Mackenzie Cooper

RESPONSE OF CENTRAL ENGLAND CO-OPERATIVE LIMITED TO REGULATION 28 REPORT 
ISSUED BY H.M. AREA CORONER FOR NOTTINGHAM CITY AND NOTTINGHAMSHIRE 

1.  This is the response of Central England Co-operative Limited to the Regulation 28 Report 

issued by H.M. Area Coroner for Nottingham City and Nottinghamshire following the Inquest 
touching upon the death of Mackenzie Cooper, dated 13th July 2023, but received on 21st 
August 2023, and requiring a response by 16th October 2023. 

2.  At the outset we take the opportunity to express our sincere condolences to the family and 

friends of Mr Cooper. We acknowledge the deep upset and sadness his tragic death at such a 
young age will have caused. 

3.  H.M. Area Coroner has raised two matters of concern for consideration. We set them out 

below for ease of reference: 

3.1  The community public access defibrillator in your store was supplied to a member of the 

public in a non-workable condition. There appears to be either no system for replacing 
the pads between uses, or an unsafe system in operation; and 

3.2  There appears to be either a training or communication issue in that staff appear to 

have known the device was missing vital equipment, but the device was supplied 
anyway. 

4.  We will in this response deal with the matters of concern in the following way: 

4.1  We will make our introductory comments and observations; 

4.2  We will set out the system in place at the time; 

4.3  We will address why it was that the defibrillator remained available for use in 
circumstances where it appears it shouldn’t have been, due to missing pads; 

4.4  We will set out what has been reviewed as a result of H.M. Area Coroner’s Regulation 

28 Report and what actions have been taken as a result or are planned to be taken; and 
the timescales in which such actions have been taken or will be taken. 

Introductory Comments 

5.  Central England Co-operative Limited has for several years, as part of its positive contribution 

to the communities it is privileged to operate in, and in accordance with its values, partnered 
with a charity, The British Heart Foundation, and with local NHS Trust Ambulance Services, in 
providing community defibrillators outside many of its retail premises.  

6.  Central England Co-operative Limited offers a freely accessible 24 hour a day, seven day a 

week service with its defibrillators and has chosen not to restrict access, unlike some models 
of defibrillator provision in use by other businesses and institutions. 

7.  As at mid-September 2023 it has 282 defibrillators outside its retail premises. In the 

approximate five years it has been providing defibrillators in this way it has not encountered 
any issues of the kind highlighted by H.M. Area Coroner in the Regulation 28 Report. 

8. 

In responding Central England Co-operative Limited acknowledges that it was the operator of 
the Co-op store at Carlton in Lindrick, Nottinghamshire and, as H.M. Area Coroner puts it, it 
was therefore the “guardian” of the defibrillator referred to in the Regulation 28 Report.  

Registered name: Central England Co-operative Limited 
Registration in England & Wales 
Registered number: 10143R 
Registered office: Central House, Hermes Road, Lichfield, Staffordshire, WS13 6RH 

 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 9.  Central England Co-operative Limited did not attend or participate in the Inquest touching 

upon the death of Mr Cooper and did not therefore have the benefit of listening to the evidence 
which H.M. Area Coroner has heard and has summarised in the Regulation 28 Report. It 
responds taking the summary provided as accurate, and it accepts for the purposes of this 
response that the defibrillator in question was effectively made available for use when the 
pads necessary for its proper function were absent. 

10.  Central England Co-operative Limited did at the time have in place a system, developed with 
those with whom it works as regards defibrillators, including The British Heart Foundation, 
which, if properly operated, should have prevented the circumstances outlined in the 
Regulation 28 Report from arising.  

11.  At all times it has been understood by Central England Co-operative Limited that the 

recommendations of The British Heart Foundation as to that system represented commonly 
adopted best practice. 

12.  That system, if operated properly at the time of events, should have resulted in the defibrillator 
at the Carlton in Lindrick store being marked on the system known as “the circuit” (to which the 
emergency services have access to check status of defibrillators) as (effectively) “out of 
service”, pending replacement of the pads. 

