16 Apr 2026 Adam Ankers · Prevention of Future Deaths report West London
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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
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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.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Resuscitation Council UK; 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 Resuscitation Council UK; 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 Resuscitation Council UK; 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 Resuscitation Council UK; 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 Resuscitation Council UK; 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
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish simplified guidance directing people to suspect cardiac arrest when an unresponsive person has abnormal breathing.
Verbatim wording from the response “Recognition of agonal breathing and cardiac arrest is a well-established challenge. Current UK Resuscitation Guidelines (2025) address this through clear and simplified messaging: cardiac arrest should be suspected in any unresponsive person, and if they are unresponsive with abnormal breathing, cardiac arrest should be assumed. The identification of agonal breathing is challenging, and it is well established that it is often mistaken for adequate breathing. Training, therefore, focusses on identifying someone who is not breathing normally, rather than trying to teach those undertaking first aid the varying and often not obvious appearance of agonal breathing.” Source location Response from Resuscitation Council UK
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with NHS England through NHS Pathways to support standardised dispatch algorithms and telephone-assisted CPR instructions.
Verbatim wording from the response “The recognition of cardiac arrest by ambulance service call handlers is also a critical component of the early response. We work closely with NHS England (through NHS Pathways) to support emergency medical dispatch systems to use standardised algorithms which support the prompt identification of cardiac arrest and enable call handlers to provide immediate telephone-assisted CPR instructions. Our systems-level guidance further recommends that ambulance services teach, monitor, and continuously improve cardiac arrest recognition within dispatch centres, recognising this as a key link in the chain of survival⁴. The challenge for an ambulance call taker to correctly recognise cardiac arrest is well established, and a significant amount of work has been undertaken to improve this vital link in the chain of survival.” Source location Response from Resuscitation Council UK
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with national partners to support public awareness, training and access to defibrillators, including collaboration with the British Heart Foundation on The Circuit.
Verbatim wording from the response “RCUK is working with national partners to support public awareness, training, and access to defibrillators. This includes collaboration with the British Heart Foundation to support The Circuit, the national defibrillator network, which enables ambulance services to direct bystanders to nearby devices⁵. RCUK also continues to promote education and develop guidance for specific settings, including sport and community settings, to support a timely and effective response.” Source location Response from Resuscitation Council UK
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Campaign for basic life-support training to be included in national school curricula across the four nations.
Verbatim wording from the response “through each step and will only deliver a shock if it is clinically indicated⁵. The guidelines emphasise that anyone can use an AED and that it should be applied as soon as it becomes available¹. Of course, training in first aid is encouraged so that bystanders who find themselves presented with someone who has collapsed have the confidence and skills to deliver basic life support and defibrillation. RCUK and partner organisations have successfully campaigned to include basic life support training in the national curriculum across the four nations. However, it is not currently mandatory, and we continue to campaign to ensure that every child leaves school with the skills to save a life. In addition, RCUK and partners have successfully secured the inclusion of resuscitation-related questions in the driving licence theory test.” Source location Response from Resuscitation Council UK
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Promote education and develop setting-specific resuscitation guidance for sport and community environments.
Verbatim wording from the response “RCUK is working with national partners to support public awareness, training, and access to defibrillators. This includes collaboration with the British Heart Foundation to support The Circuit, the national defibrillator network, which enables ambulance services to direct bystanders to nearby devices⁵. RCUK also continues to promote education and develop guidance for specific settings, including sport and community settings, to support a timely and effective response.” Source location Response from Resuscitation Council UK
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish a national best-practice guide supporting early recognition of cardiac arrest and prompt CPR and defibrillation in community sport.
Verbatim wording from the response “RCUK has reinforced this approach through its ‘Resuscitation on the Field of Play: Best Practice Guidelines’², which aim to improve the recognition and response to sudden cardiac arrest in sporting environments. These guidelines are designed for medical teams responding to a person who collapses during or shortly after sporting activity within professional sport, including football. RCUK has also recently published ‘Resuscitation in community sports: a national best practice guide’³, aimed at grassroots sport to improve early recognition of cardiac arrest and prompt use of CPR and defibrillation.” Source location Response from Resuscitation Council UK
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Strengthen public education campaigns, including an annual Restart a Heart focus on recognising and raising awareness of agonal breathing.
Verbatim wording from the response “RCUK recognises that, despite clear guidance, the recognition of cardiac arrest in real-world settings can remain challenging, particularly in environments such as grassroots sport. In response, RCUK will continue to strengthen its public-facing education campaigns. For example, as part of RCUK’s annual Restart a Heart campaign, this year’s programme will include a focus on recognising and raising awareness of agonal breathing.” Source location Response from Resuscitation Council UK
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Cardiac screening concerns should be addressed by the UK National Screening Committee and relevant specialist cardiology and genomics organisations.
Verbatim wording from the response “In relation to Point D, concerning cardiac screening in young people, RCUK acknowledges the importance of this issue. However, cardiac screening programmes and population-level screening policy fall outside the remit of RCUK, and we do not produce guidance or training in this area. We consider that this matter is more appropriately addressed by the UK National Screening Committee and relevant specialist organisations in cardiology and genomics.” Source location Response from Resuscitation Council UK
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Population-level cardiac screening policy falls outside RCUK’s remit, so RCUK does not produce guidance or training in this area.
