16 Apr 2026 Adam Ankers · Prevention of Future Deaths report West London
View report summary
Concerns raised 5 Insufficient understanding of defibrillator use among lay persons and trained first aid persons View source Insufficient dissemination and mandatory coverage of Sudden Cardiac Arrest training across football leagues, clubs, coaches and referees View source Difficulty among lay people and ambulance call handlers in recognising signs of agonal breathing or cardiac arrest View source Unavailability of cardiac screening for all young people and football players aged 14 and upwards View source Failure of cascade communication of genetic or hereditary diseases to reach family members who need to know View source See 2 more concerns
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 3
Action
Support dissemination of guidance on consent and confidentiality in genomic medicine.
View source
Action
Raise awareness of the need to share genetic diagnoses and genomic test results within families.
View source
Action
Raise awareness of the need to share genetic diagnoses and genomic test results within families.
View source
×
AI-generated summary
Adam Ankers · 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
Adam Ankers suffered a cardiac arrest while playing grassroots football on 31 January 2024 due to a previously unidentified inherited cardiac condition, and died in hospital on 4 February 2024 following brain stem death. Agonal breathing and cardiac arrest were not recognised at the pitch or by the 999 call handler, and an AED was brought to the pitch but not used. The report identified concerns about recognition of agonal breathing and cardiac arrest, access to and use of defibrillators, dissemination of sudden cardiac arrest training, cardiac screening, and cascade communication of inherited disease information.
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. The report was sent to British Society For Genetic Medicine; that does not assign responsibility.
PFD Monitor interpretation Insufficient understanding of defibrillator use among lay persons and trained first aid persons
Wider context from the report “POINT C: That there is a need for better understanding of the use of defibrillators particularly by lay persons and trained first aid persons
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Society For Genetic Medicine; that does not assign responsibility.
PFD Monitor interpretation Insufficient dissemination and mandatory coverage of Sudden Cardiac Arrest training across football leagues, clubs, coaches and referees
Wider context from the report “POINT B: That the Football Association’s Sudden Cardiac Arrest training is not more widely disseminated or mandatory for all FA Accredited and Affiliated leagues and clubs and all grassroots football coaches and referees .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Society For Genetic Medicine; that does not assign responsibility.
PFD Monitor interpretation Difficulty among lay people and ambulance call handlers in recognising signs of agonal breathing or cardiac arrest
Wider context from the report “POINT A: That there is difficulty in lay people (trained or not) including ambulance call handlers in understanding the signs of agonal breathing or cardiac arrest
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Society For Genetic Medicine; that does not assign responsibility.
PFD Monitor interpretation Unavailability of cardiac screening for all young people and football players aged 14 and upwards
Wider context from the report “POINT D: That cardiac screening in those aged 14 and upwards reduces the risk of sudden cardiac death and this is not available to all young people or your football players
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Society For Genetic Medicine; that does not assign responsibility.
PFD Monitor interpretation Failure of cascade communication of genetic or hereditary diseases to reach family members who need to know
Wider context from the report “POINT E: That cascade communication of genetic or hereditary diseases is imperfect and does not reach more than half of those in families that need to know about it .
” 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 Support dissemination of guidance on consent and confidentiality in genomic medicine.
Verbatim wording from the response “The Joint Committee on Genomics in Medicine (JCGM) is a joint committee of BSGM, Royal College of Physicians, Royal College of Pathologists. In 2019, JCGM released the 3rd edition of the guidance document ‘Consent and confidentiality in genomic medicine’. This was written by ████████ who has given evidence in this inquest, and ████████. Many of the principles in practice within specialist clinical genetics and genomic practice are supported by the principles of this document. Genetic testing is now more embedded in clinical practice outside of the specialist genetics workforce. There are many educational activities underway to equip non genetics specialists to deliver their specific element of genetic medicine, for example by giving patients information about their genetic risk and by requesting genetic testing, giving the result and explaining the implications to the wider family.” Source location Response from British Society for Genetic Medicine
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 Raise awareness of the need to share genetic diagnoses and genomic test results within families.
Verbatim wording from the response “BSGM’s role in this situation is to raise awareness of the need to share important information about genetic diagnosis and the results of genomic tests. BSGM will also contribute to documents such as ‘Consent and confidentiality in genomic medicine’ and to help in its dissemination. BSGM through its members can also help to influence service development in both specialist genetic services and also in more mainstreamed genetic medicine. Work is currently ongoing by NHS England to review the service specification for the Clinical Genomics Services and the working group involved in this work includes many BSGM or its contributory groups (Clinical Genetics Society and Association of Genetic Nurses and Counsellors) officers.” Source location Response from British Society for Genetic Medicine
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 Raise awareness of the need to share genetic diagnoses and genomic test results within families.
Verbatim wording from the response “BSGM’s role in this situation is to raise awareness of the need to share important information about genetic diagnosis and the results of genomic tests. BSGM will also contribute to documents such as ‘Consent and confidentiality in genomic medicine’ and to help in its dissemination. BSGM through its members can also help to influence service development in both specialist genetic services and also in more mainstreamed genetic medicine. Work is currently ongoing by NHS England to review the service specification for the Clinical Genomics Services and the working group involved in this work includes many BSGM or its contributory groups (Clinical Genetics Society and Association of Genetic Nurses and Counsellors) officers.” Source location Response from British Society for Genetic Medicine
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 Implementing service change is outside the organisation’s remit; it can only influence how genetic services are delivered.
Verbatim wording from the response “While many members of BSGM sit in positions of leadership within clinical genetics services and work within cardiac genetic services, it has no remit to implement service change but rather to influence how services are delivered.” Source location Response from British Society for Genetic Medicine
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 Limited capacity, variable infrastructure and regulatory restrictions can prevent clinical teams from contacting or testing at-risk relatives directly.
Verbatim wording from the response “Despite this, we acknowledge that the sharing and dissemination of genetic information within families may not be easy and is influenced by the complexities of family structures and dynamics as well as systemic constraints. Efforts are made to encourage and facilitate timely sharing of information and cascade testing in families. Barriers to this include limited service capacity, variable infrastructure and jurisdictional or cross border regulatory frameworks that restrict if, how and when clinical teams can contact or offer testing to at risk relatives directly.” Source location Response from British Society for Genetic Medicine
Open published response
Pin
Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations