Connor Nelson

Inquest touching the death of Connor Nelson 

Response of Sherwood Forest Hospitals NHS Foundation Trust to Regulation 
28 report to prevent future deaths 

This is the organisational response from Sherwood Forest Hospitals NHS Foundation 
Trust  (SFH)  to  the  Regulation  28:  Report  To  Prevent  Future  Deaths  issued  by  HM 
Coroner,  following  the  conclusion  of  the  inquest  touching  the  death  of  Mr  Connor 
Nelson.  

We offer our condolences to Mr Nelson’s family, and we hope this response provides 
reassurance that the Trust recognises and acknowledges its failings and is committed 
to ensuring that we learn from this to prevent future deaths. 

The two matters of concern raised within the report and responses for each point are 
as follows: 

1) The lack of evidence of any improvement in the ability of Emergency 
Assessment Unit staff to respond effectively to a cardiac arrest 

During the course of the inquest, it was formally acknowledged that there had been 
delays in delivering a necessary defibrillator shock to Connor during his cardiac arrest, 
as  identified  within  the  patient  safety  incident  investigation.  Notwithstanding  the 
completion of a thorough investigation and the development of a subsequent action 
plan, a resuscitation simulation conducted on the Emergency Assessment Unit did not 
provide assurance that the required improvements had been made. This matter was 
therefore escalated to the Trust Patient Safety Incident Review Group (PSIRG) on 6th 
November 2025. 

Following  discussion  at  PSIRG,  a  supplementary  action  plan  was  formulated  and 
disclosed  during  the  inquest,  which  concluded  on  18th  November  2025.  Further 
actions undertaken since the PSIRG meeting and the inquest into Connor’s death in 
November are detailed below: 

In situ skills and drills simulation sessions: 
During  December  2025,  a  total  of  nine  simulation  sessions  were  scheduled  to  be 
undertaken  on  EAU  with  both  nursing  and  medical  staff,  with  additional  sessions 
continuing into subsequent months. These sessions were being led by the resus team 
and were set to include the following key topics: 

  Summoning help 
  Assessing signs of life 
  Timely and effective chest compressions 
  Bag/valve/mask ventilation 
  Head tilt/chin lift 
  Collection/delivery of emergency equipment 
  Attaching defibrillator pads 

 
 
 
   Timely and safe shock delivery 
  Staff roles at cardiac arrest events 

Of  the  planned  sessions,  six  were  successfully  delivered,  attended  by  18  staff 
members, resulting in an average attendance of three participants per session. Three 
sessions were cancelled due to staffing and operational constraints. Furthermore, nine 
additional sessions are scheduled for January 2026. It should be noted that, owing to 
the small group sizes and the restricted nature of the space utilised for "in situ" training, 
these sessions are not directly comparable to previous simulation events. Within the 
limitations  of  the  skills  practised,  staff  performance  was  assessed  by  the  trust 
resuscitation team to be of a satisfactory standard. 

A business case for ongoing simulation training was submitted for review and on 19th 
January 2026 it was confirmed that the delivery of a simulation project initially targeting 
EAU, ward 23 and ward 24 would be commenced. Effectiveness and consideration of 
rolling this out to other areas will be reviewed by the Trust Resuscitation services and 
Medical Education Department.    

Advanced Life Support Training:  

Since the inquest was held the Resuscitation Council UK (RCUK) has introduced a 
revision  to  training  protocols,  now  permitting  the  use  of  an  Automated  External 
Defibrillator (AED) during cardiac arrest demonstrations, as well as the discussion of 
AED usage within the CPR and defibrillation skill station as part of the Advanced Life 
Support (ALS) course. This updated course format became effective as of 1st January 
2026  nationally,  and  its  implementation  will  commence  with  the  ALS  courses, 
consisting  of  1-day  online  learning  plus  1  day  of  hands-on  training  with  a 
comprehensive  skill  station  assessment,  scheduled  for  21st  and  22nd  January  at 
Sherwood Forest Hospitals (SFH). 

Within EAU it is an established requirement that all Band 6 and 7 registered nurses 
complete ALS training. As of 23rd January 2026, 70% of Band 6 and 7 nurses have 
successfully  completed  and  passed  the  ALS  training.  An  additional  6.92%  have 
scheduled course dates and the remaining 23.08% are currently on maternity leave 
and will be enrolled onto ALS courses upon their return to work.  

It is recognised, that the rotation of new staff within EAU has the potential to affect 
training  compliance  rates,  particularly  for  training  such  as ALS.  To  address  this,  a 
comprehensive  plan  has  been  implemented  to  ensure  that  all  new  Band  6  staff 
promptly  receive  the  necessary  training  upon  appointment.  Furthermore,  measures 
are  being  explored  to  provide  existing  Band  5  registered  nurses  looking  for 
development opportunity therefore supporting both ongoing professional development 
and the maintenance of a highly skilled workforce. 

