PFD report

Romeo Miles Esposito · Prevention of Future Deaths report

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Issued 15 Mar 2024•Avon

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
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
4

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 raised2

  1. Lack of warning or training for clinical staff on interpreting respiratory effort
    Part of recurring concern: Failure to ensure staff competence in conducting and interpreting clinical observationsPart of recurring concern: Unreliable escalation of abnormal clinical observations
  2. Failure to undertake further clinical assessment of respiratory effort
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.1

  1. Action

    Provide mandatory ALS training with cardiac-arrest simulation and discussion-based learning on post-death clinical changes, escalation and senior review.

    Stated by South Western Ambulance Service NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 20 March 2024.

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

Lack of warning or training for clinical staff on interpreting respiratory effort

Wider context from the report

“(1) Romeo was making respiratory effort for about an hour after ROLE at 0952 hours and resuscitation being resumed at 1049 hours; (2) His family raised their concerns regarding this with SWAS clinical staff on a number of occasions thoughout this period; (3) Staff repeatedly ascribed the respiratory effort to “a release of air”, as opposed to a change in Romeo’s clinical condition which required further clinical assessment; (4) There was no evidence to confirm that clinical staff have been warned or trained not to use “a release of air” as an explanation for respiratory effort or a reason to avoid further clinical assessment. ”

Is this part of a recurring concern?

Yes — Failure to ensure staff competence in conducting and interpreting clinical observations; Unreliable escalation of abnormal clinical observations.

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 undertake further clinical assessment of respiratory effort

Wider context from the report

“(1) Romeo was making respiratory effort for about an hour after ROLE at 0952 hours and resuscitation being resumed at 1049 hours; (2) His family raised their concerns regarding this with SWAS clinical staff on a number of occasions thoughout this period; (3) Staff repeatedly ascribed the respiratory effort to “a release of air”, as opposed to a change in Romeo’s clinical condition which required further clinical assessment; (4) There was no evidence to confirm that clinical staff have been warned or trained not to use “a release of air” as an explanation for respiratory effort or a reason to avoid further clinical assessment. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Provide mandatory ALS training with cardiac-arrest simulation and discussion-based learning on post-death clinical changes, escalation and senior review.

Verbatim wording from the response

“As part of the mandatory training delivered to all Trust staff for 2024 to 2025, a session on advanced life support (ALS) is to be provided. This includes a simulation around cardiac arrest management in conjunction with discussion-based learning around actions that may be required following COD. This includes the potential for a change in clinical presentation with an emphasis on this being escalated for senior review. In this scenario, the guidance dictates that in these circumstances the lead clinician must observe and reassess the patient to satisfy themselves that COD is appropriate. If any uncertainty remains, the Resuscitation Advice Line can be contacted. The Major Trauma and Resuscitation Advice Line is staffed by experienced Specialist Critical Care Practitioners supported by a duty Consultant. The team are available to offer advice to ambulance crews 24/7.”

Source location

Response from South Western Ambulance Service
Page 3 · response
Published 20 March 2024

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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

    Publish the revised guidance on the JRCALC app and issue staff notifications prompting review and acknowledgement of the change.

    Stated by South Western Ambulance Service NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 20 March 2024.
  2. 2

    Launch education on using the CUSS communication tool to escalate concerns and require teams to acknowledge and act on raised concerns.

    Stated by South Western Ambulance Service NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 20 March 2024.
  3. 3

    Revise Confirmation of Death guidance to require at least five minutes between ceasing resuscitation and declaring death.

    Stated by South Western Ambulance Service NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 20 March 2024.

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 the revised guidance on the JRCALC app and issue staff notifications prompting review and acknowledgement of the change.

Verbatim wording from the response

“The aim is for the new guideline to be live on the Trust’s JRCALC clinical app by the week ending 7 June 2024. This is an app that can be accessed by all Trust members of staff as well as those contracted to work on behalf of SWASFT. In addition, once confirmation has been received that the guideline is ready to be published, a Clinical Notice alerting staff to the revisions will be issued to all staff via email and as a pop-up on the app prompting them to review the change. Once an individual has accessed the guidance, they are prompted to press a button to acknowledge the change, allowing the Trust the functionality to monitor how many Trust staff acknowledge it, which in turn provides assurance around the number of staff reviewing updated guidance.”

Source location

Response from South Western Ambulance Service
Page 2 · response
Published 20 March 2024

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

Launch education on using the CUSS communication tool to escalate concerns and require teams to acknowledge and act on raised concerns.

Verbatim wording from the response

“The Trust is also launching education around how to escalate concerns using the I am Concerned, I am Uncomfortable, this is a Safety issue and Stop (CUSS) communication tool. CUSS is a technique that uses a graded assertiveness approach to communicating. Should someone be concerned with a process or intervention being put in place, they can raise concerns, becoming more assertive if they feel their concerns are not listened to. The key to this education is further training on how individuals and teams acknowledge and take steps to act on concerns raised.”

Source location

Response from South Western Ambulance Service
Page 3 · response
Published 20 March 2024

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

Revise Confirmation of Death guidance to require at least five minutes between ceasing resuscitation and declaring death.

Verbatim wording from the response

“During the review undertaken by the Trust, it was clear that everyone on scene had worked tirelessly to save Romeo; however, some learning points were identified. This included revisiting the Confirmation of Death guidance contained within the Cardiac Arrest guidelines, specifically the amount of time that should be given between ceasing resuscitation and confirmation of death (COD). At the time of Romeo’s death the guidance in place required the clinician to observe the patient for five minutes between ceasing resuscitation and COD. Allowing sufficient time between ceasing resuscitation and confirming ROLE allows the attending clinician to fully assess whether there are any signs of life indicating resuscitation should be resumed. This was subsequently revised to ‘a few minutes’.”

Source location

Response from South Western Ambulance Service
Page 2 · response
Published 20 March 2024

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