First reported 21 May 2015•Latest report 16 Apr 2026
Definition
What this concern includes
Includes failures of any dedicated recognition, training, triage, prompting or response control for agonal breathing where the control is intended to ensure timely identification and emergency action.
Not included
Excludes failures concerning recognition of unrelated medical conditions or general patient deterioration.
Excludes generic first-aid, staffing or communication deficiencies not explicitly tied to agonal-breathing recognition.
Excludes failures limited to the subsequent delivery of CPR or rescue breaths where recognition of agonal breathing is not the issue.
Reports
7
Distinct published reports
Individual concerns
7
A report can raise multiple concerns
Date range
2015–2026
First to latest report issue date
Stated actions
25
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.
Department of Health and Social Care3
Association of Ambulance Chief Executives1
British Society For Genetic Medicine1
Cardiac Risk in the Young1
Care Quality Commission1
College of Policing1
Emirates1
Faculty of Sport and Exercise Medicine UK1
London Ambulance Service NHS Trust1
London Central & West Unscheduled Care Collaborative Limited1
Manchester Airports Group plc1
Metropolitan Police Service1
NHS England1
NHS Pathways1
North East Ambulance Service NHS Foundation Trust1
NHS trust4
Ministerial department3
Sub-organisation2
Airport operator1
Air transport operator1
Executive non-departmental public body1
Health and social care service regulator1
Health professional body1
Health-sector membership body1
Independent healthcare provider1
National policing body1
Other public body1
Police force1
Registered charity1
Sport governing body1
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.
West London
Concerns raised1
Difficulty among lay people and ambulance call handlers in recognising signs of agonal breathing or cardiac arrest
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these 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.20
Action
Support national initiatives that increase cardiac-arrest recognition, CPR education and first-aid training.
Stated by Association of Ambulance Chief ExecutivesStated in progressThe respondent said that this action was in progress when they made their response on 27 April 2026.
Action
Support Restart a Heart and related public cardiac-arrest awareness and CPR-education initiatives.
Stated by Association of Ambulance Chief ExecutivesStated in progressThe respondent said that this action was in progress when they made their response on 27 April 2026.
Action
Encourage and support Community First Responders across the ambulance sector to provide early CPR and defibrillation.
Stated by Association of Ambulance Chief ExecutivesStated in progressThe respondent said that this action was in progress when they made their response on 27 April 2026.
Action
Use a breathing-rate threshold to support recognition of agonal breathing in NHS Pathways triage.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 27 April 2026.
Action
Presume cardiac arrest in NHS Pathways when a person collapses and becomes unconscious during exercise or sport, including when fitting is reported.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 27 April 2026.
Action
Work with MPDS and NHS Pathways coding sub-groups to consider further measures supporting recognition of agonal breathing or cardiac arrest.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 27 April 2026.
Action
Train CPR participants to recognise agonal breathing and commence CPR when a person is unresponsive and not breathing normally.
Stated by St John AmbulanceStated completedThe respondent said that this action was complete when they made their response on 27 April 2026.
Action
Incorporate updated national guidance into training so CPR is commenced immediately when someone collapses during exercise and is unresponsive.
Stated by St John AmbulanceStated in progressThe respondent said that this action was in progress when they made their response on 27 April 2026.
Action
Strengthen emergency call-taker training with audible agonal-breathing examples, listening-skills guidance and clinical-escalation emphasis.
Stated by South Central Ambulance Service NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 27 April 2026.
Action
Trial the Pre-Sieve Questions Project to reduce pre-sieve questioning and accelerate Nature of Call selection.
Stated by South Central Ambulance Service NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 27 April 2026.
Action
Replace the computer-aided dispatch system and use the pilot outcome to inform its pre-sieve question set.
Stated by South Central Ambulance Service NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 27 April 2026.
Action
Review another ambulance service’s video-assisted resuscitation guidance pilot to assess whether implementation would benefit local telephone triage.
Stated by South Central Ambulance Service NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 27 April 2026.
Action
Use a less-than-one-breath-per-ten-seconds threshold in NHS Pathways to support recognition of agonal breathing.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 27 April 2026.
Action
Presume collapse with unconsciousness during exercise or sport, including reported fitting, to be cardiac arrest regardless of apparent regular breathing.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 27 April 2026.
