Recurring concern

Unreliable procedures for recognising and confirming death

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First reported 8 Jan 2016•Latest report 18 Jul 2018

Definition

What this concern includes

Includes failures in processes for recognising death or arranging its confirmation, including local policies, reference guidance, call-out criteria, staff awareness, training and escalation to emergency services or GPs where these controls directly support death confirmation.

Not included

Excludes post-death investigation, coronial autopsy, inquest disclosure and death-notification-record concerns where the issue arises after death has been reliably recognised and confirmed.
Excludes resuscitation-performance failures, including CPR or recognition of agonal breathing, unless they directly concern the decision or process for recognising and confirming death.
Excludes prison-specific death-verification assertions where the existing narrower prison concern is the more faithful boundary.
Excludes generic policy, training or communication deficiencies that are not directly tied to recognising death or arranging its confirmation.

Reports: 3
Individual concerns: 4
Date range: 2016–2018
Stated actions: 3

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Care Quality Commission1

Cornwall and the Isles of Scilly Safeguarding Adults Board1

Department of Health and Social Care1

East Midlands Ambulance Service NHS Trust1

Manchester University NHS Foundation Trust1

Royal College of Obstetricians and Gynaecologists1

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.

18 Jul2018
Manchester (West)
Concerns raised1
1. Diminishing of scans for confirmation of fetal death
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.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Mohamed Rahman · 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

Baby Mohamed Rahman was born at 01:45 on 17 February 2018 after an elective feticide procedure and was confirmed dead at 02:48 that day. The principal concerns were that fetal asystole was not unequivocally confirmed before discharge, that the mother and professionals were unprepared for the birth, and that documentation and guidance about confirming fetal demise and explaining the procedure to parents required consideration.

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
Diminishing of scans for confirmation of fetal death
Wider context from the report
“1. Mother in particular but also the experienced professionals involved were wholly unprepared for what they witnessed and the feelings of birth when “stunned”, “shocked” and “distressed” were amongst the epithets given in evidence to describe their experience with the birth. The Neonatal team were not present and would not have expected to be present and had to be called urgently to review what had occurred. However well-intentioned - the attempt to reduce the time that a patient waits for the Department of Fetal Medicine scan is time performed by diminishing the scan for confirmation of fetal death contributed to this unintended outcome after termination of the pregnancy. ”
Source location
Mohamed Rahman · Prevention of Future Deaths report
Page 2 · concerns
Open source report
31 Jan2017
Nottinghamshire
Concerns raised2
1. Lack of clarity and consistency in the diagnosis-of-death procedure
2. Unavailability of a reference guide reflecting local diagnosis-of-death policies
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 3
1. 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 completed
2. 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 completed
3. Action
  Issue the updated action cards to all ambulance clinicians.
  Stated by East Midlands Ambulance Service NHS TrustStated planned
Respondent positions 1
1. Position
  The Diagnosis of Death Procedure was based on national guidance and was deemed safe, although it was subsequently reviewed and revised.
  Stated by East Midlands Ambulance Service NHS TrustDisputes the concern
AI-generated summary

Dipa Rameshchandra Lad · 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

Dipa Lad died after using an item of clothing to ligate on 4 March 2016; the medical cause of death was ligature pressure to the neck. The principal concerns related to differences between national guidance and the local ambulance protocol for stopping resuscitation, including the lack of guidance on when resuscitation was futile, staff awareness and training, and the clarity of the procedure. A further concern related to the technique used by one technician when giving chest compressions.

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 and consistency in the diagnosis-of-death procedure
Wider context from the report
“6. I do not consider the current EMAS ‘Diagnosis of Death Procedure’ to be sufficiently clear / consistent (particularly when comparing the wording and the flow - charts). This also contains no guidance on when resuscitation should be considered ‘futile’, as referred to above. ”
Source location
Dipa Rameshchandra Lad · 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
Unavailability of a reference guide reflecting local diagnosis-of-death policies
Wider context from the report
“5. We heard that staff carry JRCALC pocketbooks as reference guides. EMAS policy around diagnosis of death differs in a key respect from JRCALC guidelines – but there is no equivalent pocketbook / amendment to existing pocketbook / similar which reflects local policies. ”
Source location
Dipa Rameshchandra Lad · 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
Revise and approve the Diagnosis of Death Procedure to clarify wording, align flowcharts, and provide guidance on recognising futile resuscitation.

