    Page 5 · response
    Published 13 December 2018

    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

    Finalise and implement the Goals Normal Operating Procedures and Emergency Action Plan across all clubs, incorporating emergency response procedures into regional audits.

    Verbatim wording from the response

    “In addition, the subsequent independent review of Health and Safety (commissioned following the incident) has provided a new draft document (Appendix 3) called “Goals Normal Operating Procedures and Emergency Action Plan 2019” which was created on the back of the updated “Goals First Aid risk assessment” (Appendix 9). The “Goals Normal Operating Procedures and Emergency Action Plan 2019” specifically includes (in section 2) an Emergency Action Plan for a variety of emergency scenarios. This documentation and actions within it have been agreed and a timeline for rollout across the business is as follows:”

    Source location

    2018-0303-Responses
    Page 6 · response
    Published 13 December 2018

    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 all club staff with scenario-based emergency First Aid training, including on-site role-play, video learning and annual refreshers.

    Verbatim wording from the response

    “As part of this rollout, situational training and emergency First Aid scenario training will be provided and role-played by all club staff and refreshed annually. Details of this can be found in the response to the training concern detailed in S5 (3).”

    Source location

    2018-0303-Responses
    Page 6 · response
    Published 13 December 2018

    Open published response

  2. Cheshire

    AI-generated summary

    Maureen Ann Colclough · 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

    Maureen Ann Colclough was found unresponsive at home on 16 December 2016 and was later confirmed deceased by paramedics. The report states that she was likely in a comatose state and that earlier medical intervention could have saved her. The principal concerns were inadequate staff training to recognise an emergency and reliance on presumptions when finding an unresponsive patient in a serious situation.

    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 staff training to recognise emergency situations

    Wider context from the report

    “1. Inadequate training of staff to recognise emergency situation. ”

    Source location

    Maureen Ann Colclough · 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

    Complete an inspection reviewing emergency training and service oversight.

    Verbatim wording from the response

    “We also agreed to conduct an inspection of the service, reviewing staff training in the event of an emergency and also the oversight that is provided by ████████. Two inspectors visited the service on 11 September 2017 and 21 September. I have detailed some of our findings under your specific questions below.”

    Source location

    2017-0318-Response-by-CQC
    Page 2 · response
    Published 3 December 2017

    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

    Notify all employees about emergency recognition and response requirements.

    Verbatim wording from the response

    “• All employees have been notified and almost ALL have undertaken a revised performance appraisal (regardless of any recent or up to date training) containing specific information and questions relating to recognizing an emergency situation as well as steps to take when finding an unresponsive service user.”

    Source location

    2017-0318-Response-by-Unique-Care-Services
    Page 1 · response
    Published 3 December 2017

    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

    Complete revised performance appraisals covering emergency recognition and response for remaining employees.

    Verbatim wording from the response

    “• All employees have been notified and almost ALL have undertaken a revised performance appraisal (regardless of any recent or up to date training) containing specific information and questions relating to recognizing an emergency situation as well as steps to take when finding an unresponsive service user.”

    Source location

    2017-0318-Response-by-Unique-Care-Services
    Page 1 · response
    Published 3 December 2017

    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 new starters with emergency-response information and assess their competence through questions and demonstration.

    Verbatim wording from the response

    “• All new starters will be given the relevant information and must answer a series of questions and show a satisfactory level of competence and understanding in recognizing an emergency situation and responding accordingly. (Employees have always been given this information in the past in the form of a handbook and have been required to sign to confirm receipt)”

    Source location

    2017-0318-Response-by-Unique-Care-Services
    Page 1 · response
    Published 3 December 2017

    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

    Notify employees that attendance at an additional Emergency First Aid course is mandatory.

    Verbatim wording from the response

    “• All employees of Unique Care Services have been made aware of that they MUST attend an extra Emergency First Aid training course on either of the dates provided and confirmed (Tuesday 26th September & Tuesday 3rd October)”

    Source location

    2017-0318-Response-by-Unique-Care-Services
    Page 1 · response
    Published 3 December 2017

    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 the additional mandatory Emergency First Aid course on one of the confirmed dates.

    Verbatim wording from the response

    “• All employees of Unique Care Services have been made aware of that they MUST attend an extra Emergency First Aid training course on either of the dates provided and confirmed (Tuesday 26th September & Tuesday 3rd October)”

    Source location

    2017-0318-Response-by-Unique-Care-Services
    Page 1 · response
    Published 3 December 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

    The claim that relevant first-aid training was not provided is disputed; training records and qualification certificates were supplied as evidence.