Verbatim wording from the response “In relation to Point D, concerning cardiac screening in young people, RCUK acknowledges the importance of this issue. However, cardiac screening programmes and population-level screening policy fall outside the remit of RCUK, and we do not produce guidance or training in this area. We consider that this matter is more appropriately addressed by the UK National Screening Committee and relevant specialist organisations in cardiology and genomics.” Source location Response from Resuscitation Council UK
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3 Jun 2025 Benjamin Finch Arnold · Prevention of Future Deaths report West Yorkshire Eastern
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Concerns raised 6 Unequal provision of maternity services between LGI and SJUH View source Ambiguity about the classification and operating parameters of the SJUH maternity unit View source Limited nursing and medical support available to the SJUH site View source Lack of standardised guidelines for performing LISA procedures View source Insufficient national guidelines for identifying and treating reversible causes of cardiac arrest in newborn babies View source Lack of on-site paediatric cover at SJUH View source See 3 more concerns
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Benjamin Finch Arnold · 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
Benjamin Finch Arnold was born prematurely at Saint James’ University Hospital after his mother was redirected there because the intended delivery unit was closed due to lack of capacity. He developed breathing difficulties during a LISA procedure, suffered bilateral pneumothoraces and a subsequent right-sided tension pneumothorax, and died after a devastating brain injury caused by prolonged low oxygen levels. The concerns included the organisation and classification of maternity services, the lack of standardised guidance for LISA procedures and newborn cardiac arrest, and updates to the hospital risk register.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Resuscitation Council UK; that does not assign responsibility.
PFD Monitor interpretation Unequal provision of maternity services between LGI and SJUH
Wider context from the report “(1) The provision of maternity services across the Leeds Teaching Hospitals Trust (LTHT) continues to be split unequally between LGI and SJUH , with, for example, no on-site paediatric cover at SJUH. What was described by LTHT witnesses as the “isolation” of the SJUH site, particularly as it related to the limited nursing and medical support that can be called upon, was a recurrent theme in the inquest. The inquest was told that a long held ambition to bring LTHT’s maternity services under one roof had been recently frustrated by the announcement that the building of a new hospital for Leeds would not begin until 2030. Secretary of State for Health and Social Care to respond.
” 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 Resuscitation Council UK; that does not assign responsibility.
PFD Monitor interpretation Ambiguity about the classification and operating parameters of the SJUH maternity unit
Wider context from the report “(2) The evidence at the inquest disclosed an ambiguity as to whether the SJUH maternity unit, officially a “Level 1” centre, was operating outside the parameters of that classification . That ambiguity was demonstrated by a witness (whose evidence was admitted in writing under R23 due to her poor health) who described it as a “Level 2” unit , and by a witness in person who described it as a “Level 1 and a half” unit, which last classification does not exist . LTHT to respond.
” 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 Resuscitation Council UK; that does not assign responsibility.
PFD Monitor interpretation Limited nursing and medical support available to the SJUH site
Wider context from the report “(1) The provision of maternity services across the Leeds Teaching Hospitals Trust (LTHT) continues to be split unequally between LGI and SJUH, with, for example, no on-site paediatric cover at SJUH. What was described by LTHT witnesses as the “isolation” of the SJUH site, particularly as it related to the limited nursing and medical support that can be called upon , was a recurrent theme in the inquest. The inquest was told that a long held ambition to bring LTHT’s maternity services under one roof had been recently frustrated by the announcement that the building of a new hospital for Leeds would not begin until 2030. Secretary of State for Health and Social Care to respond.
” 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 Resuscitation Council UK; that does not assign responsibility.
PFD Monitor interpretation Lack of standardised guidelines for performing LISA procedures
Wider context from the report “(3) The evidence disclosed concerns that guidelines for the performing of a LISA procedure are not standardised across the NHS , particularly with reference to the performing of a chest x-ray to exclude pneumothorax before commencing the procedure , and to the necessity of seeking consultant approval before undertaking the procedure . BAPM, RCPCH, RCUK and NN all to respond.
” 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 Resuscitation Council UK; that does not assign responsibility.
PFD Monitor interpretation Insufficient national guidelines for identifying and treating reversible causes of cardiac arrest in newborn babies
Wider context from the report “(4) The evidence disclosed concerns whether national guidelines on the reversible causes of cardiac arrest (the “4 H’s and 4 T’s”) were sufficient for the purposes of identifying and treating the potential causes of cardiac arrest in a newborn baby . BAPM, RCPCH, RCUK and NN all to respond.
” 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 Resuscitation Council UK; that does not assign responsibility.
PFD Monitor interpretation Lack of on-site paediatric cover at SJUH
Wider context from the report “(1) The provision of maternity services across the Leeds Teaching Hospitals Trust (LTHT) continues to be split unequally between LGI and SJUH, with, for example, no on-site paediatric cover at SJUH . What was described by LTHT witnesses as the “isolation” of the SJUH site, particularly as it related to the limited nursing and medical support that can be called upon, was a recurrent theme in the inquest. The inquest was told that a long held ambition to bring LTHT’s maternity services under one roof had been recently frustrated by the announcement that the building of a new hospital for Leeds would not begin until 2030. Secretary of State for Health and Social Care to respond.
” Open source report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Include reversible causes of non-response in newborn resuscitation guidance, algorithms, course teaching and manuals.
Verbatim wording from the response “Within RCUK’s Newborn Resuscitation and Support of Transition of Infants at Birth Guidelines⁴, it is specifically advised that in an arrest situation, in the absence of an adequate response, the team should:” Source location Response from Resus Council UK
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The NLS approach and algorithm adequately address potential causes of non-response during newborn resuscitation.
Verbatim wording from the response “Within RCUK’s Newborn Resuscitation and Support of Transition of Infants at Birth Guidelines⁴, it is specifically advised that in an arrest situation, in the absence of an adequate response, the team should:” Source location Response from Resus Council UK
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Current evidence and international guidelines do not support recommending a single optimum LISA method or fully standardised national approach.
