NHS England
NHS / Health Body
Noted
NHS England noted the concerns, clarifying CQC's role in overseeing emergency preparedness in care settings. It deferred to Choice Support, the care provider, for details on actions taken, and highlighted its national working group for sharing PFD learnings. (AI summary)
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Dear Ms Brown, Re: Regulation 28 Report to Prevent Future Deaths – Jake Daniel Taylor who died on 20th January 2025.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 8th May 2026 concerning the death of Jake Daniel Taylor on 20th January 2025. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Jake’s family and loved ones. NHS England is keen to assure the family and yourself that the concerns raised about Jake’s care have been listened to and reflected upon.
Your Report raised the following concerns:
1. An AED (Defibrillator) was not immediately available in a healthcare setting responsible for adults with high tier complex needs.
2. There was no individualised care plan to set out details of the appropriate First Aid response including necessary equipment required to be available and the appropriateness of conducting CPR.
3. Registered nursing staff were not adequately trained to carry out required basic life support when an emergency arose. Nursing Staff Training Research undertaken in relation to resuscitation has highlighted the importance of human factors, team interaction, communication, and leadership which all play a role and can influence the performance of CPR and the avoidance of any shortcomings. In the absence of a valid, documented Do Not Attempt CPR (DNACPR) or Advance Decision to Refuse Treatment (ADRT), the default clinical expectation, supported by joint guidance from the British Medical Association (BMA), Resuscitation Council UK, and Royal College of Nursing (RCN) is that CPR must be initiated without delay. DNACPR is a clinical recommendation rather than a legally binding instruction, and undocumented or informal discussions must not influence emergency response. In this case, although DNACPR had been discussed informally, it had not been formalised following transition to adult services. . National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG
19th June 2026
Current Resuscitation Council UK (2025) guidelines reinforce that CPR should be initiated promptly in cardiac arrest, supported by effective systems, early defibrillation, and appropriate airway management. The NMC Code (2018, updated 2024) and Future Nurse Standards require registered nurses to act without delay in emergencies and maintain competence in life-saving interventions, including airway management and recognising deterioration, consistent with NICE CG50 - Acutely ill adults in hospital: recognising and responding to deterioration. Nationally agreed Universal Principles for Advance Care Planning set out a voluntary process of person-centred discussion between an individual and their care providers about their preferences and priorities for their future care. These are likely to involve a number of conversations over time and with whoever the person wishes to involve. When advance care planning is done well, people feel they have had the opportunity to plan for their future care. People feel more confident that their care and treatment will be focused on what matters most to them in a personalised, holistic way and helps them to live as well as possible. This aligns with NICE Guideline NG216 (2022), which emphasises person-centred, anticipatory care planning for adults with learning disabilities, and findings from the Learning from Lives and Deaths (LeDeR) programme, led by NHS England, which highlights the need for proactive, individualised planning due to increased risk of avoidable mortality in this population
Care Planning Emergency care for individuals with high-tier, complex health needs represents a safety-critical aspect of service delivery across health and social care systems. Although deterioration and life-threatening events in this cohort are often clinically predictable due to underlying conditions (including neurological disorders, epilepsy, aspiration risk, and physical disabilities), the onset of such emergencies is frequently sudden and requires an immediate, coordinated, and confident response. From a systems and nursing perspective, emergency preparedness for this population must be understood as a structured, proactive intervention rather than an ad hoc response. Individual care plans must reflect the person’s specific clinical risks, resuscitation status and agreed escalation decisions. Plans should be developed collaboratively, documented and be readily accessible and known to all staff. National learning, including that from the LeDeR programme, demonstrates that people with learning disabilities and complex needs are at increased risk of avoidable harm where care planning is insufficiently robust or not consistently applied. National guidance and professional standards consistently emphasise that emergency responses should not rely on informal knowledge or assumed understanding. Instead, safe practice requires standardised processes that reduce variation and support staff to act decisively in high-pressure situations. This includes clarity that, in the absence
of a documented DNACPR or equivalent directive, cardiopulmonary resuscitation should be initiated without delay. From a system perspective, emergency care planning must be consistently embedded within commissioning expectations and provider delivery. Plans should be person- centred, clearly defining clinical risks, escalation pathways, and resuscitation decisions, and must be formally documented, known to all staff caring for the patient / person and accessible at the point of care, and regularly reviewed to reflect changes in condition or circumstance.
Variation in the quality, completeness, or review of such plans introduces avoidable risk. Where planning is absent, outdated, or insufficiently detailed, staff may lack the clarity required to act promptly and confidently in an emergency, increasing the likelihood of delayed or suboptimal care. It is expected that a person with complex needs, such as Jake, would have an emergency health care plan in place or at least such information would be integrated within their care plan (which may include an ADRT, a Recommended Summary Plan for Emergency Care and Treatment ReSPECT form, or other locally agreed template). It would also be best practice for the person to have a health and care passport in place which, if completed correctly, would suitably capture critical information about the person’s complex health needs and how best these should be supported/managed. It is beneficial for people with a learning disability and autistic people to have a health and care passport which can be regularly updated in response to changes in their health and wellbeing and interaction in the health and care services they use. Availability of an AED Defibrillator The Care Quality Commission (CQC) are responsible for the oversight of AED defibrillators in health care settings. Whilst the CQC does not mandate that care homes have to have an AED onsite, they do require care homes to be able to handle medical emergencies. The CQC Regulation 12 (Safe Care and Treatment) further mandates that providers assess and mitigate risks, ensuring staff are appropriately trained and equipped. This includes consideration of emergency equipment such as AEDs, particularly in settings with residents at increased cardiac risk, as encouraged by NHS England and RCUK guidance. Failure to provide necessary training, equipment, or clear documentation represents a breach of expected standards of safe and effective care. Regional Input London regional colleagues have liaised with the care provider Choice Support, who ran the care home Roy Kinner House where Jake was living. Choice Support advised that they recognised that this incident highlighted opportunities to strengthen clarity, consistency and anticipatory planning and have taken actions to rectify this. We are aware Choice Support has responded directly to the Coroner, and would refer the Coroner there for more details.
I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Jake, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.
Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 8th May 2026 concerning the death of Jake Daniel Taylor on 20th January 2025. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Jake’s family and loved ones. NHS England is keen to assure the family and yourself that the concerns raised about Jake’s care have been listened to and reflected upon.
Your Report raised the following concerns:
1. An AED (Defibrillator) was not immediately available in a healthcare setting responsible for adults with high tier complex needs.
2. There was no individualised care plan to set out details of the appropriate First Aid response including necessary equipment required to be available and the appropriateness of conducting CPR.
3. Registered nursing staff were not adequately trained to carry out required basic life support when an emergency arose. Nursing Staff Training Research undertaken in relation to resuscitation has highlighted the importance of human factors, team interaction, communication, and leadership which all play a role and can influence the performance of CPR and the avoidance of any shortcomings. In the absence of a valid, documented Do Not Attempt CPR (DNACPR) or Advance Decision to Refuse Treatment (ADRT), the default clinical expectation, supported by joint guidance from the British Medical Association (BMA), Resuscitation Council UK, and Royal College of Nursing (RCN) is that CPR must be initiated without delay. DNACPR is a clinical recommendation rather than a legally binding instruction, and undocumented or informal discussions must not influence emergency response. In this case, although DNACPR had been discussed informally, it had not been formalised following transition to adult services. . National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG
19th June 2026
Current Resuscitation Council UK (2025) guidelines reinforce that CPR should be initiated promptly in cardiac arrest, supported by effective systems, early defibrillation, and appropriate airway management. The NMC Code (2018, updated 2024) and Future Nurse Standards require registered nurses to act without delay in emergencies and maintain competence in life-saving interventions, including airway management and recognising deterioration, consistent with NICE CG50 - Acutely ill adults in hospital: recognising and responding to deterioration. Nationally agreed Universal Principles for Advance Care Planning set out a voluntary process of person-centred discussion between an individual and their care providers about their preferences and priorities for their future care. These are likely to involve a number of conversations over time and with whoever the person wishes to involve. When advance care planning is done well, people feel they have had the opportunity to plan for their future care. People feel more confident that their care and treatment will be focused on what matters most to them in a personalised, holistic way and helps them to live as well as possible. This aligns with NICE Guideline NG216 (2022), which emphasises person-centred, anticipatory care planning for adults with learning disabilities, and findings from the Learning from Lives and Deaths (LeDeR) programme, led by NHS England, which highlights the need for proactive, individualised planning due to increased risk of avoidable mortality in this population
Care Planning Emergency care for individuals with high-tier, complex health needs represents a safety-critical aspect of service delivery across health and social care systems. Although deterioration and life-threatening events in this cohort are often clinically predictable due to underlying conditions (including neurological disorders, epilepsy, aspiration risk, and physical disabilities), the onset of such emergencies is frequently sudden and requires an immediate, coordinated, and confident response. From a systems and nursing perspective, emergency preparedness for this population must be understood as a structured, proactive intervention rather than an ad hoc response. Individual care plans must reflect the person’s specific clinical risks, resuscitation status and agreed escalation decisions. Plans should be developed collaboratively, documented and be readily accessible and known to all staff. National learning, including that from the LeDeR programme, demonstrates that people with learning disabilities and complex needs are at increased risk of avoidable harm where care planning is insufficiently robust or not consistently applied. National guidance and professional standards consistently emphasise that emergency responses should not rely on informal knowledge or assumed understanding. Instead, safe practice requires standardised processes that reduce variation and support staff to act decisively in high-pressure situations. This includes clarity that, in the absence
of a documented DNACPR or equivalent directive, cardiopulmonary resuscitation should be initiated without delay. From a system perspective, emergency care planning must be consistently embedded within commissioning expectations and provider delivery. Plans should be person- centred, clearly defining clinical risks, escalation pathways, and resuscitation decisions, and must be formally documented, known to all staff caring for the patient / person and accessible at the point of care, and regularly reviewed to reflect changes in condition or circumstance.
Variation in the quality, completeness, or review of such plans introduces avoidable risk. Where planning is absent, outdated, or insufficiently detailed, staff may lack the clarity required to act promptly and confidently in an emergency, increasing the likelihood of delayed or suboptimal care. It is expected that a person with complex needs, such as Jake, would have an emergency health care plan in place or at least such information would be integrated within their care plan (which may include an ADRT, a Recommended Summary Plan for Emergency Care and Treatment ReSPECT form, or other locally agreed template). It would also be best practice for the person to have a health and care passport in place which, if completed correctly, would suitably capture critical information about the person’s complex health needs and how best these should be supported/managed. It is beneficial for people with a learning disability and autistic people to have a health and care passport which can be regularly updated in response to changes in their health and wellbeing and interaction in the health and care services they use. Availability of an AED Defibrillator The Care Quality Commission (CQC) are responsible for the oversight of AED defibrillators in health care settings. Whilst the CQC does not mandate that care homes have to have an AED onsite, they do require care homes to be able to handle medical emergencies. The CQC Regulation 12 (Safe Care and Treatment) further mandates that providers assess and mitigate risks, ensuring staff are appropriately trained and equipped. This includes consideration of emergency equipment such as AEDs, particularly in settings with residents at increased cardiac risk, as encouraged by NHS England and RCUK guidance. Failure to provide necessary training, equipment, or clear documentation represents a breach of expected standards of safe and effective care. Regional Input London regional colleagues have liaised with the care provider Choice Support, who ran the care home Roy Kinner House where Jake was living. Choice Support advised that they recognised that this incident highlighted opportunities to strengthen clarity, consistency and anticipatory planning and have taken actions to rectify this. We are aware Choice Support has responded directly to the Coroner, and would refer the Coroner there for more details.
I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Jake, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.
Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.