ALS training compliance will now be included in the service line performance meetings 
monthly commencing February 2026 to enable consistent monitoring and escalation 
as required.  

 
 Immediate Life Support Training: 
As of 23rd January 2026 91% of registered nurses working on EAU had undergone 
Immediate  Life  Support  Training  and  the  remaining  9%  of  staff  are  booked  onto 
courses.  

Similarly  to  the  ALS  training  rotation  of  new  staff  has  the  potential  to  affect  this 
compliance rate and as such there is a plan to ensure all new staff are booked onto 
the next available course upon commencing in their role. ILS training compliance will 
now  be  included  in  the  service  line  performance  meetings  monthly  commencing 
February 2026 to enable consistent monitoring and escalation as required.  

Mandatory resuscitation training: 
In  addition,  further  measures  have  been  implemented  to  enhance  resuscitation 
training across all staff at SFH. Additional AEDs have been procured to facilitate the 
inclusion of AEDs as a practical, hands-on component within mandatory resuscitation 
training  sessions.  The  introduction  of  this  practical  element  will  commence  in April 
2026, following the conclusion of the winter pause in mandatory training. This initiative 
will  be  delivered  in  conjunction  with  the  E-Learning  for  Healthcare  (E-LfH)  content, 
which will be utilised by nursing, midwifery, and allied health professional (N,M&AHP) 
staff to fulfil Resuscitation Level 1 and 2 theoretical requirements, in alignment with 
the broader NHS training transferability plan. Simultaneously, mandatory sessions for 
medical staff will also be adapted to incorporate practical AED training from April 2026 
onwards. 

Changes to Doctor induction: 
Effective from 3rd December 2025, the doctor induction programme now incorporates 
a dedicated session delivered by the trust resuscitation service. This session provides 
an overview of the adult resuscitation trolley and its contents, as well as instruction on 
the  two  defibrillator  models  used  at  SFHFT  and  their  operational  functions.  The 
session is made available to Foundation Year 2 (FY2) doctors and higher at each entry 
point throughout the training year. Foundation Year 1 (FY1) doctors receive a separate 
induction covering the same material in July. 

Review of cardiac arrests on EAU in December 2025: 
To provide further assurance regarding improvements in the management of a cardiac 
arrest,  all  cardiac  arrests  on  EAU  during  the  period  from  1st  December  to  30th 
December 2025 were reviewed by the trust resus team. It was confirmed that EAU 
initiated  three  2222  calls  (emergency  calls),  of  these,  one  was  categorised  as  a 
medical emergency for which cardiopulmonary resuscitation (CPR) was not required. 
The  remaining  two  incidents  were  audited  in  accordance  with  the  cardiac  arrest 
governance process. One case raised no concerns, while the other identified issues 
related 
(DNACPR) 
documentation—specifically,  that  although  the  DNACPR decision  appeared  to  have 

to  Do  Not  Attempt  Cardiopulmonary  Resuscitation 

 
 
 
 
 been  made,  the  corresponding  form  had  not  been  completed.  This  omission  was 
subsequently identified and documented via an incident report on the Datix system. 
The resus team have provided assurance that all reported cardiac arrests trust wide 
are reviewed by the resus team and any feedback is initiated at the earliest opportunity 
to the appropriate area lead.  

Support from resus advisory group: 
The RCUK Quality Standard stipulates that resus advisory meetings should be held at 
a minimum frequency of every six months. This requirement has been met to date. 
Moving forward, meetings will be scheduled on a bimonthly basis. The initial meeting 
was planned for December 2025; however, this was postponed due to bereavement 
and staff sickness. The next meeting is now scheduled for February 2026, upon the 
return of the group chair to the Trust. The Terms of Reference and membership list are 
currently under review and will be circulated to the group for comment and subsequent 
ratification at the February meeting. 

Review of action plan: 
It  is  acknowledged  that  there  are  ongoing  actions  as  outlined  in  the  Patient  Safety 
Incident Investigation Action Plan, which was included in the disclosure bundle. The 
Trust  will  continue  to  advance  these  actions,  and  documentation  evidencing  their 
completion will be obtained and securely stored on the Trust’s Datix system alongside 
the relevant action ID number to provide assurance of their completion. 

The Trust will assess and assure the sustainability of the actions as noted. This will be 
undertaken  through  a  structured  and  ongoing  review  process  led  by  the  acute 
medicine  leadership  team,  which  will  ensure that  improvements  are  embedded  into 
routine practice and maintained over time. Sustainability checks will focus on whether 
actions have been fully implemented, are consistently applied in day-to-day operations 
and continue to deliver the intended outcomes without additional short-term support 
or escalation. 