Verbatim wording from the response “Similarly, neither the 2025 International Liaison Committee on Resuscitation (ILCOR) Consensus on Science with Treatment Recommendations for newborns¹, nor the European Resuscitation Council guidelines², on which the UK Resuscitation Guidelines are based, define a single optimum method. The British Association of Perinatal Medicine (BAPM) does have a LISA checklist for safe administration (enclosed), which includes checking for pneumothorax.” Source location Response from Resus Council UK
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Requiring a chest X-ray before LISA is not generally advisable because delaying urgent intervention may be harmful.
Verbatim wording from the response “The RCUK Resuscitation Guidelines are intended for urgent resuscitation or stabilisation, and therefore, delaying intervention to obtain a chest X-ray is generally not advisable in most situations.” Source location Response from Resus Council UK
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25 Aug 2023 Miss C · Prevention of Future Deaths report Northamptonshire
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Concerns raised 1 Inadequate policy for out-of-hours availability of Resuscitation Officers View source
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Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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Miss C · 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
Miss C died at Northampton General Hospital on 5 October 2021. The primary underlying causes were recent weight loss with nutritional deficiencies and interstitial pneumonia. During her deterioration, a doctor’s review was delayed, representing a missed opportunity for enhanced supportive care and an earlier peri-arrest call. Concerns also included the out-of-hours availability of Resuscitation Officers and aspects of the cardiac-arrest management, including inconsistent records of dextrose administration.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Resuscitation Council UK; that does not assign responsibility.
PFD Monitor interpretation Inadequate policy for out-of-hours availability of Resuscitation Officers
Wider context from the report “Resuscitation Council UK and NGH NHS Trust should consider a review of their policy in relation to the out of hours availability of Resuscitation Officers .
” Open source report
13 May 2022 RITA GIULIANNA NICOLA BRITTEN · Prevention of Future Deaths report West Yorkshire (Western)
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Concerns raised 1 Lack of clear national emergency and resuscitation guidance for choking emergencies where conventional abdominal thrusts are not possible or effective View source
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RITA GIULIANNA NICOLA BRITTEN · 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
Rita Giuliana Nicola Britten, a detained patient, choked while trying to swallow pieces of fresh apple and later died in hospital after life support was withdrawn. The report records concerns about the lack of clear guidance and effective rescue techniques for choking incidents involving overweight, obese or bariatric individuals, including the possible use of inversion techniques and specialist equipment. The jury also recorded concerns about communication and handover, recording and access to key information, incomplete risk assessments, and inadequate first aid training.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Resuscitation Council UK; that does not assign responsibility.
PFD Monitor interpretation Lack of clear national emergency and resuscitation guidance for choking emergencies where conventional abdominal thrusts are not possible or effective
Wider context from the report “The concern is of want of clear guidance on the steps to be taken to most effectively rescue the individual from the urgent and developing choking emergency when that individual does not conform to the competent adult to whom conventional abdominal thrusts are possible or might be effectively applied. In particular, this concern relates to but is not limited to the overweight/obese/bariatric individual (however that may be best described).
a) There should be clear national emergency /resuscitation guidelines for dealing effectively with choking incidents where the individual is overweight/obese or otherwise where “conventional abdominal thrusts” are not possible or are less able to be effectively applied. In Mrs Britten’s case a significant element of early rescue techniques was compromised. It is perceived this will be an increasing present and future risk in the UK population due to obesity.
b) There should be early review and assessment of papers that discuss the efficacy (or otherwise) in such circumstances of “inversion” of the affected choking individual said to be set out in:
Hubert Blaine et al in American Journal of Medicine ref, Am J Med 2010 Dec; 123 (12)
And
“Effect of body position on relieve of foreign body from the airway”, Artur Luczak AIMS Public Health 6(2): 154-159
And how this or similar technique(s) might have application in the Hospital/clinical setting in which this choking episode occurred.
c) There should be identified and assessed any specialist equipment to assist in these circumstances.
” Open source report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Teach healthcare professionals to use laryngoscopes and Magill’s forceps for foreign-body removal under direct vision in the advanced life support course.
Verbatim wording from the response “Our guidelines recommend that healthcare professionals use a laryngoscope (a device put in the mouth with a light on the end) and Magill’s forceps (like pincers) to remove the foreign body under direct vision. Our recommendations are informed by our experience as well as published evidence demonstrating this can be an effective technique.⁴” Source location Response from Resuscitation Council
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Assess abdominal-thrust alternatives for people with increased body mass and exclude supine abdominal thrusts from guidance because of safety and effectiveness concerns.
Verbatim wording from the response “Chest compressions in the supine position (on their back) typically raise intrathoracic pressure to a greater extent than abdominal thrusts.⁵ They can be delivered irrespective of the persons size as it does not require the rescuer to encircle their arms around the person as is required for abdominal thrusts.” Source location Response from Resuscitation Council
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Set out a stepwise choking-management approach in basic life support guidance, including chest compressions when abdominal thrusts fail or cannot be administered.
Verbatim wording from the response “Resuscitation Council UK sets out its guidance for the management of foreign body airway obstruction ('choking') in our basic life support guidelines.¹ These guidelines are drawn from the recommendations” Source location Response from Resuscitation Council
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Add a frequently asked question to the national website explaining the position on choking management when abdominal thrusts are not possible.
Verbatim wording from the response “In preparing our guidance we considered the use of abdominal thrusts with the person lying on their back but decided not to include them given that chest compressions are probably more effective and our assessment that there is a higher risk life threatening abdominal injuries from the use of the abdominal thrust.” Source location Response from Resuscitation Council
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Include immediate availability of laryngoscopes and Magill’s forceps in quality standards for mental health inpatient care.
Verbatim wording from the response “Our guidelines recommend that healthcare professionals use a laryngoscope (a device put in the mouth with a light on the end) and Magill’s forceps (like pincers) to remove the foreign body under direct vision. Our recommendations are informed by our experience as well as published evidence demonstrating this can be an effective technique.⁴” Source location Response from Resuscitation Council
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Assess suction-based airway-clearance devices for safety and effectiveness and determine whether evidence supports routine use.
Verbatim wording from the response “We have also assessed the evidence for suction-based airway clearance devices but consider there is insufficient evidence currently about either their safety or effectiveness, to advocate for their routine use. This view is aligned with the 2022 Evidence update on this topic from the International Liaison Committee on Resuscitation.” Source location Response from Resuscitation Council
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Inversion or chair/table manoeuvres will not be introduced because evidence is insufficient and manual handling poses injury risks.
Verbatim wording from the response “b) There should be early review and assessment of papers that discuss the efficacy (or otherwise) in such circumstances of “inversion” of the affected choking individual said to be set out in Hubert Blaine et al in American Journal of Medicine ref, Am J Med 2010 Dec; 123 (12) And “Effect of body position on relieve of foreign body from the airway”, Artur Luczak AIMS Public Health 6(2):154-159” Source location Response from Resuscitation Council
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing basic life support guidelines provide a stepwise choking response, including chest compressions suitable for people of any size.
Verbatim wording from the response “Resuscitation Council UK sets out its guidance for the management of foreign body airway obstruction ('choking') in our basic life support guidelines.¹ These guidelines are drawn from the recommendations” Source location Response from Resuscitation Council
Open published response
13 Dec 2021 Mrs Hurrun Maksur · Prevention of Future Deaths report East London
View report summary
Concerns raised 4 Guidance failing to accurately specify point-of-care ultrasound scanning without requiring trauma View source Failure to perform a point-of-care ultrasound scan to exclude intra-abdominal bleeding when pulmonary embolism is suspected View source Failure to incorporate MBRRACE guidance into national obstetric cardiac arrest guidance View source Lack of specific training for obstetricians to identify intra-abdominal bleeding View source See 1 more concern
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Mrs Hurrun Maksur · 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
Hurrun Maksur, who was 19 weeks pregnant, suffered a seizure and cardiac arrest after developing severe abdominal pain on 6 June 2020. She was treated for suspected pulmonary embolism, but an intra-abdominal bleed from a ruptured interstitial ectopic pregnancy was subsequently discovered; she died during further surgery on 7 June 2020. Concerns included the failure to perform a FAST scan before thrombolysis, the absence of the guidance from national obstetric cardiac arrest guidance, and specific training for obstetricians to identify intra-abdominal bleeding.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Resuscitation Council UK; that does not assign responsibility.
PFD Monitor interpretation Guidance failing to accurately specify point-of-care ultrasound scanning without requiring trauma
Wider context from the report “The guidance from MBRRACE UK 2019, provides that:
Women of reproductive age, presenting to the ED collapsed, in whom a pulmonary embolism is suspected, should have a Focussed Assessment with Sonography in Trauma (FAST) scan to exclude intra-abdominal bleeding from a ruptured ectopic pregnancy especially in the presence of anaemia.
A FAST scan did not take place before the diagnosis of pulmonary embolism was confirmed. If the MBRRACE guidance had been followed in this case, it is likely to have prevented the administration of Alteplase in a lady who was suffering from intra-abdominal bleeding.
The 2019 MBRRACE guidance has now been incorporated into the local Trust's resuscitation policy, but has not been incorporated into the National, Resuscitation Council UK, Obstetric Cardiac Arrest guidance.
Concern was raised during the course of the inquest in relation to the reference to the “FAST” scan. It was considered that reference should be to a “Point-of-Care Ultrasound Scan”, as trauma is not a necessary pre-condition for the scan to take place.
Finally, concern was raised during the course of the inquest, that obstetricians do not receive specific training to identify intra-abdominal bleeding.
” 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 Resuscitation Council UK; that does not assign responsibility.
PFD Monitor interpretation Failure to perform a point-of-care ultrasound scan to exclude intra-abdominal bleeding when pulmonary embolism is suspected
Wider context from the report “The guidance from MBRRACE UK 2019, provides that:
Women of reproductive age, presenting to the ED collapsed, in whom a pulmonary embolism is suspected, should have a Focussed Assessment with Sonography in Trauma (FAST) scan to exclude intra-abdominal bleeding from a ruptured ectopic pregnancy especially in the presence of anaemia.
A FAST scan did not take place before the diagnosis of pulmonary embolism was confirmed. If the MBRRACE guidance had been followed in this case, it is likely to have prevented the administration of Alteplase in a lady who was suffering from intra-abdominal bleeding.
The 2019 MBRRACE guidance has now been incorporated into the local Trust's resuscitation policy, but has not been incorporated into the National, Resuscitation Council UK, Obstetric Cardiac Arrest guidance.
Concern was raised during the course of the inquest in relation to the reference to the “FAST” scan. It was considered that reference should be to a “Point-of-Care Ultrasound Scan”, as trauma is not a necessary pre-condition for the scan to take place.
Finally, concern was raised during the course of the inquest, that obstetricians do not receive specific training to identify intra-abdominal bleeding.
” 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 Resuscitation Council UK; that does not assign responsibility.
