PFD report

Sydney Mya Neil · Prevention of Future Deaths report

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Issued 15 Jul 2016•Birmingham and Solihull

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
5

Raised in this report

Recipients
3

Named on the report

Responses found
3

Of 3 recipients

Stated actions
9

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised5

  1. Insufficient resuscitation expertise in GP practices
    Part of recurring concern: Failure to ensure staff competence in resuscitation
  2. Inadequate ventilation during resuscitation in GP practices
    Part of recurring concern: Unreliable airway management during emergency carePart of recurring concern: Unreliable resuscitation preparedness and response during cardiac arrest
  3. Insufficient emergency equipment in GP practices
    Part of recurring concern: Unreliable emergency response to patient collapse
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.6

  1. Action

    Ask the CQC to ensure inspections check that primary care services have equipment and skills to address respiratory emergencies.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 15 July 2016.
  2. Action

    Provide defibrillator, oxygen, oximeter and recommended CPR equipment for managing medical emergencies in the practice.

    Stated by Wychall Lane SurgeryStated completedThe respondent said that this action was complete when they made their response on 15 July 2016.
  3. Action

    Assist the practice involved in the incident to identify and address issues highlighted by the incident.

    Stated by Birmingham South Central CCGStated in progressThe respondent said that this action was in progress when they made their response on 15 July 2016.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.6

  1. Position

    Suction facilities should not be mandated nationally because training should prioritise recognising emergencies rather than maintaining suction skills.

    Stated by NHS EnglandNo action considered necessaryThe respondent said that no further action was needed.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Insufficient resuscitation expertise in GP practices

Wider context from the report

“Once Sydney collapsed in the GP surgery there was inadequate ventilation for 8 minutes. No suction was used nor was oxygen provided. I am concerned about the level of expertise in GP practices when resuscitation is required and whether they have sufficient equipment to deal with emergency situations. ”

Is this part of a recurring concern?

Yes — Failure to ensure staff competence in resuscitation.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Inadequate ventilation during resuscitation in GP practices

Wider context from the report

“Once Sydney collapsed in the GP surgery there was inadequate ventilation for 8 minutes. No suction was used nor was oxygen provided. I am concerned about the level of expertise in GP practices when resuscitation is required and whether they have sufficient equipment to deal with emergency situations. ”

Is this part of a recurring concern?

Yes — Unreliable airway management during emergency care; Unreliable resuscitation preparedness and response during 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. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Insufficient emergency equipment in GP practices

Wider context from the report

“Once Sydney collapsed in the GP surgery there was inadequate ventilation for 8 minutes. No suction was used nor was oxygen provided. I am concerned about the level of expertise in GP practices when resuscitation is required and whether they have sufficient equipment to deal with emergency situations. ”

Is this part of a recurring concern?

Yes — Unreliable emergency response to patient collapse.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to provide oxygen during resuscitation in GP practices

Wider context from the report

“Once Sydney collapsed in the GP surgery there was inadequate ventilation for 8 minutes. No suction was used nor was oxygen provided. I am concerned about the level of expertise in GP practices when resuscitation is required and whether they have sufficient equipment to deal with emergency situations. ”

Is this part of a recurring concern?

Yes — Unreliable emergency oxygen administration; Unreliable resuscitation preparedness and response during 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. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to use suction during resuscitation in GP practices

Wider context from the report

“Once Sydney collapsed in the GP surgery there was inadequate ventilation for 8 minutes. No suction was used nor was oxygen provided. I am concerned about the level of expertise in GP practices when resuscitation is required and whether they have sufficient equipment to deal with emergency situations. ”

Is this part of a recurring concern?

Yes — Unreliable airway management during emergency care; Unreliable resuscitation preparedness and response during cardiac arrest.

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

Ask the CQC to ensure inspections check that primary care services have equipment and skills to address respiratory emergencies.

Verbatim wording from the response

“I have asked ████████ Head of Primary Care Commissioning, NHS”

Source location

2016-0256-Response-by-NHS-England
Page 3 · response
Published 15 July 2016

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

Provide defibrillator, oxygen, oximeter and recommended CPR equipment for managing medical emergencies in the practice.

Verbatim wording from the response

“It suggests agreed principles for defibrillators, oxygen and oximeters (attachment 3). We have these at the practice.”

Source location

2016-0256-Response-by-Wychall-Lane-Surgery
Page 2 · response
Published 15 July 2016

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

Assist the practice involved in the incident to identify and address issues highlighted by the incident.

Verbatim wording from the response

“The CCG has been assisting the practice involved in this incident to identify and address issues that have been highlighted by this unfortunate incident and it is the intention of the CCG to circulate any learning from this incident across all GP practices that we are responsible for commissioning. We will also circulate this learning to surrounding CCGs so that they may also disseminate these lessons to their practices.”

Source location

2016-0256-Response-by-Birmingham-South-Central-Clinical-Commissioning-Group
Page 2 · response
Published 15 July 2016

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

Circulate incident learning to surrounding clinical commissioning groups for dissemination to their practices.

