PFD report

Carl Lee Thompson · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 18 Apr 2016•West Yorkshire (Western)

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
1

Named on the report

Responses found
0

Of 1 recipient

Stated actions
0

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

Open published report

Concerns and recipient responses

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

Report evidence summary

Concerns raised5

  1. Failure to maintain ambubags in a condition that permits oxygen flow
  2. Delays in ambulance and doctor arrival for emergency treatment
    Part of recurring concern: Delays in ambulance attendance
  3. Lack of suction equipment for clearing airways
    Part of recurring concern: Failure to ensure essential clinical equipment and supplies are available and serviceablePart of recurring concern: Unreliable airway management during emergency care
Responses linked to these concerns

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

No linked response statements

No respondent-stated action or position is clearly linked to these concerns.

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 maintain ambubags in a condition that permits oxygen flow

Wider context from the report

“• The emergency bag did not contain suction equipment to clear the airways • A hole in the ambubag used in the resuscitation attempts prevented the flow of oxygen • The defibrillator used during resuscitation was inoperable given it was found to have no batteries • Delay of 45 minutes to obtain a replacement defibrillator • Absence of equipment to dry the casualty • Substantial delay before the arrival of the ambulance and doctor for emergency treatment. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Delays in ambulance and doctor arrival for emergency treatment

Wider context from the report

“• The emergency bag did not contain suction equipment to clear the airways • A hole in the ambubag used in the resuscitation attempts prevented the flow of oxygen • The defibrillator used during resuscitation was inoperable given it was found to have no batteries • Delay of 45 minutes to obtain a replacement defibrillator • Absence of equipment to dry the casualty • Substantial delay before the arrival of the ambulance and doctor for emergency treatment. ”

Is this part of a recurring concern?

Yes — Delays in ambulance attendance.

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

Lack of suction equipment for clearing airways

Wider context from the report

“• The emergency bag did not contain suction equipment to clear the airways • A hole in the ambubag used in the resuscitation attempts prevented the flow of oxygen • The defibrillator used during resuscitation was inoperable given it was found to have no batteries • Delay of 45 minutes to obtain a replacement defibrillator • Absence of equipment to dry the casualty • Substantial delay before the arrival of the ambulance and doctor for emergency treatment. ”

Is this part of a recurring concern?

Yes — Failure to ensure essential clinical equipment and supplies are available and serviceable; Unreliable airway management during emergency care.

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 ensure a functioning defibrillator is immediately available

Wider context from the report

“• The emergency bag did not contain suction equipment to clear the airways • A hole in the ambubag used in the resuscitation attempts prevented the flow of oxygen • The defibrillator used during resuscitation was inoperable given it was found to have no batteries • Delay of 45 minutes to obtain a replacement defibrillator • Absence of equipment to dry the casualty • Substantial delay before the arrival of the ambulance and doctor for emergency treatment. ”

Is this part of a recurring concern?

Yes — Unreliable availability and readiness of defibrillators for emergency response.

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

Lack of equipment to dry the casualty

Wider context from the report

“• The emergency bag did not contain suction equipment to clear the airways • A hole in the ambubag used in the resuscitation attempts prevented the flow of oxygen • The defibrillator used during resuscitation was inoperable given it was found to have no batteries • Delay of 45 minutes to obtain a replacement defibrillator • Absence of equipment to dry the casualty • Substantial delay before the arrival of the ambulance and doctor for emergency treatment. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report
Back to top

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

Official responses located
0/1

Data last updated 7 September 2026

No official response is included in the current published snapshot.