PFD Monitor interpretation Failure to incorporate MBRRACE guidance into national obstetric cardiac arrest guidance
Wider context from the report “The guidance from MBRRACE UK 2019, provides that:
Women of reproductive age, presenting to the ED collapsed, in whom a pulmonary embolism is suspected, should have a Focussed Assessment with Sonography in Trauma (FAST) scan to exclude intra-abdominal bleeding from a ruptured ectopic pregnancy especially in the presence of anaemia.
A FAST scan did not take place before the diagnosis of pulmonary embolism was confirmed. If the MBRRACE guidance had been followed in this case, it is likely to have prevented the administration of Alteplase in a lady who was suffering from intra-abdominal bleeding.
The 2019 MBRRACE guidance has now been incorporated into the local Trust's resuscitation policy, but has not been incorporated into the National, Resuscitation Council UK, Obstetric Cardiac Arrest guidance.
Concern was raised during the course of the inquest in relation to the reference to the “FAST” scan. It was considered that reference should be to a “Point-of-Care Ultrasound Scan”, as trauma is not a necessary pre-condition for the scan to take place.
Finally, concern was raised during the course of the inquest, that obstetricians do not receive specific training to identify intra-abdominal bleeding.
” 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 Resuscitation Council UK; that does not assign responsibility.
PFD Monitor interpretation Lack of specific training for obstetricians to identify intra-abdominal bleeding
Wider context from the report “The guidance from MBRRACE UK 2019, provides that:
Women of reproductive age, presenting to the ED collapsed, in whom a pulmonary embolism is suspected, should have a Focussed Assessment with Sonography in Trauma (FAST) scan to exclude intra-abdominal bleeding from a ruptured ectopic pregnancy especially in the presence of anaemia.
A FAST scan did not take place before the diagnosis of pulmonary embolism was confirmed. If the MBRRACE guidance had been followed in this case, it is likely to have prevented the administration of Alteplase in a lady who was suffering from intra-abdominal bleeding.
The 2019 MBRRACE guidance has now been incorporated into the local Trust's resuscitation policy, but has not been incorporated into the National, Resuscitation Council UK, Obstetric Cardiac Arrest guidance.
Concern was raised during the course of the inquest in relation to the reference to the “FAST” scan. It was considered that reference should be to a “Point-of-Care Ultrasound Scan”, as trauma is not a necessary pre-condition for the scan to take place.
Finally, concern was raised during the course of the inquest, that obstetricians do not receive specific training to identify intra-abdominal bleeding.
” 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 Share the response with the Advanced Life Support Group overseeing the Managing Medical and Obstetric Emergencies and Trauma course.
Verbatim wording from the response “5. To address the variance with the MBRRACE UK 2019 guidance, RCUK will further emphasise the need to exclude major bleeding as the cause of collapse before giving thrombolytic drugs for suspected PE in pregnancy. We will also consider other learning from this case. The following areas will be reviewed and updated as necessary:” Source location 2021-0418-Response-from-Resuscitation-Council-UK_Published
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 Include guidance on abdominal ultrasound and massive-haemorrhage protocols for suspected haemorrhage during pregnancy-related cardiac arrest.
Verbatim wording from the response “2. The RCUK Advanced Life Support Manual (8th Edition, May 2021) includes the following regarding haemorrhage:” Source location 2021-0418-Response-from-Resuscitation-Council-UK_Published
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 Further emphasise excluding major bleeding before administering thrombolytic drugs for suspected pulmonary embolism in pregnancy.
Verbatim wording from the response “5. To address the variance with the MBRRACE UK 2019 guidance, RCUK will further emphasise the need to exclude major bleeding as the cause of collapse before giving thrombolytic drugs for suspected PE in pregnancy. We will also consider other learning from this case. The following areas will be reviewed and updated as necessary:” Source location 2021-0418-Response-from-Resuscitation-Council-UK_Published
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 Emphasise ultrasound use during advanced life support to identify reversible causes, including haemorrhage, across cardiac-arrest guidance.
Verbatim wording from the response “1. The RCUK updates its guidelines on a regular basis using a process that is accredited by the National Institute for Health and Care Excellence (NICE). The most recent update was in May 2021. With regards to the use of sonography (ultrasound is the more commonly used term), the latest 2021 RCUK guidelines include:” Source location 2021-0418-Response-from-Resuscitation-Council-UK_Published
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 Include pregnancy-specific guidance to identify and treat reversible causes, with focused ultrasound available for skilled operators.
Verbatim wording from the response “b. Specific guidelines for cardiac arrest in the pregnant patient including 'Identify and treat reversible causes (e.g. haemorrhage). Focused ultrasound by a skilled operator can be used to identify reversible causes and may also be used to assess if a fetal heart rate is present.' See https://www.resus.org.uk/library/2021-resuscitation-guidelines/special-circumstances-guidelines” Source location 2021-0418-Response-from-Resuscitation-Council-UK_Published
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 Consider additional learning from the case and review relevant guidance and teaching materials for necessary updates.
Verbatim wording from the response “5. To address the variance with the MBRRACE UK 2019 guidance, RCUK will further emphasise the need to exclude major bleeding as the cause of collapse before giving thrombolytic drugs for suspected PE in pregnancy. We will also consider other learning from this case. The following areas will be reviewed and updated as necessary:” Source location 2021-0418-Response-from-Resuscitation-Council-UK_Published
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 Universal ultrasound requirements are limited because skilled operators and equipment may be unavailable and ultrasound could delay time-critical treatment.
Verbatim wording from the response “a. Firstly, RCUK is mindful that its guidelines address all cardiac arrests and that maternal cardiac arrests make up a very small proportion of these arrests. In addition the specialist skills and equipment required for ultrasound during resuscitation are not always immediately available in all settings. Any changes therefore need to be proportionate and recognise the risks of delaying time critical treatments such as fibrinolysis in patients with a suspected PE.” Source location 2021-0418-Response-from-Resuscitation-Council-UK_Published
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 Existing RCUK guidance and teaching materials already address ultrasound use and reversible causes, including haemorrhage, during cardiac arrest in pregnancy.
