Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2026-0217, written 16 Apr 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 16 Apr 2025 |
|---|---|
| Reference | 2026-0217 |
| Deceased | Adam Ankers |
| Coroner | Valerie Charbit |
| Coroner area | West London |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. South Central Ambulance Service 2. Association of Ambulance Chief Executives 3. National Health Service England (NHSE) 4. Department of Health and Social Care (DHSC) 5. Resuscitation Council UK 6. St John Ambulance 7. UK National Screening Committee 8. The British Society for Genetic Medicine 9. Sudden Cardiac Arrest UK (SCA UK) 10. Cardiac Risk in the Young (CRY) 11. The Football Association 12. Faculty of Sport and Exercise Medicine UK 13. UK Sports Institute (formerly the English Institute of Sport) 1 CORONER I am Valerie Charbit, Assistant Coroner, for the coroner area of West London Coroner’s Court 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 INVESTIGATION and INQUEST On 17 May 2024 an investigation was commenced into the death of ADAM ANKERS whose date of birth was 19 October 2006. The investigation concluded at the end of the inquest on 9 March 2026. The conclusion of the inquest was Adam Ankers collapsed with a cardiac arrest whilst playing football on 31 January 2024. Agonal breathing and cardiac arrest were not identified by the 999 call handler or those on the pitch. An Automated External Defibrillator (AED) device was brought onto the pitch but not used. Basic Life Support was first delivered by paramedics and Adam suffered hypoxic brain injury. Adam was taken to hospital and died on 4 February 2024 following tests concluding brain stem death. He died due to an inherited heart condition (ARVC) which had not been identified at the time of his death. The medical cause of death was: 1a hypoxic brain injury 1b cardiac arrest 1c Arrhythmogenic right ventricular cardiomyopathy (ARVC) 1 4 CIRCUMSTANCES OF THE DEATH 1. On 31 January 2024, Adam Ankers was playing a Foundation grass roots football game. He had a sudden cardiac arrest due to a previously unknown inherited cardiac condition. 2. His agonal breathing at the pitch was not identified and he therefore was not given Basic Life Support and no Automated External Defibrillator (AED) was used. 3. His paternal grandmother’s cousin had been diagnosed with ARVC in 2018 in Scotland but he had failed to cascade important information contained in a letter from a genetic counsellor to Adam’s immediate family. 4. Adam’s grandmother was made aware of ARVC by her cousin in 2022 and she told Papworth Hospital when she was admitted for an ablation. Although a subsequent referral was made back to Papworth Hospital, in error no appointment was made for her despite the triaging of the referral. 5. By the time of Adam’s death, Adam, his parents, siblings and grandmother had not had any genetic testing for ARVC or the gene variant that had been identified in Glasgow in 2018. 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – 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. South Central Ambulance Service 2. Association of Ambulance Chief Executives 3. NHSE 4. DHSC 5. The Football Association 6. 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. NHSE 2. DHSC 3. UK National Screening Committee 4. Resuscitation Council UK 5. 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. NHSE (NHS Inherited Cardiac Conditions Clinic) 2. DHSC 3. UK National Screening Committee 4. The British Society for Genetic Medicine 5. 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 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you AND/OR your organisation have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 11 June 2026. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons and to the LOCAL SAFEGUARDING BOARD. I have also sent it to the following bodies who may find it useful or of interest: 1. Genomics England 2. Joint Royal Colleges Ambulance Liaison Committee 3. The Royal College of Physicians 4. The Royal College of Pathologists 5. The Royal College of Paediatrics and Child Health 6. The British Heart Foundation 7. The Premier League Defibrillator Fund 8. Sport England I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any other person who I believe may find it useful or of interest. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response. 9 16.04.2026 Valerie Charbit 4
2 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
British Society for Genetic Medicine (BSGM) PO Box 43, 95 Mortimer Street, London. W1W 7GB Neville Sinclair, HM Coroner’s Officer 25 Bagley’s Lane, Fulham SW6 2QA 05.05.2026 Dear Mr Sinclair, Regulation 28, Prevention of Future Deaths response from BSGM regarding Adam Ankers Following an inquest into the death of Adam Ankers who died from a cardiac arrest on 9th March 2026, the coroner issued a Regulation 28 report to prevent future deaths. Adam Ankers had an inherited cardiac condition (ARVC) which had not been identified at the time of his death. The British Society of Genetic Medicine was asked to respond to 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. British Society of Genetic Medicine - BSGM BSGM is a registered charity ( ) that provides a forum for a wide spectrum of clinical, laboratory and researchers involved in genetics and genomics both in clinical service and research. BSGM’s objectives include a) the promotion, encouragement and advancement of the study and practice of clinical genetics and genomics. b) the advancement of education, research and innovation in clinical genetics and BSGM is a registered UK