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
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
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 UK National Screening Committee; 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 UK National Screening Committee; 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 UK National Screening Committee; 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 UK National Screening Committee; 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 UK National Screening Committee; 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
6 Mar 2016 Edward Paddon-Bramley · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 3 Inconsistent use of intrapartum antibiotics View source Inconsistent treatment guidance and practice for prolonged rupture of membranes View source Inconsistent GBS screening practice during pregnancy View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Edward Paddon-Bramley · 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
Edward Paddon-Bramley was born following prolonged rupture of membranes and developed severe infection, including Group B Streptococcus infection. Despite neonatal care, he died aged 9 days. The report identified differing practices and opinions regarding the treatment of prolonged rupture of membranes and whether pregnant women should be screened for Group B Streptococcus and given intrapartum antibiotics.
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 UK National Screening Committee; that does not assign responsibility.
PFD Monitor interpretation Inconsistent use of intrapartum antibiotics
Wider context from the report “Evidence was provided to the Court by way of National guidelines (NICE 2008, Induction of labour), Trust guidelines (more than one Trust), The Royal College (Green-top guideline no 36) and by Consultants.
Trust guidelines as to the treatment of prolonged rupture of membranes (PROM) differed from those provided by NICE and the use of anti-biotics, after varying times of rupture, irrespective of the clinical picture.
Consultants views as to the best practice for treating PROM and whether women should be screened for GBS during pregnancy differed from those provided by NICE.
In conclusion, evidence was given at the inquest that there is a difference of opinion and practice in the treatment of mothers (and their babies) who suffer from ROM of a prolonged period. Both clinicians and Trusts appear to be at odds with NICE.
There also appears to be arguable opinion that GBS screening in pregnant women together with the use of intra-partum anti-biotics ought to re-viewed.
” 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 UK National Screening Committee; that does not assign responsibility.
PFD Monitor interpretation Inconsistent treatment guidance and practice for prolonged rupture of membranes
Wider context from the report “Evidence was provided to the Court by way of National guidelines (NICE 2008, Induction of labour), Trust guidelines (more than one Trust), The Royal College (Green-top guideline no 36) and by Consultants.
Trust guidelines as to the treatment of prolonged rupture of membranes (PROM) differed from those provided by NICE and the use of anti-biotics, after varying times of rupture, irrespective of the clinical picture.
Consultants views as to the best practice for treating PROM and whether women should be screened for GBS during pregnancy differed from those provided by NICE.
In conclusion, evidence was given at the inquest that there is a difference of opinion and practice in the treatment of mothers (and their babies) who suffer from ROM of a prolonged period. Both clinicians and Trusts appear to be at odds with NICE.
There also appears to be arguable opinion that GBS screening in pregnant women together with the use of intra-partum anti-biotics ought to re-viewed.
” 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 UK National Screening Committee; that does not assign responsibility.
PFD Monitor interpretation Inconsistent GBS screening practice during pregnancy
Wider context from the report “Evidence was provided to the Court by way of National guidelines (NICE 2008, Induction of labour), Trust guidelines (more than one Trust), The Royal College (Green-top guideline no 36) and by Consultants.
Trust guidelines as to the treatment of prolonged rupture of membranes (PROM) differed from those provided by NICE and the use of anti-biotics, after varying times of rupture, irrespective of the clinical picture.
Consultants views as to the best practice for treating PROM and whether women should be screened for GBS during pregnancy differed from those provided by NICE.
In conclusion, evidence was given at the inquest that there is a difference of opinion and practice in the treatment of mothers (and their babies) who suffer from ROM of a prolonged period. Both clinicians and Trusts appear to be at odds with NICE.
There also appears to be arguable opinion that GBS screening in pregnant women together with the use of intra-partum anti-biotics ought to re-viewed.
” 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 Review the recommendation on screening for Group B Streptococcus in pregnancy after the update review and consultation.
Verbatim wording from the response “National screening policy is set by an expert Committee, the UK National Screening Committee (UK NSC), which advises Ministers and the NHS about all aspects of screening policy. In November 2012, the UK NSC recommended that antenatal screening for GBS carriage should not be offered. This is because testing women in late pregnancy to see if they carry GBS is not very effective in predicting whether the baby is likely to be affected by early onset GBS disease. This means that thousands of women in labour who carry GBS as a harmless bacterium would be offered antibiotics they didn’t need. The balance of benefits and harms from this strategy is uncertain. In December 2015 the UK NSC commissioned an update review into antenatal screening for GBS as per its published process. A public consultation is expected to be held in the autumn for a three-month period.” Source location 2016-0099-Response-by-NSC
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 Commission an update review of antenatal screening for Group B Streptococcus carriage.
Verbatim wording from the response “National screening policy is set by an expert Committee, the UK National Screening Committee (UK NSC), which advises Ministers and the NHS about all aspects of screening policy. In November 2012, the UK NSC recommended that antenatal screening for GBS carriage should not be offered. This is because testing women in late pregnancy to see if they carry GBS is not very effective in predicting whether the baby is likely to be affected by early onset GBS disease. This means that thousands of women in labour who carry GBS as a harmless bacterium would be offered antibiotics they didn’t need. The balance of benefits and harms from this strategy is uncertain. In December 2015 the UK NSC commissioned an update review into antenatal screening for GBS as per its published process. A public consultation is expected to be held in the autumn for a three-month period.” Source location 2016-0099-Response-by-NSC
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 antenatal GBS screening is not offered because testing poorly predicts disease and the benefits and harms are uncertain.
Verbatim wording from the response “National screening policy is set by an expert Committee, the UK National Screening Committee (UK NSC), which advises Ministers and the NHS about all aspects of screening policy. In November 2012, the UK NSC recommended that antenatal screening for GBS carriage should not be offered. This is because testing women in late pregnancy to see if they carry GBS is not very effective in predicting whether the baby is likely to be affected by early onset GBS disease. This means that thousands of women in labour who carry GBS as a harmless bacterium would be offered antibiotics they didn’t need. The balance of benefits and harms from this strategy is uncertain. In December 2015 the UK NSC commissioned an update review into antenatal screening for GBS as per its published process. A public consultation is expected to be held in the autumn for a three-month period.” Source location 2016-0099-Response-by-NSC
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 Health professionals are advised to follow established NICE and RCOG risk-based guidance for GBS prevention.
Verbatim wording from the response “In the UK, health professionals are advised to follow the risk-based guidance established by NICE and the RCOG. Though it is not possible to comment on individual cases, it appears that this case is relevant to that guidance. This is because of the prolonged membrane rupture and chorioamnionitis described in your” Source location 2016-0099-Response-by-NSC
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 NICE and RCOG are better placed to respond to the issues raised about risk-based GBS guidance.
Verbatim wording from the response “report. I note that NICE and RCOG have received this report and they are better placed to respond to the issues raised. However, it may be of interest to you to know that research is currently underway to evaluate the value of using rapid tests in labour to detect GBS in women with the kind of risk factors experienced by ████████ This is sponsored by the NIHR HTA Programme.” Source location 2016-0099-Response-by-NSC
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