Verbatim wording from the response “4. The RCUK ALS subcommittee's opinion is that the issues raised by the MBRRACE report and the Inquest are addressed in the most recent RCUK guidance and teaching materials. Specifically:” Source location 2021-0418-Response-from-Resuscitation-Council-UK_Published
Open published response
Concerns raised 3 Confusing definitions of post-death signs in CPR decision-making guidance View source Insufficient nursing staff understanding of identifying hypostasis and rigor mortis View source Insufficient life support training coverage of hypostasis and rigor mortis identification View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Darren Adams · 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
Darren Adams was transferred between prisons and, within 24 hours of arrival, experienced a deterioration in his mental health. He was found ligatured in his cell on 12 November 2017 and was declared dead at hospital on 13 November 2017; the inquest concluded that he died by suicide. Concerns included nursing staff misdiagnosing hypostasis and rigor mortis, insufficient training in identifying these conditions, and potentially confusing definitions in CPR guidance.
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 Resuscitation Council UK; that does not assign responsibility.
PFD Monitor interpretation Confusing definitions of post-death signs in CPR decision-making guidance
Wider context from the report “4. It was seen during the evidence that definitions in Annex A of the document “Guidance to support the decision-making process of when not to perform Cardiopulmonary Resuscitation in prisons and immigration removal centre (IRC)” could be confusing , for example the word “mottling” was interpreted by different people in different ways (both lay and medical) .
” 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 Resuscitation Council UK; that does not assign responsibility.
PFD Monitor interpretation Insufficient nursing staff understanding of identifying hypostasis and rigor mortis
Wider context from the report “1. The Nursing Staff misdiagnosed hypostasis. It was apparent in evidence that they did not have a sufficient understanding of the process and how to identify it.
2. The Nursing Staff misdiagnosed rigor mortis. It was apparent in evidence that they did not have a sufficient understanding of the process and how to identify it.
” 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 Resuscitation Council UK; that does not assign responsibility.
PFD Monitor interpretation Insufficient life support training coverage of hypostasis and rigor mortis identification
Wider context from the report “3. Management of the nurses accepted in evidence that more focus on the identification of those conditions should have been covered in better depth during the nurse’s life support training .
” 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 Share the response with the guidance authors and the RCUK Community and Ambulance Resuscitation committee.
Verbatim wording from the response “11. Finally, RCUK has shared this response with:” Source location 2021-0125-Response-from-Resuscitation-Council-UK_Published
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 Detailed training in recognising rigor mortis and hypostasis falls outside the scope of RCUK training courses.
Verbatim wording from the response “6. Training and clinical experience are required to be able to reliably diagnose irreversible death based on the presence of rigor mortis and hypostasis. Detailed training in the recognition of rigor mortis and hypostasis is outside the scope of RCUK training courses.” Source location 2021-0125-Response-from-Resuscitation-Council-UK_Published
Open published response
12 Mar 2020 Mitica Marin · Prevention of Future Deaths report East London
View report summary
Concerns raised 3 Failure to review the defibrillator during resuscitation View source LP15 defibrillator defaulting to manual mode View source Failure to activate the LP15 defibrillator in automatic mode View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mitica Marin · 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
Mitica Marin, aged 35, was found unresponsive at home on 11 April 2019 and died in hospital after prolonged resuscitation attempts. The cause of death was unascertained. The LAS investigation identified a four-minute delay in delivering the first defibrillator shock while Mr Marin was in a shockable rhythm, associated with the defibrillator being used in manual rather than automatic mode.
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 Resuscitation Council UK; that does not assign responsibility.
PFD Monitor interpretation Failure to review the defibrillator during resuscitation
Wider context from the report “The LAS serious incident investigation identified a 4-minute delay between LP15 defibrillator pads being placed on Mr Marin’s chest and the administration of the first shock. During this period Mr Marin’s heart was in a shockable rhythm.
Paramedic A accepted that they had not reviewed the defibrillator as they were distracted by events.
Paramedic A did not activate the defibrillator in “automatic” mode. Had this setting been applied, any shockable rhythm would have been detected and an alert would have prompted the paramedic to shock to the patient.
This is not an isolated incident, the LAS conceded that it had undertaken a review of similar cases of delayed defibrillation. The review found that a factor was that the LP15 defibrillator model, defaults to manual mode requiring the user to switch to automatic mode before use.
2 studies cited by the LAS indicated that every minute a patient is delayed effective resuscitation; their prospects of survival diminishes by between 10-22%.
The LAS have introduced remedial measures to prevent such actions occurring, incorporating; training on the use of the LP15, labelling on units and the issuing of revised guidance.
If the LP15 defaulted to automatic mode or on start-up required, the choice of manual or automatic mode it is possible that such delays could be avoided.
I understand that procurement decisions regarding the future supply of defibrillators are imminent.
” 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 Resuscitation Council UK; that does not assign responsibility.
PFD Monitor interpretation LP15 defibrillator defaulting to manual mode
Wider context from the report “The LAS serious incident investigation identified a 4-minute delay between LP15 defibrillator pads being placed on Mr Marin’s chest and the administration of the first shock. During this period Mr Marin’s heart was in a shockable rhythm.
Paramedic A accepted that they had not reviewed the defibrillator as they were distracted by events.
Paramedic A did not activate the defibrillator in “automatic” mode. Had this setting been applied, any shockable rhythm would have been detected and an alert would have prompted the paramedic to shock to the patient.