charity (No: 1058821) genomics c) the promotion of public awareness of genetics and genomics as they relate to health and disease d) the support of the professions contributing to applications of genetics and genomics in the health care systems of the United Kingdom e) the making available of informed opinion on issues of public interest in relation to genetics and genomics While many members of BSGM sit in positions of leadership within clinical genetics services and work within cardiac genetic services, it has no remit to implement service change but rather to influence how services are delivered. The Joint Committee on Genomics in Medicine (JCGM) is a joint committee of BSGM, Royal College of Physicians, Royal College of Pathologists. In 2019, JCGM released the 3rd edition of the guidance document ‘Consent and confidentiality in genomic medicine’ .This was written by , who has given evidence in this inquest, and . Many of the principles in practice within specialist clinical genetics and genomic practice are supported by the principles of this document. Genetic testing is now more embedded in clinical practice outside of the specialist genetics workforce. There are many educational activities underway to equip non genetics specialists to deliver their specific element of genetic medicine, for example by giving patients information about their genetic risk and by requesting genetic testing, giving the result and explaining the implications to the wider family. The principles of the ‘Consent and confidentiality in genomic medicine’ document underpin much of this education. Despite this, we acknowledge that the sharing and dissemination of genetic information within families may not be easy and is influenced by the complexities of family structures and dynamics as well as systemic constraints. Efforts are made to encourage and facilitate timely sharing of information and cascade testing in families. Barriers to this include limited service capacity, variable infrastructure and jurisdictional or cross border regulatory frameworks that restrict if, how and when clinical teams can contact or offer testing to at risk relatives directly. We note from the Regulation 28 Report that the proband (index case) in this family was Adam’s paternal grandmother’s cousin who had been diagnosed with ARVC. Genetic testing identified a variant which enabled genetic testing for other family members. A letter with important information was written by a genetic counsellor for dissemination to the family. This information was received by Adam’s grandmother but no testing had been undertaken in this branch of the family, including Adam. The information was passed onto a cardiologist by his grandmother who attempted to make an appointment to address this, but no appointment was made in error. This was not followed up either by the family or the cardiologist. BSGM’s role in this situation is to raise awareness of the need to share important information about genetic diagnosis and the results of genomic tests. BSGM will also contribute to documents such as ‘Consent and confidentiality in genomic medicine’ and to help in its dissemination. BSGM through its members can also help to influence service development in both specialist genetic services and also in more mainstreamed genetic medicine. Work is currently ongoing by NHS England to review the service specification for the Clinical Genomics Services and the working group involved in this work includes many BSGM or its contributory groups (Clinical Genetics Society and Association of Genetic Nurses and Counsellors) officers. It is of note that there is work ongoing nationally, funded by British Heart Foundation (BHF), to embed genetic testing recommendations into Coronial pathways following sudden unexplained death. A more sustainable funding model for this important work would be extremely valuable for families with ARVC where a sudden death occurs. I have enclosed a copy of the ‘Consent and confidentiality in genomic medicine’ document for your information. Please do not hesitate to get in touch if you would like further information. Yours sincerely, Chair On behalf of the British Society for Genetic Medicine ENC Consent and confidentiality in genomic medicine
Mr Neville Sinclair HM Assistant Coroner West London Coroner’s Office 25 Bagley’s Lane Fulham SW6 2QA 26 May 2026 Dear Mr Neville Sinclair, Regulation 28 Report to Prevent Future Deaths – Adam Ankers Thank you for your report dated 14 April 2025 regarding the death of Adam Ankers. On behalf of Resuscitation Council UK (RCUK), I would like to express our sincere condolences to Adam’s family and all those affected by this tragic event. based resuscitation guidelines used across UK health services, runs You have asked RCUK to respond to specific matters of concern arising from the inquest. The RCUK is a charity that develops evidence and accredits structured life support courses and promotes public cardiopulmonary resuscitation (CPR) and automatic external defibrillator (AED) awareness and training. Although we aim to influence national policy and standards related to resuscitation, we have no statutory role or responsibility; that is ultimately the role of NHS England and the Department for Health and Social Care. ‑ In relation to the points you raise, we have addressed Points A and C. We have also clarified our position regarding Point D. 