This will be achieved through a combination of quantitative and qualitative measures, 
including  performance  metrics  and  feedback  from  staff.  Ownership  for  sustaining 
improvements will be clearly assigned to the Divisional Leadership Team, with actions 
incorporated into business-as-usual processes such as policies, standard operating 
procedures, ongoing training programmes, and governance reporting cycles. 

Where evidence indicates deterioration or risk to sustainability, this will trigger early 
escalation,  review,  and  corrective  action.  This  approach  ensures  that  regulatory 
actions  and  transformation  improvements  are  not  only  delivered  but  are  durable, 
resilient, and continuously reinforced 

2) The lack of understanding by medical staff, of the importance of identifying 
prolonged  QTc  syndrome  in  patients  attending  KMH,  with  a  lack  of  a  robust 

 
 
 
 process  for  ensuring  necessary  referral and  investigation  of  the  condition  by 
the KMH Cardiology team. 

During the investigation into the patient safety incident, it was determined that there 
were  knowledge  gaps  in  the  recognition  and  management  of  Long  QT  syndrome 
among  medical  staff. Actions  were  subsequently  implemented  to  enhance  both  the 
identification and treatment of this condition as detailed within the inquest. The inquest 
highlighted  additional  opportunities  to  reinforce  and  strengthen  the  actions  already 
taken,  and  these  have  been  addressed  by  the  cardiology  team  to  further  improve 
patient safety as follows: 

Recognition of Long QT: 

With  regard  to  the  recognition  of  Long  QT  syndrome,  it  was  noted  that  there  were 
several missed opportunities to identify a prolonged QT interval on Connor’s ECGs as 
the QT did not appear to have been measured. On 22nd January 2025, a dedicated 
teaching  session  was  conducted  for  medical  staff  at  Grand  Round,  led  by  the 
cardiology team, which specifically addressed the methodology for measuring the QT 
interval and the relevant cut-off values. To support the ongoing sustainability of this 
training,  the  accompanying  PowerPoint  presentation  has  been  disseminated  to  all 
current medical consultants, to enable regular educational sessions to be maintained 
for  the  broader  medical  team.  In  addition,  across  all  specialty  and  divisional 
governance reports in February 2026 information on the importance of measuring QT 
when undertaking an ECG will be included as a hot topic for further trust wide learning 
and signposting to the Prolonged QT Interval Identified on ECG in Adults Pathway.  

The governance support unit will continue to monitor incidents for trends and themes 
and  ensure  any  concerns  with  incidents  regarding  recognition  of  Long  QT  are 
escalated to the appropriate specialty for review.  

Knowledge of drugs which impact on QT: 

Since the inquest, the Cardiology team has collaborated with both the Pharmacy team 
and the Electronic Prescribing and Medicines Administration (EPMA) team to submit 
a proposal for a notification alert within the EPMA system. If development of an alert 
is possible the alert would be activated when a medication with the potential to prolong 
the QT interval is prescribed, thereby prompting the prescriber to review the patient's 
medical history and consider alternative treatments if a diagnosis of long QT syndrome 
is present. Given the complexity associated with identifying all medications that have 
the potential to prolong the QT interval, as well as the ongoing requirement to maintain 
and  review  this  list  when  new  drugs  are  introduced,  the  development  of  this  alert 
system may present additional risks and challenges. Accordingly, the outcome of this 
proposal will be brought before the Patient Safety Committee in March 2026, at which 
point further actions will be determined and subject to ongoing monitoring. 

Management of Long QT:  

During  the  patient  safety  incident  investigation,  it  was  identified  that  there  was  a 
knowledge gap regarding the management of Long QT and the Prolonged QT Interval 
Identified  on  ECG  in  Adults  Pathway  was  developed  which  outlines  the  causes, 

 investigations and treatments required for patients with Long QT. The pathway was 
issued on 29th September 2025 and was immediately made available to all trust staff 
via the intranet when searching “long QT”.  

During the inquest, the introduction of this new clinical document was duly noted. 
However, concerns were raised regarding its level of detail, particularly in relation to 
its suitability for staff without specialised experience in cardiology. Consequently, 
amendments have been implemented to address these concerns, as reflected in the 
draft pathway provided in Attachment 2. The draft pathway is progressing through 
the specialty and divisional sign off process with an anticipated completion date at 
the end of February 2026. 

Summary of amendments to the new pathway: 

1)  The pathway now incorporates an assessment of the likelihood of hereditary 
factors, including genetic predisposition and family history. Where hereditary 
risk is unknown, the pathway advises the clinical to proceed via the 'no' route. 

2)  Criteria have been defined for referral to cardiology services, distinguishing 
between urgent, inpatient, and routine referrals in accordance with clinical 
necessity. 

3)  The pathway outlines the process for repeating electrocardiograms (ECGs), 
specifying circumstances under which repeat testing is indicated and when.