13.  Having conducted an investigation as a result of the concerning matters reported to it by H.M. 
Area Coroner in the Regulation 28 Report it has been established that the immediate cause of 
the defibrillator being left “in service” whilst it was missing the pads necessary for its use was 
human oversight on the part of a member of staff at the Carlton in Lindrick store.  

14.  The member of staff accessing the system as part of a check conducted in advance of the 
tragic events involving Mr Cooper failed to mark the defibrillator as “out of service” on “the 
circuit”, as they should have done, and as the system provided for. 

15.  The investigation has though taken the opportunity to look at matters more broadly and what is 

set out below by way of actions and planned actions results from that broader review. 

The System in place at the time 

16.  Central England Co-operative Limited has adopted a system for maintaining and denoting the 
accurate status of defibrillators based on the guidance issued by The British Heart Foundation, 
and in partnership with them. 

17.  The system involves: 

17.1  Written instructions to stores with defibrillators from the British Heart Foundation 

relating to registering the defibrillator on “the Circuit”; 

17.2 

Stores with defibrillators have received short awareness sessions from Kays Medical, 

who are a distributor for medical products and service, on when and how to use a 
defibrillator, how to access the defibrillator cabinet, and the checks that stores will 
undertake when the store has a defibrillator fitted. Residents and local businesses are 
invited to and participate in these awareness sessions. The store will not be able to 
access “the circuit” until the awareness session has been conducted. Stores can request 
refresher awareness sessions; 

17.3 

Although not mandated there is additional training and awareness available for all staff 

of Central England Co-operative Limited. A learning course entitled ‘Defibrillators – Know 
the Facts’ is hosted via the “Let’s Learn” online learning portal. This consists of three 
modules, a) Defibrillator Overview (video), b) How to use a defibrillator (video) and c) 
Defibrillators – know the facts (a two-page pdf fact sheet). Internal training is not a 
requirement stipulated by The British Heart Foundation but is something which Central 
England Co-operative Limited has created for its own purposes; 

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 17.4 

The details and log-ins provided in written instructions to Store Managers and Duty 
Managers allow the store to access “the circuit” and confirm the status of a defibrillator as 
available for use or not available for use; 

17.5 

The status may need changing to inactive/not available for use for a variety of 

reasons: for example, (a) taken/used; (b) otherwise missing; (c) vandalised; or (d) missing 
or out of date parts (consumables). Examples of parts/consumables are: heavy duty 
scissors, towelette for drying away moisture to ensure the pads adhere, a safety razor, a 
face shield; 

17.6 

A monthly programmed check by the store on the defibrillators, prompted by written 
reminders each month, is conducted. This is conducted as an exercise as part of Central 
England Co-operative Limited’s legal compliance monitoring checks. The monthly interval 
for the check, and the checks themselves, are in accordance with The British Heart 
Foundation Guidelines;  

17.7 

The defibrillator check covers: (a) whether the defibrillator is missing (and provides for 

a check with the relevant ambulance service to see whether the unit has been used but 
not returned. If the defibrillator is not returned within 14 days (post-event) then a 
replacement is ordered); (b) the defibrillator cabinet is vandalised, damaged, faulty or 
difficult to shut; or (c) parts/consumables required. 