This is not an isolated incident, the LAS conceded that it had undertaken a review of similar cases of delayed defibrillation. The review found that a factor was that the LP15 defibrillator model, defaults to manual mode requiring the user to switch to automatic mode before use.
2 studies cited by the LAS indicated that every minute a patient is delayed effective resuscitation; their prospects of survival diminishes by between 10-22%.
The LAS have introduced remedial measures to prevent such actions occurring, incorporating; training on the use of the LP15, labelling on units and the issuing of revised guidance.
If the LP15 defaulted to automatic mode or on start-up required, the choice of manual or automatic mode it is possible that such delays could be avoided.
I understand that procurement decisions regarding the future supply of defibrillators are imminent.
” 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 Resuscitation Council UK; that does not assign responsibility.
PFD Monitor interpretation Failure to activate the LP15 defibrillator in automatic mode
Wider context from the report “The LAS serious incident investigation identified a 4-minute delay between LP15 defibrillator pads being placed on Mr Marin’s chest and the administration of the first shock. During this period Mr Marin’s heart was in a shockable rhythm.
Paramedic A accepted that they had not reviewed the defibrillator as they were distracted by events.
Paramedic A did not activate the defibrillator in “automatic” mode. Had this setting been applied, any shockable rhythm would have been detected and an alert would have prompted the paramedic to shock to the patient.
This is not an isolated incident, the LAS conceded that it had undertaken a review of similar cases of delayed defibrillation. The review found that a factor was that the LP15 defibrillator model, defaults to manual mode requiring the user to switch to automatic mode before use.
2 studies cited by the LAS indicated that every minute a patient is delayed effective resuscitation; their prospects of survival diminishes by between 10-22%.
The LAS have introduced remedial measures to prevent such actions occurring, incorporating; training on the use of the LP15, labelling on units and the issuing of revised guidance.
If the LP15 defaulted to automatic mode or on start-up required, the choice of manual or automatic mode it is possible that such delays could be avoided.
I understand that procurement decisions regarding the future supply of defibrillators are imminent.
” Open source report
×
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 Automatic defibrillator start-up is not considered safer; manual defibrillation is preferred for advanced life support because it may improve survival outcomes.
Verbatim wording from the response “Although defibrillators can be set to start up in either automatic or manual mode, the latter is preferred. This is because when used correctly, studies have shown that a manual mode results in greater chance of return of spontaneous circulation and subsequent survival to hospital discharge, compared with an automatic mode. Manual defibrillation is therefore recommended for advanced life support, as delivered by ambulance paramedics.” Source location 2020-0066-Response-from-Resusciation-Council-UK-Redacted
Open published response
5 Dec 2016 Christopher Brennan · Prevention of Future Deaths report South London
View report summary
Concerns raised 2 Unavailability of laryngoscopes in emergency equipment on the unit View source Lack of adequate policy or guidance for assessing and managing self-harm risks from items on adolescent psychiatric units View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Christopher Brennan · 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
Christopher Brennan, aged 15, was a patient at an adolescent psychiatric unit and died on 31 August 2014 after swallowing the lid of a roll-on deodorant, causing acute upper airway obstruction and cardiac arrest. The report identified concerns about the lack of clear and consistent guidance for managing items that could be used for self-harm and the absence of a laryngoscope from the unit’s emergency equipment.
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 Resuscitation Council UK; that does not assign responsibility.
PFD Monitor interpretation Unavailability of laryngoscopes in emergency equipment on the unit
Wider context from the report “(2) With regard to resuscitation: the emergency equipment on the unit did not include a laryngoscope . The item obstructing Christopher’s airway was subsequently used by ambulance personnel using Magill forceps with a laryngoscope, and this combination had been successfully used on a previous occasion when Christopher had swallowed a bottle top.
Laryngoscopes are not part of the standardised items on the unit , and are not included in the Resuscitation Council guidance for mental healthcare settings. It has been suggested that this is because they are complex devices that require intense training and competency assessments before staff can use them, and that it may be counterproductive to make them available. However, in view of the circumstances of Christopher’s death, and the apparent prevalence of self harm in adolescent units, the matter is reported for consideration, both in relation to the laryngoscope itself and the access to staff trained in its use.
” 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 Resuscitation Council UK; that does not assign responsibility.
PFD Monitor interpretation Lack of adequate policy or guidance for assessing and managing self-harm risks from items on adolescent psychiatric units
Wider context from the report “(1) In respect of the in-patient management: that there was no separate policy or guidance, other than a partial wall chart, regarding the assessment and management of risks posed by items that might be used to cause self harm . The complexities of managing these risks on an adolescent in-patient psychiatric unit were not therefore adequately considered , and this led to a lack of clarity and consistency .
” Open source report
25 Oct 2016 Jane Louise Reason · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 3 Insufficient public education in the use of public access defibrillators View source Inadequate placement of public access defibrillators View source Insufficient availability of public access defibrillators in colleges and schools View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jane Louise Reason · 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
Jane Louise Reason, a lecturer, collapsed at work on 28 April 2016 and was later declared deceased in hospital; the medical cause of death was recorded as hypertensive heart disease. The inquest highlighted the importance of early defibrillation and CPR and raised concern about the availability and public education surrounding public access defibrillators, particularly in colleges and schools.
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 Resuscitation Council UK; that does not assign responsibility.
PFD Monitor interpretation Insufficient public education in the use of public access defibrillators
Wider context from the report “1. Evidence at the inquest confirmed that the greatest chance of survival following an arrhythmic out of cardiac arrest is with early defibrillation and CPR. I heard evidence that there was a need for more public access defibrillators particularly in colleges and school. Further consideration needs to be given to the placement of public access defibrillators and education of the public in their use .