Verbatim wording from the response

“The CCG has been assisting the practice involved in this incident to identify and address issues that have been highlighted by this unfortunate incident and it is the intention of the CCG to circulate any learning from this incident across all GP practices that we are responsible for commissioning. We will also circulate this learning to surrounding CCGs so that they may also disseminate these lessons to their practices.”

Source location

2016-0256-Response-by-Birmingham-South-Central-Clinical-Commissioning-Group
Page 2 · response
Published 15 July 2016

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

Conduct contract visits to ensure GP practices adhere to emergency equipment, training and protocol guidance.

Verbatim wording from the response

“All organisations providing primary care should also have appropriate equipment and drugs for managing other life-threatening emergencies (e.g. anaphylaxis). The CCG would expect all GP staff to be trained to deliver basic CPR to patients, to have this training updated on a regular basis and have appropriate protocols in place to deal with such emergencies. The CCG has a programme of contract visits where we will ensure that practices are adhering to the guidance provided above”

Source location

2016-0256-Response-by-Birmingham-South-Central-Clinical-Commissioning-Group
Page 1 · response
Published 15 July 2016

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

Circulate learning from the incident to all commissioned GP practices.

Verbatim wording from the response

“The CCG has been assisting the practice involved in this incident to identify and address issues that have been highlighted by this unfortunate incident and it is the intention of the CCG to circulate any learning from this incident across all GP practices that we are responsible for commissioning. We will also circulate this learning to surrounding CCGs so that they may also disseminate these lessons to their practices.”

Source location

2016-0256-Response-by-Birmingham-South-Central-Clinical-Commissioning-Group
Page 2 · response
Published 15 July 2016

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

Suction facilities should not be mandated nationally because training should prioritise recognising emergencies rather than maintaining suction skills.

Verbatim wording from the response

“In relation to the requirement for suction facilities to facilitate ventilator support, I have sought the views of NHS England’s National Clinical Directors. Whilst a number of practices will have some access to suction facilities, it was not felt that this should become a national requirement of primary care. BTS guidance highlights the risks associated with ventilatory support and non-invasive ventilation, (NIV) in severe asthma. It is the view of my Clinical Directors therefore better to target training in primary care on recognising an emerging emergency situation rather than to attempt to train and maintain skills in using suction equipment in challenging emergency situations. As a result, I do not feel it appropriate to mandate all general practices to purchase and maintain suction facilities which would necessarily include ensuring all relevant staff are appropriately trained.”

Source location

2016-0256-Response-by-NHS-England
Page 3 · response
Published 15 July 2016

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

Except in remote or inaccessible locations, practices may rely on rapid access to emergency services when determining appropriate equipment and training.

Verbatim wording from the response

“The Care Quality Commission (CQC) as the regulator of general practice needs to be assured that practices are able to immediately respond to the needs of a person who becomes seriously ill. The CQC does not have explicit guidance around emergency equipment; however does state that if the practice does not have oxygen they are unlikely to be able to demonstrate they are equipped for dealing with emergencies.²”

Source location

2016-0256-Response-by-NHS-England
Page 3 · response
Published 15 July 2016

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

The CQC is responsible for using its inspection regime to ensure primary care services carry necessary equipment and skills for respiratory emergencies.

Verbatim wording from the response

“The Care Quality Commission (CQC) as the regulator of general practice needs to be assured that practices are able to immediately respond to the needs of a person who becomes seriously ill. The CQC does not have explicit guidance around emergency equipment; however does state that if the practice does not have oxygen they are unlikely to be able to demonstrate they are equipped for dealing with emergencies.²”

Source location

2016-0256-Response-by-NHS-England
Page 3 · response
Published 15 July 2016

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

GP practices do not need to maintain suction equipment because its use is extremely rare and competence would be difficult to maintain.

Verbatim wording from the response

“We have met with Birmingham South Central CCG and after a detailed significant event analysis they have stated:- “All organisations providing primary care should also have appropriate equipment and drugs for managing other life-threatening emergencies (e.g. anaphylaxis). The CCG would expect all staff to be trained to deliver basic CPR to patients, to have this training updated on a regular basis and have appropriate protocols in place to deal with such emergencies. In respect of suction being available, the CCG view would be that there would be no requirement for GP practices to have suction available on a regular basis as the use of such equipment would be extremely rare and it would be difficult for GPs to maintain their competence in using this type of equipment.”

Source location

2016-0256-Response-by-Wychall-Lane-Surgery
Page 2 · response
Published 15 July 2016

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

General practice is not an emergency service and is not contracted, equipped or organised to deliver team-based emergency care.

Verbatim wording from the response

“We have taken advice from the Local Medical Committee and General Practice Committee (GPC) of the BMA who commissioned ████████ who is a senior GP who has held roles including provision of and teaching of immediate care, now known as Pre-Hospital Emergency Medicine and is chair of BASICS Education Ltd, who aim to improve emergency care outside hospital, to comment on the care the Practice provided to Miss Neil and provide his general thoughts on this incident. He states general practice and general practitioners are not an emergency service…… General practitioners who very, very infrequently have to deal with life threatening emergencies and are neither equipped, contracted nor organised to deliver such team based emergency care.”