    Verbatim wording from the response

    “Please allow me to state that we as a company have ALWAYS provided the relevant training as well as promoting the options of many other training courses and qualifications even for developing skills unrelated to Domiciliary Care.”

    Source location

    2017-0318-Response-by-Unique-Care-Services
    Page 2 · response
    Published 3 December 2017

    Open published response

  3. Inner North London

    AI-generated summary

    Nasar AHMED · 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

    Nasar died following an anaphylactic reaction contributed to by asthma while he was in the internal exclusion room at school. The concerns included delayed or inappropriate advice about using his adrenaline auto-injector, discrepancies and gaps in asthma and allergy care planning, unsuitable emergency inhaler equipment, inadequate medication review systems, and shortcomings in staff awareness, training and emergency procedures.

    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 refresher training and information sharing for trained staff

    Wider context from the report

    “The respiratory paediatrician who gave evidence at inquest was firmly of the view that generic adrenaline auto-injectors should be available, in much the same way as defibrillators, in public spaces. Is this a suggestion that could be given wider consideration? 1. While staff at Nasar’s school were waiting for an ambulance, they asked for advice from the call operator about whether to administer his EpiPen. They were put through to a paramedic, who advised not to use it, I think because the classic signs of anaphylaxis were not obvious. However, the firm view expressed to me at inquest by Nasar’s respiratory paediatrician was that, if a person has an adrenaline auto-injector and: - has any respiratory compromise, or - there is a loss of consciousness, or - if there is doubt, then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately. He explained that any harm caused by giving intra muscular adrenaline from an auto-injector in this situation is likely to be minimal, even if it proves not to have been needed, whereas the good if it is needed is potentially lifesaving. 1. The picture presented by Nasar to his respiratory paediatrician did not accord, the consultant discovered at inquest, with that given to Nasar’s general practitioner. Nasar reported to his consultant that he was experiencing few symptoms, and he did extremely well in his last lung function test. Yet his GP found Nasar’s asthma control score to be 14 out of 25, which is poor; and his GP was prescribing 30 inhalers a year, the necessity for which is well recognised as being a risk factor for death. Nasar should have seen his consultant again. There must be a way of identifying a child in his position. For instance, could there be an automatic flag raised if excess medication is prescribed? 2. The asthma pump in Nasar’s medication box at school was an Accuhaler, which I heard from his respiratory consultant is inappropriate for an emergency situation such as this, and would not have assisted him. Moreover, the appropriate inhaler should have been accompanied by a spacer for best administration. I wonder whether there is a widespread lack of understanding of the best treatment in this situation? 3. The school nurse had updated Nasar’s care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before, the allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it. There must be a way of ensuring that the care plan is accurate and up to date, and that there are identical copies stored at home, school, the GP surgery and within the hospital records. 4. Even if the correct action plan had been used, it does not give the instruction that if a person has an adrenaline auto-injector and: - has any respiratory compromise, or - there is a loss of consciousness, or - if there is doubt, then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately. This was the very firm view of Nasar’s respiratory consultant. Is there a way of disseminating this advice more widely? 1. Although Nasar’s mother was present for Nasar’s medication review conducted by the school nurse, there was no school representative such as the year learning manager there for the meeting, contrary to school policy. 2. The school nurse identified Nasar’s medication as being out of date, and asked that in-date medication be provided, but there was no robust system for ensuring that he was booked in for further review when this was provided. 3. Although all staff at the Bow School were encouraged to familiarise themselves with pupils’ care plans, they often did not unless there was a school excursion. The internal exclusion room (IER) supervisor had not done this for the pupils in the IER. Even the deputy headteacher, who had in the past taught Nasar, did not know about Nasar’s food allergies or the fact that he had a care plan and allergy action plan when he placed Nasar in the IER. 4. Not everyone involved in trying to help Nasar was first aid trained, most notably not the learning assistant who was supervising the IER. She said that she would not have thought of looking for and retrieving his care plan. 5. Even those members of staff who were first aid trained it seemed might benefit from additional and/or more frequent training. One member of staff did not share with others the fact that Nasar had asked for this asthma pump. Another looked at his individual healthcare plan, but could not remember looking at the allergy action plan. 6. One member of staff forgot Nasar’s name. It is of course not possible for members of staff to remember the names of all pupils, but perhaps typed forms accompanied by a photograph might help? 7. Although not followed in this instance, I heard that the school policy dictates that the headteacher’s personal assistant should be contacted to telephone the emergency services. Such a stipulation would surely be guaranteed to add delay. 1. When the school nurse (employed by Compass Wellbeing) conducted a review of Nasar’s medication in May 2016, he did not have the medication stored in school in front of him at the time, but relied on its description by a school receptionist. 2. Although Nasar’s mother was present for the review, there was no school representative, such as the year learning manager (head of year), there for the meeting. 3. The school nurse then updated the care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it. 4. He identified the medication as being out of date, and asked that in-date medication be provided, but did not diary forward to the following week to ensure that current medication was now in the box. This meant that he also did not complete the action plan with the dose of the relevant medication. These points raise issues about the actions of this particular nurse and potentially of other nurses in this role in other schools. ”

    Source location

    Nasar AHMED · Prevention of Future Deaths report
    Page 12 · 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

    Review school-nurse training requirements and deliver competency-framework retraining and IHCP training to staff.

    Verbatim wording from the response

    “CWB has also fully reviewed and identified the training received by school nurses and what they are required to receive in order to complete IHCPs in line with CWB's Competency Framework. The Competency Framework is a learning and development resource for nurses and this is completed upon their induction to the service. Re-training has been delivered in line with this Competency Framework. IHCP training has also been undertaken by all staff on 22 June 2017 in order to re-emphasise the role of a qualified nurse with reference to the guidance and the support of administering medication by non-”

    Source location

    Response from Compass Wellbeing
    Page 3 · response
    Published 3 May 2023

    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 tailored biannual school-nursing training covering record keeping, communication, action follow-up, electronic diaries and diary management.

    Verbatim wording from the response

    “In addition to the above training, the bi-annual training received by the school nursing service was delivered in June 2017. During bi-annual training, the service is suspended and training takes place across all staff groups. The training has been tailored to support the key learning points from the tragic death of Nasar Ahmed and the requirements and expectations of a school nurse. It covered a range of key areas including how to improve record keeping and the importance of this, the increased function of school nurse administrators in communication and following up of actions with key staff in school and the parents, the use of electronic diary systems and diary management. A copy of the training schedule undertaken in June 2017 is attached.”

    Source location

    Response from Compass Wellbeing
    Page 4 · response
    Published 3 May 2023

    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

    Continue delivering specific IHCP training on a biannual basis.

    Verbatim wording from the response

    “Specific IHCP training will continue to take place on a bi-annual basis. The next scheduled training is for September 2017.”

    Source location

    Response from Compass Wellbeing
    Page 4 · response
    Published 3 May 2023

    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

    Prepare a Partnership Agreement defining school and School Health Service responsibilities, including school liaison arrangements for IHCPs and review meetings.

    Verbatim wording from the response

    “Following Nasar’s sad death CWB have prepared a Partnership Agreement between CWB and schools across the Borough of Tower Hamlets. This agreement sets out arrangements for support and training for education staff, as well as detailing the expectations across the organisational boundaries. Page 7 of the Agreement (copy enclosed) outlines the roles and responsibilities of the School Health Service and the school. It specifically requires that a member of staff will be identified who will liaise with the School Health Service. The identified school staff member is the person responsible for that child and who has”

    Source location

    Response from Compass Wellbeing
    Page 4 · response
    Published 3 May 2023

    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

    Revise the asthma plan template and commence secure electronic sharing of individual asthma plans with schools and the School Health Service, supported by staff training.

    Verbatim wording from the response

    “Furthermore, as part of this partnership, CWB with the assistance of the respiratory clinical nurse specialist, has revised an asthma plan template for children and a process for sharing individual asthma plans with the school nursing service and schools has been commenced. A child’s individual asthma plan created by the GP/practice nurse or the specialist team will now be sent directly through to the School Health Service via secure generic email accounts. These email accounts are monitored on a daily basis. The plan will be attached to the child’s health record and an email sent to the relevant school nurse. Training has been given to our staff team.”

    Source location

    Response from Compass Wellbeing
    Page 5 · response
    Published 3 May 2023

    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

    Brief staff on pupils’ medical needs, provide recurring reminders and conduct Safeguarding Committee compliance spot checks.

    Verbatim wording from the response

    “The school’s SENDCo will provide briefings to all staff for children with medical needs each September. Further briefings will be provided to all staff if a child with medical needs starts in year and all new staff receive the briefing as part of their induction if they do not start in September or if a child’s needs change following a review. All staff received a briefing on the pupils with medical needs on the 05.06.17 and will receive half-termly reminders. Those reminders will also require they review their ‘class context sheets’ to ensure medical information for students is up to date. The Safeguarding Committee will undertake spot checks to ensure compliance, the first of which will be completed by the 04.07.17.”

    Source location

    Response from Bow School
    Page 3 · response
    Published 3 May 2023

    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 asthma, allergy and EpiPen training to staff who have completed HSE first-aid training, alongside refresher training.

    Verbatim wording from the response

    “First aid training programmes are added to the calendar at the start of each academic year, with staff identified for each course. This can only be amended on the authority of the Headteacher. In addition, those who have already completed their HSE first aid programme will receive an additional one-day training on asthma, allergies and Epi-Pen. This is in addition to the first aid training at work refresher courses.”

    Source location

    Response from Bow School
    Page 5 · response
    Published 3 May 2023

    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

    Hold monthly school-nurse meetings for trained first aiders to share current advice, guidance and practice.

    Verbatim wording from the response

    “Those members of staff who have already completed a HSE approved first aid training course will, from September 2017, meet monthly with the school nurse to share information and review latest advice, guidance and practice. The school’s half-termly safeguarding bulletins contain an updated list of all first aiders in the school and they have agreed to run regular briefings for staff at the start of each half-term. They will also run briefings for pupils on a rolling programme so that there is increased awareness of who on the staff team have first aid training.”

    Source location

    Response from Bow School
    Page 5 · response
    Published 3 May 2023

    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

    Brief staff on recognising and responding to escalating asthma and anaphylaxis symptoms, and repeat the briefing.

    Verbatim wording from the response

    “On the 05.06.17 a member of the Governing Body who is also a GP provided a briefing to all staff on the policy and procedures for supporting students with medical needs. . He explained how to identify Asthma and Anaphylaxis symptoms which indicate medical needs were escalating or becoming critical and how to respond. This briefing is due to be repeated in September 2017.”

    Source location

    Response from Bow School
    Page 5 · response
    Published 3 May 2023

    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

    School staff are not expected to perform first aid to the standard of clinicians; guidance requires only their best endeavours to secure pupil welfare.

    Verbatim wording from the response

    “The Coroner rightly recognised within the narrative determination this was ‘a very pressured situation’. She queried whether staff may have responded differently if they had received training or, for those who had, whether they may benefit from additional first aid training. It is important to highlight that staff administering first aid are not expected to perform those responsibilities to the standard of clinicians trained to perform emergency medical interventions where they are held. The guidance simply requires that staff use their ‘best endeavours’ to secure the welfare of the pupil. It is understood that the Coroner did not intend her comments to be taken as a criticism of the actions of staff on that day. To do so may well have an unintended consequence of deterring otherwise willing volunteers from taking on these vital responsibilities.”

    Source location

    Response from Bow School
    Page 4 · response
    Published 3 May 2023

    Open published response

  4. Inner South London

    AI-generated summary

    James O’Brien · 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 O’Brien collapsed in his room at Churchill Hospital on the night of 8/9 December 2015 and died at St Thomas’ Hospital on 9 December 2015. Concerns included delays in starting resuscitation, calling an ambulance and bringing the defibrillator, inappropriate defibrillator attachment, inadequate information provided to ambulance services, and failures in staff training, induction and ward familiarity. The inquest concluded that the emergency response by hospital staff was inadequate and that earlier intervention might have made a difference.

    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 ensure adequate staff training for emergency response

    Wider context from the report

    “(7) There was a failure to ensure that staff were adequately trained to respond to an emergency situation. ”

    Source location

    James O’Brien · 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

    Arrange oxygen-therapy training for all nursing staff.

    Verbatim wording from the response

    “1. First Aid Training – corporately, Cambian Adult Services have adopted a first aid training system which is rated between basic life support and intermediate life support. This is felt to be appropriate for psychiatric hospitals and the hospital has never had any concerns raised at inspections by CQC, as the regulator of the services that it provides, to suggest that that does not meet their requirements for such units. In addition, as they may have patients with physical health care needs that include the need for oxygen, our client has arranged for all nursing staff to be trained in oxygen therapy. To ensure however that practice is in accordance with best practice, our client has commissioned an external expert review of their Resuscitation Policy procedure and practices.”

    Source location

    2017-0082-Response-by-Cambian-Group-PLC
    Page 2 · response
    Published 24 March 2017

    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

    Commission an external expert review of resuscitation policies, procedures and practices.

    Verbatim wording from the response

    “1. First Aid Training – corporately, Cambian Adult Services have adopted a first aid training system which is rated between basic life support and intermediate life support. This is felt to be appropriate for psychiatric hospitals and the hospital has never had any concerns raised at inspections by CQC, as the regulator of the services that it provides, to suggest that that does not meet their requirements for such units. In addition, as they may have patients with physical health care needs that include the need for oxygen, our client has arranged for all nursing staff to be trained in oxygen therapy. To ensure however that practice is in accordance with best practice, our client has commissioned an external expert review of their Resuscitation Policy procedure and practices.”