17.8 

In the event that the defibrillator check identifies an issue which would prevent its 
use/availability then the instructions are clear that it should be denoted on “the circuit” as 
inactive/not available. This is something which the person at the store conducting the 
check should attend to immediately using the online system available for such purposes; 

17.9 

The system provides for missing parts/consumables to be ordered from and delivered 

by Lyreco. Again this is something the store attend to using a portal to order new 
parts/consumables; 

17.10  That the checks have been conducted by the stores is recorded on Central England 

Co-operative Limited’s Legal Compliance monitoring portal called ARCC; 

17.11 

In addition, Legal Compliance 2nd line team (i.e. independent of the store) auditors visit 

each store on a periodic basis, usually annually (occasionally more frequently), to 
undertake a full legal compliance audit. As part of this, auditors check that defibrillator 
checks have been completed by the store every month and recorded on ARCC; 

17.12  The Legal Compliance 2nd line team also monitor the completion of all programmed 
monthly checks by stores (that is all legal compliance checks, not just those which relate 
to defibrillators). Where any store appears to have completed fewer than 90% of the 
expected checks this is flagged to the store management teams and operational 
management and area management teams for action and improvement. 

Had the system been properly operated at the relevant time it was capable of avoiding the 
situation about which H.M. Area Coroner has understandably raised concerns. 

Why the Defibrillator was denoted as available for use on “the circuit” 

18.  Following receipt of H.M. Area Coroner’s Regulation 28 Report Central England Co-operative 
Limited has conducted certain investigations as a result of its deep concern at the matters 
raised. 

19.  It appears that the status of the defibrillator was not properly updated after it had been used 

shortly before the events involving Mr Cooper, due to human oversight. 

20.  A monthly defibrillator check was conducted at the Carlton in Lindrick store on 24th September 

2022, just a few days before the incident involving Mr Cooper. 

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 21.  The member of staff completing the check responded to the questions set out on the check as 

follows: 

21.1 

Is the defibrillator in the correct location? “Yes” 

21.2 

Are there two sets of in-date pads and an unopened starter kit in the cabinet? “No   

defib used this week awaiting new pads” 

21.3 

Is the battery indicator complete? “Yes” 

21.4  Has the defibrillator check been recorded on ‘The Circuit’? “Yes” 

21.5 

Enter below name of person completing this check. [please note that the member of 

staff did identify themselves, but their name has been redacted in this Response to the 
Regulation 28 Report in the interests of fairness to the individual concerned] 

22.  When questioned about matters the member of staff stated “We didn’t sign it off in the circuit 

and it was an oversight on our part, we thought it had been completed”.  

23.  Accordingly, it is clear that the member of staff knew what was required and acknowledged 

their error in failing to do what was required. 

24.  It is understood that the defibrillator had been taken from its cabinet for the purposes of 

dealing with another incident during the week before the tragic incident involving Mr Cooper. It 
is also understood that the store was not immediately aware that it had been taken away to be 
used at the time. 

25.  Had the defibrillator been confirmed as not available for use on “the circuit”, as it should have 
been, then the emergency services would not have sent the member of the public to the 
Carlton in Lindrick store. The emergency services, when accessing “the circuit” would, in those 
circumstances, have seen the defibrillator denoted as being not available for use. 

26.  Where it was confirmed by the check that the defibrillator was missing the required in-date 

pads, the unit should have been removed from service on “the circuit” to ensure the 
Ambulance Service did not send anyone to it in the event of an emergency. Regrettably the 
defibrillator status was not updated to unavailable on “the circuit” and therefore it remained 
ostensibly available for use. 

27.  On the day of the incident involving Mr Cooper the device was taken offline by the store (and 
therefore showing as unavailable on “the circuit”) when the defibrillator was not returned and 
the store contacted the Police to try and establish its whereabouts. In addition, East Midlands 
Emergency Services also contacted the store to confirm they were taking the device off “the 
circuit”. 

28.  Once the replacement pads had been received, the defibrillator was put back online on “the 
circuit” in November 2022. The British Heart Foundation have confirmed that the defibrillator 
was offline between 29th September 2022 and 30th November 2022. 

Review of System and Actions taken/planned 

29.  In light of its concerns at the matters reported by H.M. Area Coroner Central England Co-

operative Limited has reviewed its systems generally as regards defibrillators. 

