Adam Ankers
16 Apr 2025 · Coroner Valerie Charbit · West London
This report repeats 2 earlier warnings. See the linked reports.
The coroner's concerns
1. misidentification of agonal breathing leading to lack of basic life support
“difficulty in lay people (trained or not) including ambulance call handlers in understanding the signs of agonal breathing or cardiac arrest”
2. inadequate mandatory SCA training for grassroots coaches and referees
“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”
3. insufficient public and first‑aid training on defibrillator use
“need for better understanding of the use of defibrillators particularly by lay persons and trained first aid persons”
4. lack of accessible cardiac screening for youths
“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 young football players”
5. incomplete genetic disease cascade communication
“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”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“Evidence at the inquest confirmed that the greatest charice of survival following an arrhythmic out of cardiac arrest is with early defibrillation and CPR.”
This 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”
Closely relatedConfidence 0.90 · high
Earlier report
“The adequacy of the training of Emirates staff in respect of the recognition of possible cardiac arrest and signs thereof including agonal breathing and the administration of appropriate first aid/prompt CPR”
This report
“That there is difficulty in lay people (trained or not) including ambulance call handlers in understanding the signs of agonal breathing or cardiac arrest”