Source location

2016-0256-Response-by-Wychall-Lane-Surgery
Page 2 · response
Published 15 July 2016

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

Regular GP practices need not maintain suction equipment because its use is extremely rare and competence would be difficult to maintain.

Verbatim wording from the response

“In respect of suction being available, the CCG view would be that there would be no requirement for GP practices to have suction available on a regular basis since the use of such equipment would be extremely rare and it would be difficult for GPs to maintain their competence in using this type of equipment. Similarly the CCG would not expect a GP to be able to intubate a patient or to have the equipment available to undertake this procedure as this would not be within the regular skill set of a GP. This view is based on the Resuscitation Council (UK) guidance that identifies these equipment and competencies are required for GPs having an extended role in aspects such as urgent and emergency care rather than generic general practice.”

Source location

2016-0256-Response-by-Birmingham-South-Central-Clinical-Commissioning-Group
Page 2 · response
Published 15 July 2016

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.3

  1. 1

    Raise awareness of asthma management by communicating updated BTS/SIGN guidance to GP practices and sharing it with CCGs.

    Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 15 July 2016.
  2. 2

    Incorporate continuous oxygen-saturation monitoring and oxygen-use thresholds into the paediatric acute asthma management protocol.

    Stated by Wychall Lane SurgeryStated completedThe respondent said that this action was complete when they made their response on 15 July 2016.
  3. 3

    Incorporate the serious case review outcomes into the practice’s emergency protocol.

    Stated by Wychall Lane SurgeryStated completedThe respondent said that this action was complete when they made their response on 15 July 2016.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.2

  1. 1

    Generic GP practices are not expected to provide intubation because it is outside their regular skills and would require extended emergency-care competencies.

    Stated by Wychall Lane SurgeryUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
  2. 2

    Generic GPs need not intubate patients or hold intubation equipment because these skills apply to extended urgent and emergency care roles.

    Stated by Birmingham South Central CCGNo action considered necessaryThe respondent said that no further action was needed.

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 asthma management by communicating updated BTS/SIGN guidance to GP practices and sharing it with CCGs.

Verbatim wording from the response

“The 2016 update to the BTS/SIGN asthma guidelines is due to be published in the Autumn and I will use this as an opportunity to raise awareness of asthma management in primary care. I will do this by communicating to all GP practices through our GP Bulletin. I also intend to share this with the CCGs who commission secondary care and emergency services.”

Source location

2016-0256-Response-by-NHS-England
Page 3 · response
Published 15 July 2016

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

Incorporate continuous oxygen-saturation monitoring and oxygen-use thresholds into the paediatric acute asthma management protocol.

Verbatim wording from the response

“Following the initial SUDIC case discussion on 10th March 2016 recommendations from ████████ respiratory consultant at Birmingham Children’s Hospital, namely to have continual oxygen saturation readings while nebulising a child, have been incorporated into our protocol for Acute Asthma Management in children. Oxygen is used to nebulise should the oxygen saturation fall below 94% in air (attachment 1).”

Source location

2016-0256-Response-by-Wychall-Lane-Surgery
Page 1 · response
Published 15 July 2016

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

Incorporate the serious case review outcomes into the practice’s emergency protocol.

Verbatim wording from the response

“Following the SUDIC meeting in March the practice carried out a serious case review (attachment 2). The outcomes obtained from this review have all been incorporated into our emergency protocol.”

Source location

2016-0256-Response-by-Wychall-Lane-Surgery
Page 1 · response
Published 15 July 2016

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

Generic GP practices are not expected to provide intubation because it is outside their regular skills and would require extended emergency-care competencies.

Verbatim wording from the response

“Similarly the CCG would not expect a GP to be able to intubate a patient or to have the equipment available to undertake this procedure as this would not be within the regular skill set of a GP. This view is based on the Resuscitation Council (UK) guidance that identifies these equipment and competencies are required for GPs with an extended role in aspects such as urgent and emergency care rather than ‘generic general practice’” (attachment 5). I understand the CCG will be providing its own response to the Regulation 28 Report.”

Source location

2016-0256-Response-by-Wychall-Lane-Surgery
Page 2 · response
Published 15 July 2016

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

Generic GPs need not intubate patients or hold intubation equipment because these skills apply to extended urgent and emergency care roles.

Verbatim wording from the response

“In respect of suction being available, the CCG view would be that there would be no requirement for GP practices to have suction available on a regular basis since the use of such equipment would be extremely rare and it would be difficult for GPs to maintain their competence in using this type of equipment. Similarly the CCG would not expect a GP to be able to intubate a patient or to have the equipment available to undertake this procedure as this would not be within the regular skill set of a GP. This view is based on the Resuscitation Council (UK) guidance that identifies these equipment and competencies are required for GPs having an extended role in aspects such as urgent and emergency care rather than generic general practice.”

Source location

2016-0256-Response-by-Birmingham-South-Central-Clinical-Commissioning-Group
Page 2 · response
Published 15 July 2016

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026