30.  A concern identified as a result of that review is that the interval between checks on the 

defibrillator of one month, notwithstanding that this was the recommendation of The British 
Heart Foundation and understood to represent best practice, appears to leave potential, in 
certain limited circumstances (see below), a window when the defibrillator may have been 
used without the store staff or the ambulance service being aware and therefore able to take it 
offline from “the circuit” promptly. This may result in “the circuit” showing an inaccurate 
available for use status for a defibrillator. 

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 31.  To explain, it is possible, and does occasionally happen, that stores can be unaware when a 
defibrillator has been used or taken. The stores are open for a limited number of hours a day. 
The defibrillators, so that they can be accessed at any time (in accordance with Central 
England Co-operative Limited’s values that these are a general community asset) are outside 
the stores, not inside them. Therefore, a defibrillator can be used (or taken) and not returned 
or used and/or some parts/consumables be used, outside store hours and without the store 
staff being aware. Likewise, defibrillators can be subject to vandalism and other abuse about 
which the store staff may not always know immediately. 

32.  If such use was by or at the behest of the ambulance service, then no issue would arise as 
they can access “the circuit” and they would denote the defibrillator as not available for use. 

33.  Normally a member of the public needing to use the defibrillator would have to call the 

emergency services to obtain the code to open the cabinet. But it is understood that codes, 
which can be common codes in certain ambulance areas, can be known by certain members 
of the public. Therefore, it is possible that, as well as vandalism/abuse, that there could be a 
circumstance where a defibrillator was used where neither the ambulance service nor the 
store were aware and did not have the opportunity to update the status of the defibrillator on 
“the circuit”. 

34.  As a result, and after careful consideration, Central England Co-operative Limited has 

increased the frequency at which checks are conducted on the defibrillators. The decision 
made is that checks shall now be undertaken at one-week intervals. This system change will 
commence on 1st November 2023.  

35.  As an additional safeguard from September 2023 the Central England Co-operative Limited 

Facilities Management team now monitor “the circuit” on a weekly basis and generate a report 
to provide information on the status of all 282 defibrillators to store managers, operational 
managers, and senior operational managers.  

36.  The managers are then required to follow up with individual stores where any exceptions are 
highlighted to ensure the required mitigating actions have been/are executed or, if necessary, 
intervention can take place.  

37.  The information provided to managers includes details of (a) sites with defibrillators that are 
online/emergency ready, and those that are offline/not emergency ready (the question being 
asked “is the status denoted accurate?”); (b) date of “last service” of each defibrillator. This is 
the last date that the defibrillator was checked by the site; and (c) pad/battery expiry date. This 
displays all defibrillators where the pads/batteries are approaching or have exceeded their 
expiry date and need replacement. 

38.  Central England Co-operative Limited has also reviewed its provision of training and 

awareness to ensure that training/awareness both mandatory and held at intervals which will 
ensure new starters are captured promptly. In addition, the training content has been 
reviewed. From 1st November 2023 updated training is being launched which is mandated for 
all store staff and store managers (including duty managers), which includes a module on 
maintenance and correctly denoting defibrillators as available for use or not available for use. 
New starters post 1st November 2023 will be required to complete this training within four 
weeks of the commencement of their employment, effectively as part of their induction. 

39.  Finally, and importantly, Central England Co-operative Limited will initiate a discussion with 

The British Heart Foundation as a result of the concerns identified by H.M. Area Coroner and 
its own careful consideration of matters. Such discussions will be initiated prior to 1st 
November 2023. At this stage it is not possible to place a timescale on when such discussions 
will conclude, but the intention on the part of Central England Co-operative Limited is that the 
discussions should take place promptly. Central England Co-operative Limited believes that 
this step has potential for strengthening controls generally and therefore having a positive 
impact more widely.  

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 Summary 

40.  We hope that what is set out above is of assistance to H.M. Area Coroner. 

41.  Dealing with the specific concerns raised by H.M. Area Coroner we summarise (we hope 

helpfully) as follows: 

41.1 

The community public access defibrillator in your store was supplied to a member of 

the public in a non-workable condition. There appears to be either no system for replacing 
the pads between uses, or an unsafe system in operation; and 

41.2 

There appears to be either a training or communication issue in that staff appear to 
have known the device was missing vital equipment, but the device was supplied anyway. 

