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I have initiated this Adjournment debate on behalf of my late constituent and his family. It concerns a tragic case that raises serious questions about emergency response, clinical training, information sharing, and whether the systems meant to save young lives are fit for purpose.
On 31 January 2024, Adam Ankers, aged just 17, collapsed while playing football for the Wycombe Wanderers Foundation’s under-19 development team. He was a much-loved son, brother, friend and team-mate. He dreamed of a career in professional football, and on the captain’s armband that he was wearing that day he had written the words “strength, inspiration, leader, desire.” Despite the presence of first-aid-trained coaches, despite a defibrillator being brought straight to the pitch, and despite multiple calls to 999, no one recognised that Adam was in sudden cardiac arrest. No cardiopulmonary resuscitation was started.
The coroner found that Adam’s brain had been was starved of oxygen for about eight minutes because no one had attempted CPR, and heard evidence that for every minute without CPR, the chances of survival decrease by 10%. South Central Ambulance Service’s serious incident review reached the same conclusion independently, acknowledging an eight-minute period in which CPR should have started and did not. The ambulance arrived within 11 minutes of the first 999 call, at 2.31 pm, but by then the critical window in which to act, having been led by telephone, had already been missed.
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The hon. Member has raised a heart-rending and very difficult case, and I congratulate him on that.
The British Heart Foundation estimates that in Northern Ireland one person under the age of 35 dies every month from an undiagnosed heart condition. In view of that, does the hon. Member agree that more must be done to ensure that the public are equipped to perform effective CPR and to use a defibrillator, and are confident about carrying out bystander CPR?
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I do agree with the hon. Gentleman, and I will explore many of those issues later in my speech.
When paramedics arrived, they found Adam cold, blue, not breathing, and without a pulse. They immediately started CPR, and took him to Harefield hospital, with the support of Thames Valley Air Ambulance. Despite the best efforts of clinicians, Adam was declared brain-stem dead on 4 February—in law, that was the moment of his death—and his heart stopped for the final time on 5 February, when life support was withdrawn. His parents, Alastair Ankers and Naomi Wakefield, both work in healthcare. Through devastating experience, they came to the conclusion that Adam’s death could have been prevented.
Adam’s parents fought for more than two years for a proper, in-depth inquest, rather than the four-hour online hearing first offered. They were represented by a single barrister, paid for by remortgaging their house, against an array of solicitors and counsel for the NHS bodies and the Football Association. That is not a fair fight. The underlying condition was arrhythmogenic right ventricular cardiomyopathy—ARVC, a genetic heart disease, the first sign of which can be sudden cardiac arrest. This was a failure to identify a life-threatening emergency in real time, and it is why recognition, escalation and response matter so much.
The inquest raised serious concerns about the handling of 999 calls and the ability of call handlers to recognise abnormal breathing and cardiac arrest. Ambulance services in England use one of two systems: MPDS—the medical priority dispatch system—and NHS Pathways. NHS Pathways is used by just over half of 999 services and by all 111 services in England, and it was the system used on the call that day. The inquest heard expert evidence from paramedic David Davis—not the one of this parish—who told the court,
“I am unable to say that NHS Pathways as is currently configured can always properly support members of the public to identify agonal or ineffective breathing. I am also uncertain as to whether NHS Pathways can adequately identify potential out-of-hospital cardiac arrest where there is seizure-like activity at the outset.”
That is about as serious a warning as an expert witness can give. If the system cannot reliably recognise the signs of cardiac arrest, people are being put in danger, and if the public are left uncertain about whether to follow the advice they are given or to act on instinct, that is a public safety problem.
The coroner issued a five-point prevention of future deaths report on 16 April this year. It was addressed to 13 bodies, including NHS England, the Department of Health and Social Care, the Football Association, South Central Ambulance Service, the UK National Screening Committee and Cardiac Risk in the Young. Responses were due by 11 June. There is a pattern in those responses: every organisation expressed sympathy and described some work under way, but almost none attached a date to anything. NHS England says that a genetic service specification is “currently being revised”, but with no timetable. Staff at Resuscitation Council UK say that responsibility sits with NHS England and the Department of Health and Social Care, not them. The Association of Ambulance Chief Executives says that it is
“not constituted to mandate or instruct ambulance services”.
Everybody has pointed to somebody else, and there have been warnings for years about call handlers and cardiac arrest, sepsis and other conditions, with no clear public evidence of improvement. Why?
I therefore ask the Minister to instruct the Care Quality Commission to urgently and regularly assess ambulance services on call-handler skill in detecting and managing abnormal breathing and suspected cardiac arrest. A CQC inspection of South Central Ambulance Service before Adam’s death had already found call handlers struggling to recognise abnormal breathing, with serious incidents leading to patient harm as a result—this is not new information to the trust. South Central Ambulance Service’s own response to the coroner’s report suggests that the public should understand that call handlers follow a fixed script, and that callers may need to act independently of the advice given. If it is genuinely the Government’s position that people in the worst moment of their life should second-guess the emergency services, the public deserve to hear that plainly, not discover it buried in a filing after a child has died.
Training alone will not be enough. NHS Pathways plays a central role in how millions of emergency and urgent care calls are handled every year, yet there is strikingly little publicly available data on its safety and effectiveness. That is not good enough.