Action
Work with MPDS and NHS Pathways coding sub-groups to consider further measures helping the public recognise agonal breathing or cardiac arrest.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 27 April 2026.
Action
Revise SCA, first-aid and defibrillator training content to incorporate current guidance, case learning and clearer emergency-response instructions.
Stated by The Football AssociationStated completedThe respondent said that this action was complete when they made their response on 27 April 2026.
Action
Require tutors to reinforce key SCA-response messages and show abnormal-breathing videos at every face-to-face course.
Stated by The Football AssociationStated completedThe respondent said that this action was complete when they made their response on 27 April 2026.
Action
Publish simplified guidance directing people to suspect cardiac arrest when an unresponsive person has abnormal breathing.
Stated by Resuscitation Council UKStated completedThe respondent said that this action was complete when they made their response on 27 April 2026.
Action
Work with NHS England through NHS Pathways to support standardised dispatch algorithms and telephone-assisted CPR instructions.
Stated by Resuscitation Council UKStated in progressThe respondent said that this action was in progress when they made their response on 27 April 2026.
Action
Strengthen public education campaigns, including an annual Restart a Heart focus on recognising and raising awareness of agonal breathing.
Stated by Resuscitation Council UKStated plannedThe respondent said that this action was planned when they made their response on 27 April 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
Training and education of ambulance staff and the public, including defibrillator use, are outside the organisation’s responsibilities.
Stated by Association of Ambulance Chief ExecutivesOutside remitThe respondent said that this matter was outside its role or authority.
Position
Pre-sieve questions cannot be integrated into the current computer-aided dispatch system because of its technological limitations.
Stated by South Central Ambulance Service NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
NHS England will respond on concerns about recognising agonal breathing or cardiac arrest, defibrillator use, and cascade communication of hereditary conditions.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Manchester North
Concerns raised1
Failure to provide training on recognising agonal breathing
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.1
Action
Complete the FALP review and update learning outcomes to cover agonal gasps, cardiac arrest recognition and basic life support.
Stated by College of PolicingStated completedThe respondent said that this action was complete when they made their response on 28 June 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Individual forces are responsible for developing FALP learning materials, including video content, under local clinical governance procedures.
Stated by College of PolicingRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The reviewed FALP and new PPST are considered to provide policing with the necessary skills to preserve life and keep the public safe.
Stated by College of PolicingExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
East London
Concerns raised1
Failure to recognise agonal breaths
This report raised 9 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
Introduce agonal-breathing video clips into Emergency Life Support training.
Stated by Metropolitan Police ServiceStated plannedThe respondent said that this action was planned when they made their response on 23 August 2019.
Manchester City
Concerns raised1
Inadequate training of airline staff to recognise cardiac arrest and administer first aid or prompt CPR
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.
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
Provide initial and annual refresher first-aid and CPR training to cabin crew, including recognition of abnormal breathing as a cardiac-arrest sign.
Stated by EmiratesStated completedThe respondent said that this action was complete when they made their response on 2 October 2017.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing training, manuals and ongoing monitoring of resuscitation developments are considered sufficient; no additional cardiac-arrest training action is proposed.
Stated by EmiratesExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Inner North London
Concerns raised1
Lack of a triage tool to recognise agonal or inadequate breathing
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.
Inner North London
Concerns raised1
Insufficient training of 111 call handlers in recognising agonal breathing
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Northumberland (North)
Concerns raised1
Failure of the Pathways system to prompt CPR advice for patients with agonal breathing
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.2
Action
Conduct a comprehensive NEAS inspection covering call-handler support, ambulance dispatch, arrival-time breaches, and patient handover procedures.
Stated by Care Quality CommissionStated plannedThe respondent said that this action was planned when they made their response on 21 May 2015.
Action
Require NEAS to provide evidence of how it is mitigating risks in the Pathways system and working with the Pathways programme to improve it.
Stated by Care Quality CommissionStated completedThe respondent said that this action was complete when they made their response on 21 May 2015.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
NHS Pathways disputes that the system is faulty, stating it already identifies noisy breathing as requiring CPR advice.
Stated by Department of Health and Social CareDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
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Includes failures of any dedicated recognition, training, triage, prompting or response control for agonal breathing where the control is intended to ensure timely identification and emergency action.