42.  It is accepted that the defibrillator was effectively made available for use when it was not in a 

workable condition. Clearly this is much regretted. It is accepted that the defibrillator should 
have been denoted as not being available for use. It is hoped that for the reasons explained 
above H.M. Area Coroner will see that there was (and is) a system in place for replacing the 
pads and for notifying “the circuit” that a defibrillator is not available for use. The system was 
not therefore unsafe in itself. The issue was primarily one of human oversight, and the system 
was not, on this occasion, operated satisfactorily.  

43.  The store management were aware of the requirements to denote the defibrillator as not 

available for use but failed properly to update “the circuit” to reflect that so that the emergency 
services were aware. 

44.  As referred to above a review has been conducted and certain improvements have been or 

are shortly to be made to the system operated by Central England Co-operative Limited, and 
further discussions with The British Heart Foundation will take place in due course in the 
interests of a wider positive impact. Central England Co-operative Limited is committed to 
offering public access defibrillators in the communities in which it operates 24 hours a day 
seven days a week and is committed to ensure that it, and others offering defibrillators, does 
so in a way which will ensure prevention of any recurrence. 

Signed:

For and on behalf of Central England Co-operative Society 

Dated: 13 October 2023 

6

From the Rt Hon Andrew Stephenson CBE MP 
Minister of State for Health and Secondary Care 
Department of Health and Social Care 

39 Victoria Street 
London 
SW1H 0EU 

020 7210 4850 

13th May 2024 

Our Ref: 

Laurinda Bower 
The Council House 
Old Market Square 
Nottingham  
NG1 2DT  

By email: 

Dear Ms Laurinda Bower, 

Thank you for your Regulation 28 report to prevent future deaths dated 13 July 2023 about 
the death of Mackenzie Cooper. I am replying as Minister with responsibility for defibrillators. 

Firstly, I  would  like to  say  how  saddened  I  was to read  of  the  circumstances of  Mackenzie 
Cooper’s  death,  and  I  offer  my  sincere  condolences  to  their  family  and  loved  ones.  The 
circumstances your report describes are very concerning and I am grateful to you for bringing 
these matters to my attention. Please accept my sincere apologies for the delay in responding 
to this matter and I thank you for the additional time provided to the department to provide a 
response. 

The report raises concerns over the provision of community public access defibrillators and 
the process for ensuring there is an appropriate system for ensuring they are maintained and 
that ambulance trusts/999 operatives know the status and availability of the defibrillators. 

The  Government  has  provided  funding  of  £1m  for  a  grant  scheme  to  buy  life-saving 
defibrillators  for  community  spaces,  which  launched  in  September  2023.  All  Automatic 
External Defibrillators (AED’s) granted by the fund must be registered on The Circuit – The 
British  Heart  Foundation’s  national  defibrillator  database  which  is  synchronised  with  the 
Computer  Aided  Dispatch  systems  of  the  14  Ambulance  Trusts  in  the  UK  and  holds  the 
location and where required access codes for defibrillators. 

All AEDs detailed on The Circuit have a guardian who holds responsibility for ensuring the 
AED is defib ready. There is a requirement for guardians to check the AED every 90 days and 
confirm this on The Circuit; if an AED has not been checked and updated by the guardian on 
The Circuit then the AED will automatically be shown as not emergency ready.  Guardians are 
notified via email of when a defib is taken offline either due to being deployed or not being 
checked. When a call handler directs a person to an AED, that specific AED is taken out of 
use  and  a  request  sent  to  the  AED  guardian  to  check  it  and  notify  The  Circuit  when  it  is 
operational again.  

I hope this response is helpful. Thank you for bringing these concerns to my attention. 

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 Yours sincerely, 

MINISTER OF STATE