PFD report

Frances Ann NEWBURY · Prevention of Future Deaths report

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Issued 10 Nov 2023•Inner North London

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.

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Concerns
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
5

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 raised1

  1. Failure to administer Naloxone to patients with an opiate misuse history when other potential reversible causes have been treated
    Part of recurring concern: Unsafe access to and application of Naloxone guidancePart of recurring concern: Unsafe medication administration
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.3

  1. Action

    Request a review of current JRCALC guidance on naloxone use in opioid-related cardiac arrest.

    Stated by London Ambulance Service NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 14 November 2023.
  2. Action

    Work with agencies regularly contacting opioid users to improve naloxone availability.

    Stated by London Ambulance Service NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 14 November 2023.
  3. Action

    Provide high-concentration naloxone on specialist Trust resources for cases involving potentially potent synthetic opioids.

    Stated by London Ambulance Service NHS TrustStated completedThe respondent said that this action was complete when they made their response on 14 November 2023.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    For confirmed cardiac arrest, standard resuscitation with high-quality compressions and ventilation should take priority over naloxone.

    Stated by London Ambulance Service NHS TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so 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

Failure to administer Naloxone to patients with an opiate misuse history when other potential reversible causes have been treated

Wider context from the report

“Despite paramedics being informed that Ms Newbury had taken illicit drugs the previous evening (albeit the report being of ████████) and obvious signs of ‘popping’ scars on her legs from ████████, Naloxone was not administered. Although in Ms Newbury’s case, it would have made no difference, I am concerned that in another case it may. This is not the first inquest in which I have queried why Naloxone has not been administered to patients (with a opiate misuse history) when all other potential reversible causes have been treated. ”

Is this part of a recurring concern?

Yes — Unsafe access to and application of Naloxone guidance; Unsafe medication administration.

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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

Request a review of current JRCALC guidance on naloxone use in opioid-related cardiac arrest.

Verbatim wording from the response

“Overall the evidence base suggests that where cardiac arrest is established and confirmed from opioid use, naloxone has limited efficacy in reversing the cardiac arrest. The Joint Royal Colleges Ambulance Liaison Committee (JRCALC) Clinical Practice Guidance advise the use of naloxone in cardiac arrest, noting that this has been unchanged and more recently the empirical reviews of the clinical evidence have been undertaken. I have asked that our Consultant Paramedics and Associate Clinical Directors who both are members of the JRCALC resuscitation group, request that a review is undertaken of JRCALC current guidance in light of the emerging clinical evidence, in respect of opioids.”

Source location

Response from London Ambulance Service
Page 3 · response
Published 14 November 2023

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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

Work with agencies regularly contacting opioid users to improve naloxone availability.

Verbatim wording from the response

“increasing the accessibility to public access defibrillators and trained responders and we are working with our agencies who have regular contact with opioid users around utility of naloxone to be available to them.”

Source location

Response from London Ambulance Service
Page 4 · response
Published 14 November 2023

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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

Provide high-concentration naloxone on specialist Trust resources for cases involving potentially potent synthetic opioids.

Verbatim wording from the response

“That said, the LAS is absolutely of the view that naloxone should be administered where a patient presents with respiratory depression and/or is peri (near) arrest, in this instance it is recognised to be lifesaving and we absolutely support its administration. In March 2022, the London Ambulance Service initiated the availability of high concentration naloxone on specialist resources utilised by the Trust. This was in recognition of the potential for highly potent synthetic opioids where stronger doses of naloxone may be required. We are also highly supportive of naloxone in community programs, for those where there is a high risk of overdose.”

Source location

Response from London Ambulance Service
Page 3 · response
Published 14 November 2023

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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

For confirmed cardiac arrest, standard resuscitation with high-quality compressions and ventilation should take priority over naloxone.

Verbatim wording from the response

“Asphyxia (deprivation of oxygen), through the respiratory depression (reduction in an individual’s breathing), develops and this leads to further cerebral hypoxia. Ultimately it is the hypoxia/hypercarbia which cause a diminishing cardiac output and may finally sadly result in a patient’s cardiac arrest. Where a patient is in cardiac arrest, there is immediate and ongoing artificial ventilation in an attempt to correct any ventilatory failure. Naloxone is a competitive antagonist (receptor site blocker) for the opioid and its administration aims to diminish the effects of the opioid, however, once a patient is in cardiac arrest (as opposed to respiratory arrest) the focus should be on high quality standard life support including artificial ventilation, chest compressions and adrenaline administration.”

Source location

Response from London Ambulance Service
Page 2 · response
Published 14 November 2023

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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

Established cardiac arrest and absent immediate opioid-use evidence meant naloxone was not mandated and would not have changed the outcome.

Verbatim wording from the response

“Whilst it is recognised that Ms Newbury had a long term history of opioid use, naloxone was not considered at the time of the cardiac arrest as there was no immediate history of opioid use and a clinically feasible cause of the arrest was identified, which was a current infection. The resuscitation attempt focused on high quality chest compressions and effective ventilation. It was recognised by the clinicians that naloxone would not have reversed the effects of ████████. The information reported to the clinicians at the time of attendance was that Ms Newbury had taken ████████ the previous evening.”

Source location

Response from London Ambulance Service
Page 1 · response
Published 14 November 2023

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.2

  1. 1

    Run a London-wide programme to increase early bystander life-support provision.

    Stated by London Ambulance Service NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 14 November 2023.
  2. 2

    Increase access to public-access defibrillators and trained responders.

    Stated by London Ambulance Service NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 14 November 2023.

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

Run a London-wide programme to increase early bystander life-support provision.

Verbatim wording from the response

“We would be very happy to discuss and present the work the LAS is doing to improve cardiac arrest survival in London. This includes a London wide programme to increase early bystander life support as well as”

Source location

Response from London Ambulance Service
Page 3 · response
Published 14 November 2023

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

Increase access to public-access defibrillators and trained responders.

Verbatim wording from the response

“We would be very happy to discuss and present the work the LAS is doing to improve cardiac arrest survival in London. This includes a London wide programme to increase early bystander life support as well as”

Source location

Response from London Ambulance Service
Page 3 · response
Published 14 November 2023

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