    Source location

    2017-0082-Response-by-Cambian-Group-PLC
    Page 2 · response
    Published 24 March 2017

    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

    Establish local emergency-response and alarm protocols covering escalation, responder responsibilities and radio use.

    Verbatim wording from the response

    “3. Responding to Emergencies – all staff are required to undertake the on-line training provided by Cambian Adult Services on responding to emergencies.”

    Source location

    2017-0082-Response-by-Cambian-Group-PLC
    Page 3 · response
    Published 24 March 2017

    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

    Run twice-monthly unannounced resuscitation simulations, audit outcomes and feed learning into staff feedback and clinical governance.

    Verbatim wording from the response

    “4. Practice Drills – to assist in identifying any skills gaps, unannounced resuscitation simulations take place twice a month at the Cambian Churchill Hospital with the outcomes discussed in monthly clinical governance meetings. A resuscitation doll has been purchased specifically for these drills and this enables the resuscitation exercise to be as realistic as possible. Practice drills are recorded and audited. Areas of good practice and learning points are recorded and this information is fed back to the staff team who attended that particular simulation exercise. It is then further discussed in clinical governance meetings so that any themes or trends can be identified and addressed.”

    Source location

    2017-0082-Response-by-Cambian-Group-PLC
    Page 3 · response
    Published 24 March 2017

    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

    Review induction processes to cover record keeping, observation and emergency response, including orientation tours for unfamiliar staff.

    Verbatim wording from the response

    “5. Induction – the hospital had already reviewed its induction processes. This specifically includes the topics of record keeping, observation and responding to emergencies. Staff that are not familiar with the hospital are provided with a “tour” by more experienced staff when they first start work at the hospital. The hospital is committed to using its own staff and their pool of bank staff wherever possible rather than agency staff. To ensure appropriate staffing levels on any particular shift, managers are required to plan bank staff cover in advance to address planned staff absences. Since August 2016, no agency staff have been used at the hospital.”

    Source location

    2017-0082-Response-by-Cambian-Group-PLC
    Page 3 · response
    Published 24 March 2017

    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 the NEWS system and train all hospital staff to use its observations-based escalation tool.

    Verbatim wording from the response

    “1. Cambian Adult Services have introduced at the hospital the NEWS system (National early warning signs for acutely unwell patients) developed recently by the Royal College of psychiatrists. This is a”

    Source location

    2017-0082-Response-by-Cambian-Group-PLC
    Page 3 · response
    Published 24 March 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

    The former operator no longer controls future hospital safety steps, which fall to the successor operator.

    Verbatim wording from the response

    “The Churchill Hospital was at the date of Mr O’Brien’s death operated by Cambian Healthcare Limited which was then part of our Group. However, in December 2016 we sold our adult services division, including Cambian Healthcare Limited. The Group, therefore, no longer has any executive responsibility in relation to the hospital. Cambian Healthcare Limited is now a subsidiary of Cygnet Healthcare Limited and its Chief Executive Officer is Dr Tony Romero.”

    Source location

    2017-0082-Response-by-Cambian-Group-PLC
    Page 1 · response
    Published 24 March 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

    The existing first-aid training system is considered appropriate for psychiatric hospitals and sufficient to meet regulatory requirements.

    Verbatim wording from the response

    “1. First Aid Training – corporately, Cambian Adult Services have adopted a first aid training system which is rated between basic life support and intermediate life support. This is felt to be appropriate for psychiatric hospitals and the hospital has never had any concerns raised at inspections by CQC, as the regulator of the services that it provides, to suggest that that does not meet their requirements for such units. In addition, as they may have patients with physical health care needs that include the need for oxygen, our client has arranged for all nursing staff to be trained in oxygen therapy. To ensure however that practice is in accordance with best practice, our client has commissioned an external expert review of their Resuscitation Policy procedure and practices.”

    Source location

    2017-0082-Response-by-Cambian-Group-PLC
    Page 2 · response
    Published 24 March 2017

    Open published response

  5. Inner West London

    AI-generated summary

    Patricia Mercieca · 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

    Patricia Mercieca, who had severe COPD and asthma and lived in assisted accommodation, pulled her emergency cord on 14 July 2015 and said that she could not breathe. She arrested shortly afterwards and was found deceased when the ambulance service arrived. Concerns included failures to provide correct information and follow up when she did not respond, to contact the resident manager, and to pass on relevant medical history and information requested by emergency services.

    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 refresher training for contacting resident managers after Westminster residents' medical emergency calls

    Wider context from the report

    “(1) That the call handlers need to be refresher trained in relation to contacting resident managers for Westminster residents following a medical emergency call. ”

    Source location

    Patricia Mercieca · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026