First reported 31 Jan 2017•Latest report 19 Sep 2023
Definition
What this concern includes
Includes failures of guidance, protocols or decision criteria specifically governing whether to continue, stop or withhold resuscitation, including definitions of futility, timing thresholds and consistency between national and local guidance.
Not included
Excludes failures to recognise cardiac arrest or agonal breathing where the decision guidance itself is not deficient.
Excludes failures in CPR delivery, resuscitation equipment, staffing or emergency leadership unless they directly concern criteria for stopping or withholding resuscitation.
Excludes general clinical decision-making or guidance deficiencies unrelated to resuscitation-limitation decisions.
Excludes treatment decisions about hospital transfer or thrombolysis unless they are part of the same explicit decision about continuing or stopping resuscitation.
Reports
5
Distinct published reports
Individual concerns
5
A report can raise multiple concerns
Date range
2017–2023
First to latest report issue date
Stated actions
19
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.
Association of Ambulance Chief Executives2
Care Quality Commission1
Department of Health and Social Care1
East Midlands Ambulance Service NHS Trust1
Joint Royal Colleges Ambulance Liaison Committee1
Practice Plus Group1
Resuscitation Council UK1
South Western Ambulance Service NHS Foundation Trust1
Yorkshire Ambulance Service NHS Trust1
NHS trust3
Health-sector membership body2
Health and social care service regulator1
Health professional body1
Health professional committee1
Independent healthcare provider1
Ministerial department1
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.
South Yorkshire (Western)
Concerns raised1
Lack of guidance or protocols on when to stop resuscitation
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.5
Action
Update termination-of-resuscitation guidance, extending the recommended termination decision point from 20 to 30 minutes.
Stated by Association of Ambulance Chief ExecutivesStated completedThe respondent said that this action was complete when they made their response on 22 November 2023.
Action
Continue reviewing and updating ambulance clinical guidance regularly and when new evidence becomes available.
Stated by Association of Ambulance Chief ExecutivesStated in progressThe respondent said that this action was in progress when they made their response on 22 November 2023.
Action
Participate in the ongoing national study examining how and where to stop out-of-hospital cardiac-arrest resuscitation attempts.
Stated by Association of Ambulance Chief ExecutivesStated in progressThe respondent said that this action was in progress when they made their response on 22 November 2023.
Action
Review and update clinical documentation supporting decisions to terminate resuscitation attempts.
Stated by Yorkshire Ambulance Service NHS Trust (YASStated plannedThe respondent said that this action was planned when they made their response on 22 November 2023.
Action
Cover decisions to terminate resuscitation attempts in annual clinical refresher training.
Stated by Yorkshire Ambulance Service NHS Trust (YASStated plannedThe respondent said that this action was planned when they made their response on 22 November 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Existing JRCALC guidance provides resuscitation, termination, thrombolysis and conveyance instructions for ambulance clinicians.
Stated by Association of Ambulance Chief ExecutivesExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Existing JRCALC and Resuscitation Council guidelines clearly address resuscitation and potentially reversible causes, including suspected pulmonary embolism.
Stated by Yorkshire Ambulance Service NHS Trust (YASExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
South Yorkshire (Eastern)
Concerns raised1
Confusing definitions of post-death signs in CPR decision-making guidance
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.3
Action
Share the response with the guidance authors and the RCUK Community and Ambulance Resuscitation committee.
Stated by Resuscitation Council UKStated completedThe respondent said that this action was complete when they made their response on 4 May 2021.
Action
Teach staff the practical meaning of terminology used in Resuscitation Council UK guidance.
Stated by Practice Plus GroupStated plannedThe respondent said that this action was planned when they made their response on 4 May 2021.
Action
Incorporate revisions to the relevant guidance into Practice Plus Group training.
Stated by Practice Plus GroupStated plannedThe respondent said that this action was planned when they made their response on 4 May 2021.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Changing the terminology in the prison CPR guidance is outside the respondent’s control.
Stated by Practice Plus GroupOutside remitThe respondent said that this matter was outside its role or authority.
Wiltshire and Swindon
Concerns raised1
Failure to limit Do Not Resuscitate document applicability to natural deaths
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.8
Action
Promote a specific inspection focus on apparent suicide attempts where a do-not-resuscitate order is present.
Stated by Care Quality CommissionStated plannedThe respondent said that this action was planned when they made their response on 20 April 2020.
Action
Review and strengthen JRCALC guidance on resuscitation exceptions and DNACPR application.
Stated by Association of Ambulance Chief ExecutivesStated plannedThe respondent said that this action was planned when they made their response on 20 April 2020.
Action
Commission a review of pandemic-era DNACPR use to identify recommendations preventing inappropriate notices on patient records.
Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 20 April 2020.
Action
Drive forward implementation of the Care Quality Commission’s recommendations on pandemic-era DNACPR use.
Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 20 April 2020.
Action
Continue consulting on regulatory next steps and reviewing and updating regulatory approaches, including scope for end-of-life and DNAR/TEP regulation.
Stated by Care Quality CommissionStated in progressThe respondent said that this action was in progress when they made their response on 20 April 2020.
Action
Continue responding to DNAR/TEP risks through routine regulatory monitoring and inspection during the consultation period.
Stated by Care Quality CommissionStated in progressThe respondent said that this action was in progress when they made their response on 20 April 2020.
Action
Publish a national report on findings and recommendations concerning DNACPR decisions during the COVID-19 pandemic.
Stated by Care Quality CommissionStated plannedThe respondent said that this action was planned when they made their response on 20 April 2020.
Action
Share key learning and practice points from the inquest with inspectors.
Stated by Care Quality CommissionStated plannedThe respondent said that this action was planned when they made their response on 20 April 2020.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
The healthcare professionals responsible for immediate care retain the final decision on whether attempting CPR is clinically appropriate.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Previous inspections found no relevant concerns about either practice’s policies, training, systems, or end-of-life care arrangements.
Stated by Care Quality CommissionDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Manchester North
Concerns raised1
Ambiguous and inconsistent guidance on diagnosis of death and timing of resuscitation decisions
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.
Nottinghamshire
Concerns raised1
Lack of guidance for determining when resuscitation is futile
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.3
Action
Revise and approve the Diagnosis of Death Procedure to clarify wording, align flowcharts, and provide guidance on recognising futile resuscitation.
Stated by East Midlands Ambulance Service NHS TrustStated completedThe respondent said that this action was complete when they made their response on 19 February 2017.
Action
Update the clinician action card with Diagnosis of Death Procedure guidance on futility and when resuscitation should not be commenced or continued.
Stated by East Midlands Ambulance Service NHS TrustStated completedThe respondent said that this action was complete when they made their response on 19 February 2017.
Action
Issue the updated action cards to all ambulance clinicians.
Stated by East Midlands Ambulance Service NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 19 February 2017.
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Includes failures of guidance, protocols or decision criteria specifically governing whether to continue, stop or withhold resuscitation, including definitions of futility, timing thresholds and consistency between national and local guidance.
