Romeo Esposito

4 June 2024 

HM Assistant Coroner, Dr Simon Fox, KC 
The Coroner’s Court 
Old Weston Road 
Flax Bourton 
BS48 1UL 

Trust Headquarters 
Abbey Court 
Eagle Way 
Exeter 
Devon 
EX2 7HY 

Website: www.swast.nhs.uk 

Dear Dr Fox 

Prevention for future deaths report touching on the death of Romeo Esposito 

I write in connection with your enquires touching on the tragic death of Romeo Esposito 
and in response to the Prevention for Future Deaths report issued to South Western 
Ambulance Service NHS Foundation Trust (SWASFT) on 15 March 2024. 

I was extremely saddened to hear of Romeo’s death and understand that the 
circumstances surrounding his death would have been extremely distressing for his family. 
I would like to take this opportunity to offer my personal and sincere condolences to 
Romeo’s family and to provide reassurance that a significant amount of work has been 
undertaken to ensure any learning identified is embedded across the organisation. 

As outlined in the report, HM Coroner has identified the following principal concerns, which 
I have sought to address below: 

➢  Romeo was making respiratory efforts for about an hour after ROLE (recognition of 

life extinct) at 09.52 and resuscitation resumed at 10.49. 

➢  His family raised concerns regarding this with SWASFT staff on a number of 

occasions throughout this period. 

➢  Staff repeatedly ascribed this respiratory effort to a ‘release of air’ as opposed to a 
change in Romeo’s clinical condition, which required further clinical assessment. 
➢  There was no evidence to confirm that clinical staff have been warned or trained 

not to use ‘release of air’ as an explanation for respiratory effort or reason to avoid 
further clinical assessment. 

Following Romeo’s death, the Trust undertook a comprehensive review of the 
circumstances surrounding his death. This was done with a view to establishing a clear 

 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 chronology of events but also to elicit any learning which can be used to inform service 
improvement.  

By way of context, a 999 call was received at 08.42 during which it was reported that 
Romeo was sadly not breathing and not conscious. Cardiopulmonary resuscitation (CPR) 
instruction was provided over the telephone whilst resources were allocated to help 
Romeo. Following the arrival of resources on scene, advanced life support (ALS) 
commenced and continued for around an hour, compared with the recommended 20 
minutes as per guidance. The senior clinician on scene, who had not detected any signs of 
life, and in recognition of the fact that Romeo had been in cardiac arrest for more than 75 
minutes, made the decision to cease resuscitation at 09.50 with ROLE confirmed at 09.52. 

During the review undertaken by the Trust, it was clear that everyone on scene had 
worked tirelessly to save Romeo; however, some learning points were identified. This 
included revisiting the Confirmation of Death guidance contained within the Cardiac Arrest 
guidelines, specifically the amount of time that should be given between ceasing 
resuscitation and confirmation of death (COD). At the time of Romeo’s death the guidance 
in place required the clinician to observe the patient for five minutes between ceasing 
resuscitation and COD. Allowing sufficient time between ceasing resuscitation and 
confirming ROLE allows the attending clinician to fully assess whether there are any signs 
of life indicating resuscitation should be resumed. This was subsequently revised to ‘a few 
minutes’. As a result of Romeo’s case, the Confirmation of Death guidance has now been 
revised to reflect that there should be at least 5 minutes between ceasing resuscitation 
and COD being declared, as opposed to the previous ambiguous reference to a ‘few 
minutes’. A copy of the new guidance has been appended to this letter for reference.  

The aim is for the new guideline to be live on the Trust’s JRCALC clinical app by the week 
ending 7 June 2024. This is an app that can be accessed by all Trust members of staff as 
well as those contracted to work on behalf of SWASFT. In addition, once confirmation has 
been received that the guideline is ready to be published, a Clinical Notice alerting staff to 
the revisions will be issued to all staff via email and as a pop-up on the app prompting 
them to review the change. Once an individual has accessed the guidance, they are 
prompted to press a button to acknowledge the change, allowing the Trust the functionality 
to monitor how many Trust staff acknowledge it, which in turn provides assurance around 
the number of staff reviewing updated guidance. 

Furthermore, during the review and in communications with Romeo’s family, it was 
identified that following the initial confirmation of death at 09.52, members of Romeo’s 
family alerted staff on several occasions to Romeo making a gasping sound. The response 
provided by staff suggested this was a normal presentation following death with no senior 
clinical review requested. In terms of the release of air or gasping sound described by 
Romeo’s family, it is not uncommon to see a few gasping breaths after death. This is 
because the brainstem at the base of the brain, which controls respiration will continue to 
work for a brief period of time after the heart has stopped or after a period of CPR. It is not 
possible to diagnose death until this activity has stopped. If it persists beyond 5 minutes, 
this is potentially an indicator of signs of life mandating review by a senior clinician. 

 
 
 
 
 
 
 
 As part of the mandatory training delivered to all Trust staff for 2024 to 2025, a session on 
advanced life support (ALS) is to be provided. This includes a simulation around cardiac 
arrest management in conjunction with discussion-based learning around actions that may 
be required following COD. This includes the potential for a change in clinical presentation 
with an emphasis on this being escalated for senior review. In this scenario, the guidance 
dictates that in these circumstances the lead clinician must observe and reassess the 
patient to satisfy themselves that COD is appropriate. If any uncertainty remains, the 
Resuscitation Advice Line can be contacted.. The Major Trauma and Resuscitation Advice 
Line is staffed by experienced Specialist Critical Care Practitioners supported by a duty 
Consultant. The team are available to offer advice to ambulance crews 24/7.  The aim is 
for 85% of Trust staff to have completed this training by the end of 2025, accounting for 
any absences attributable to maternity, paternity and sick leave.  

The Trust is also launching education around how to escalate concerns using the I am 
Concerned, I am Uncomfortable, this is a Safety issue and Stop (CUSS) communication 
tool. CUSS is a technique that uses a graded assertiveness approach to communicating. 
Should someone be concerned with a process or intervention being put in place, they can 
raise concerns, becoming more assertive if they feel their concerns are not listened to. The 
key to this education is further training on how individuals and teams acknowledge and 
take steps to act on concerns raised.  

In conclusion, I hope Romeo’s family, with whom the Trust continues to work, and HM 
Coroner will be assured by the steps taken by the Trust to address the concerns raised 
within the Prevention for Future Deaths report. 

Yours sincerely 

Chief Executive Officer 

Enc:   
1.  Confirmation of Death guidelines