Verbatim wording from the response
“Although the procedure was based upon national guidance and was deemed to be safe following this inquest the current EMAS Diagnosis of Death Procedure has been reviewed again against the national guidance. The revised version has been approved within EMAS and I have attached a copy for your reference.”

Source location
2017-0019-Response-by-East-Midlands-Ambulance-Service-NHS-Trust
Page 2 · response
Published 19 February 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
Update the clinician action card with Diagnosis of Death Procedure guidance on futility and when resuscitation should not be commenced or continued.

Verbatim wording from the response
“To support clinicians and assist clinicians with recognising when resuscitation may be futile, an action card has been updated to include the relevant parts of the update of the Diagnosis of Death Procedure which assists with identifying the key features if managing a cardiac arrest with appropriate management plans. This will include the guidance around ‘futility’ and when resuscitation should not be commenced/continued. The action cards will be issued to all ambulance clinicians to support them within their role.”

Source location
2017-0019-Response-by-East-Midlands-Ambulance-Service-NHS-Trust
Page 5 · response
Published 19 February 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
Issue the updated action cards to all ambulance clinicians.

Verbatim wording from the response
“To support clinicians and assist clinicians with recognising when resuscitation may be futile, an action card has been updated to include the relevant parts of the update of the Diagnosis of Death Procedure which assists with identifying the key features if managing a cardiac arrest with appropriate management plans. This will include the guidance around ‘futility’ and when resuscitation should not be commenced/continued. The action cards will be issued to all ambulance clinicians to support them within their role.”

Source location
2017-0019-Response-by-East-Midlands-Ambulance-Service-NHS-Trust
Page 5 · response
Published 19 February 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 Diagnosis of Death Procedure was based on national guidance and was deemed safe, although it was subsequently reviewed and revised.

Verbatim wording from the response
“The development of the EMAS Diagnosis of Death Procedure has been reviewed and the procedure was developed around and is based upon current national guidance. Decisions Relating to Cardiopulmonary Resuscitation was a guidance document issued from the British Medical Association (BMA), the Resuscitation Council (UK) (RCUK) and the Royal College of Nursing (RCN) and was used when developing the procedure. The 3rd edition (1st revision) was published in 2016 and a copy has been included with our response letter. During the development of the procedure it was sent out for consultation to a wide range of stakeholders including HM Coroners across the East Midlands region and any feedback received was incorporated into the document. Following the amendments, the procedure was approved through the normal EMAS governance procedures.”

Source location
2017-0019-Response-by-East-Midlands-Ambulance-Service-NHS-Trust
Page 2 · response
Published 19 February 2017
Open published response
8 Jan2016
Cornwall
Concerns raised1
1. Lack of adequate care-home policies and staff preparation for recognising or arranging confirmation of death
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.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Norman Dorn · 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

Norman Dorn was found presumed dead in an armchair at a residential home after eating a jam sandwich, with food in his mouth. He was known to have swallowing problems, and staff did not remove the food or attempt resuscitation; the report also states that the GP and other emergency services did not attend in a timely manner. The concerns included whether care homes had adequate policies and staff training for recognising or confirming death and for resuscitation.

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 adequate care-home policies and staff preparation for recognising or arranging confirmation of death
Wider context from the report
“1. That some care homes in Cornwall may not have adequate policies in place for their residence to appropriately recognise or arrange confirmation of death (i.e. when to call Emergency Service and or GP to recognise death). If such policies are in place that they are regularly updated and the staff are made aware of them and given the appropriate training. ”
Source location
Norman Dorn · Prevention of Future Deaths report
Page 1 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Diminishing of scans for confirmation of fetal death

Concerns raised2

Lack of clarity and consistency in the diagnosis-of-death procedure

Unavailability of a reference guide reflecting local diagnosis-of-death policies

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Lack of adequate care-home policies and staff preparation for recognising or arranging confirmation of death

Actions described in response 3

Respondent positions 1