” 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 Resuscitation Council UK; that does not assign responsibility.
PFD Monitor interpretation Inadequate placement of public access defibrillators
Wider context from the report “1. Evidence at the inquest confirmed that the greatest chance of survival following an arrhythmic out of cardiac arrest is with early defibrillation and CPR. I heard evidence that there was a need for more public access defibrillators particularly in colleges and school. Further consideration needs to be given to the placement of public access defibrillators and education of the public in their use.
” 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 Resuscitation Council UK; that does not assign responsibility.
PFD Monitor interpretation Insufficient availability of public access defibrillators in colleges and schools
Wider context from the report “1. Evidence at the inquest confirmed that the greatest chance of survival following an arrhythmic out of cardiac arrest is with early defibrillation and CPR. I heard evidence that there was a need for more public access defibrillators particularly in colleges and school . Further consideration needs to be given to the placement of public access defibrillators and education of the public in their use.
” 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 Contribute to a national framework recommending improved public access defibrillator availability and cardiac arrest care.
Verbatim wording from the response “• Collaboration
We regularly work with statutory and non-statutory organisations where we share common aims in order to promote the use of PADs. We have been contributing a major project with the Department of Health to produce a national framework to improve the treatment of patients with cardiac arrest (Resuscitation to Recovery: A National Framework to improve care of people with Out-of-Hospital Cardiac Arrest (OHCA) in England. 2016) This document makes specific recommendations with regards to improving availability of PADs.” Source location 2016-0376-Response-by-Resuscitation-Council-UK
Open published response
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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 Organise public Restart a Heart Day events that train children and young people in basic life support.
Verbatim wording from the response “• Education
We recognise education facilitates many of the aims of the RC (UK). We work closely with UK ambulance service, other first aid organisations and the European Resuscitation Council to encourage all members of the public to learn first aid (BLS and AED use). In the UK, we have recently organised the annual ‘European Restart a Heart Day’ which through hundreds of events that took place across the UK, trained over 150,000 children and young people in basic life support.” Source location 2016-0376-Response-by-Resuscitation-Council-UK
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 Work with the Department of Health to oversee distribution of £1,000,000 funding for public access defibrillators across UK communities.
Verbatim wording from the response “• Improving the availability of AEDs
We are currently working with the Department of Health to oversee the distribution of £1,000,000 funding for public access defibrillators across communities in the UK.
After extensive public consultation, we have redesigned the signage to be used for all PADs in order to improve the visibility of the devices and increase their use at cardiac arrests in public areas.” Source location 2016-0376-Response-by-Resuscitation-Council-UK
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 Publish guidance explaining automated external defibrillators and their deployment in communities.
Verbatim wording from the response “• Guidelines
The RC (UK) is a contributor to international and European resuscitation guidelines from which are distilled the UK resuscitation guidelines. We work with key first aid organisations (e.g. ambulance service, RNLI, St John etc.) to ensure that recommendations relating to bystander CPR and defibrillation are disseminated as appropriate throughout the entire UK. Additionally, in conjunction with the British Heart Foundation, we have recently published ‘A guide to Automated External Defibrillators’ which is designed to provide information about AEDs and how they can be deployed within the community to help resuscitate a victim of sudden cardiac arrest.” Source location 2016-0376-Response-by-Resuscitation-Council-UK
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 Campaign for mandatory basic life support and automated external defibrillator teaching for schoolchildren.
Verbatim wording from the response “We have been campaigning at all levels to make BLS and AED teaching mandatory for all school children. Although disappointing we have not managed to make this mandatory part of the school curriculum, our campaign has undoubtedly raised the need for this training and improved the numbers of school children who are taught these vital life skills.” Source location 2016-0376-Response-by-Resuscitation-Council-UK
Open published response
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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 Council has no power to mandate public access defibrillator provision or mandatory basic life support and defibrillator education.
Verbatim wording from the response “In summary, whilst being actively engaged with the above requirements, we have no power to mandate these. We would ask that your recommendations are shared with the Department of Education, in particular that all children are trained in BLS and defibrillator awareness as a mandatory part of the curriculum.” Source location 2016-0376-Response-by-Resuscitation-Council-UK
Open published response
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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 Recommendations for mandatory basic life support and defibrillator training should be directed to the Department for Education.
Verbatim wording from the response “In summary, whilst being actively engaged with the above requirements, we have no power to mandate these. We would ask that your recommendations are shared with the Department of Education, in particular that all children are trained in BLS and defibrillator awareness as a mandatory part of the curriculum.” Source location 2016-0376-Response-by-Resuscitation-Council-UK
Open published response
19 Jul 2016 ROSEMARIE DEES · Prevention of Future Deaths report London Inner (South)
View report summary
Concerns raised 1 Failure to make SGA use conditional on laryngoscopy to detect foreign body airway obstruction View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
ROSEMARIE DEES · 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
Rosemarie Dees died at home on 18 April 2016 after choking on a boiled sweet and losing consciousness. The medical cause of death was recorded as asphyxia caused by a food bolus in the larynx. The report raised concern that use of a supra-glottic airway may be inhibited by an undetected foreign-body airway obstruction.
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 Resuscitation Council UK; that does not assign responsibility.
PFD Monitor interpretation Failure to make SGA use conditional on laryngoscopy to detect foreign body airway obstruction
Wider context from the report “that the use of an SGA may be inhibited by an undetected foreign body airway obstruction . Such an obstruction might be spotted if the use of an SGA was made conditional on the carrying out of a laryngoscopy which it is understood will soon be LAS protocol.
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations