“I heard expert evidence from and other evidence which indicated To: 1”
Dated 16 Apr 2025, from the coroner for West London. Sent to 13 organisations or people.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
Report put online after its 56 daysOrganisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk; a reply may have been sent and not yet published.
judiciary.uk put this report online on 27 Apr 2026, after the 56 days for replies had ended (11 Jun 2025). These dates can’t tell us whether a reply was due before it went online. A reply may have been sent and not yet published.
- Report dated16 Apr 2025
- Deadline11 Jun 2025
- Published on judiciary.uk27 Apr 2026
- Today27 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| South Central Ambulance Service NHS Foundation TrustNamed in the report as “South Central Ambulance Service” | Response publishedPublished on judiciary.uk in April 2026. |
| Association of Ambulance Chief Executives | Response publishedPublished on judiciary.uk in April 2026. |
| NHS EnglandNamed in the report as “National Health Service England (NHSE)” | Response publishedPublished on judiciary.uk in April 2026. |
| Department of Health and Social CareNamed in the report as “Department of Health and Social Care (DHSC)” | Response publishedPublished on judiciary.uk in April 2026. |
| Resuscitation Council UK | Response publishedPublished on judiciary.uk in April 2026. |
| St John Ambulance | Response publishedPublished on judiciary.uk in April 2026. |
| UK National Screening Committee | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
| The British Society for Genetic Medicine | Response publishedPublished on judiciary.uk in April 2026. |
| Sudden Cardiac Arrest UK (SCA UK) | Response publishedPublished on judiciary.uk in April 2026. |
| Cardiac Risk in the Young (CRY) | Response publishedPublished on judiciary.uk in April 2026. |
| The Football Association | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
| Faculty of Sport and Exercise Medicine UK | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
| UK Sports Institute (formerly the English Institute of Sport) | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
The coroner’s concerns
I heard expert evidence from and other evidence which indicated To: 1. South Central Ambulance Service 2. NHSE 3. DHSC 4. Resuscitation Council UK 5. St John Ambulance POINT A: That there is difficulty in lay people (trained or not) including ambulance call handlers in understanding the signs of agonal breathing or cardiac arrest To: 1. The Football Association 2. Faculty of Sport and Exercise Medicine UK 3. The English Institute of Sport 2 POINT B: That 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. To: 1. 2. 3. 4. 5. 6. South Central Ambulance Service Association of Ambulance Chief Executives NHSE DHSC The Football Association St John Ambulance Service POINT C: That there is a need for better understanding of the use of defibrillators particularly by lay persons and trained first aid persons To: 1. 2. 3. 4. 5. NHSE DHSC UK National Screening Committee Resuscitation Council UK Cardiac Risk in the Young (CRY) POINT D: That 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 To: 1. 2. 3. 4. 5. NHSE (NHS Inherited Cardiac Conditions Clinic) DHSC UK National Screening Committee The British Society for Genetic Medicine Sudden Cardiac Arrest UK (SCA UK) POINT E: That 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. 3
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports, 2026-0217
- Added to Minute Book
- 8 Oct 2026
- Reuse
- We show short extracts and link to the original. We don’t host the full report.
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
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