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 Recognition of agonal breathing and cardiac arrest is a well-established challenge. Current UK Resuscitation Guidelines (2025) address this through clear and simplified messaging: cardiac arrest should be suspected in any unresponsive person, and if they are unresponsive with abnormal breathing, cardiac arrest should be assumed. The identification of agonal breathing is challenging, and it is well established that it is often mistaken for adequate breathing. Training, therefore, focusses on identifying someone who is not breathing normally, rather than trying to teach those undertaking first aid the varying and often not obvious appearance of agonal breathing. This is particularly important in the context of sport, where cardiac arrest may occur during or shortly after exertion, and breathing can appear abnormal and difficult to interpret. The 2025 UK Resuscitation Guidelines explicitly state that slow or laboured breathing, as well as abnormal patterns 1st Floor 60-62 Margaret Street, London. W1W 8TF Registered Charity Number 1168914 such as agonal gasping or panting, must be recognised as signs of cardiac arrest1; in practical terms, the key message is to focus on whether breathing is normal, and to act immediately if there is any doubt. RCUK has reinforced this approach through its ‘Resuscitation on the Field of Play: Best Practice Guidelines’ 2, which aim to improve the recognition and response to sudden cardiac arrest in sporting environments. These guidelines are designed for medical teams responding to a person who collapses during or shortly after sporting activity within professional sport, including football. RCUK has also recently published ‘Resuscitation in community sports: a national best practice guide’ 3, aimed at grassroots sport to improve early recognition of cardiac arrest and prompt use of CPR and defibrillation. The recognition of cardiac arrest by ambulance service call handlers is also a critical component of the early response. We work closely with NHS England (through NHS Pathways) to support emergency medical dispatch systems to use standardised algorithms which support the prompt identification of cardiac arrest and enable call handlers to provide immediate telephone-assisted CPR instructions. Our systems-level guidance further recommends that ambulance services teach, monitor, and continuously improve cardiac arrest recognition within dispatch centres, recognising this as a key link in the chain of survival4. The challenge for an ambulance call taker to correctly recognise cardiac arrest is well established, and a significant amount of work has been undertaken to improve this vital link in the chain of survival. RCUK recognises that, despite clear guidance, the recognition of cardiac arrest in real-world settings can remain challenging, particularly in environments such as grassroots sport. In response, RCUK will continue to strengthen its public-facing education campaigns. For example, as part of RCUK’s annual Restart a Heart campaign, this year’s programme will include a focus on recognising and raising awareness of agonal breathing. POINT C: That there is a need for better understanding of the use of defibrillators particularly by lay persons and trained first aid persons RCUK strongly supports the early use of AEDs as a critical component of the response to cardiac arrest. Evidence demonstrates that bystander CPR and defibrillation can more than double the likelihood of survival1. RCUK guidance is clear that AEDs are designed for use by members of the public and can be used safely without prior training. These devices provide clear audio and visual prompts to guide the user 1 Resuscitation Council UK (2025) Adult Basic Life Support Guidelines. 2 Resuscitation Council UK (2023) Resuscitation on the Field of Play: Best Practice Guidelines 3 Resuscitation Council UK (2026) Resuscitation in community sports: a national best practice guide 4 Resuscitation Council UK (2025) Systems Saving Lives Guidelines. 1st Floor 60-62 Margaret Street, London. W1W 8TF Registered Charity Number 1168914 through each step and will only deliver a shock if it is clinically indicated5. The guidelines emphasise that anyone can use an AED and that it should be applied as soon as it becomes available1. Of course, training in first aid is encouraged so that bystanders who find themselves presented with someone who has collapsed have the confidence and skills to deliver basic life support and defibrillation. RCUK and partner organisations have successfully campaigned to include basic life support training in the national curriculum across the four nations. However, it is not currently mandatory, and we continue to campaign to ensure that every child leaves school with the skills to save a life. In addition, RCUK and partners have successfully secured the inclusion of resuscitation-related questions in the driving licence theory test. RCUK is working with national partners to support public awareness, training, and access to defibrillators. This includes collaboration with the British Heart Foundation to support The Circuit, the national defibrillator network, which enables ambulance services to direct bystanders to nearby devices5. RCUK also continues to promote education and develop guidance for specific settings, including sport and community settings, to support a timely and effective response. 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 In relation to Point D, concerning cardiac screening in young people, RCUK acknowledges the importance of this issue. However, cardiac screening programmes and population-level screening policy fall outside the remit of RCUK, and we do not produce guidance or training in this area. We consider that this matter is more appropriately addressed by the UK National Screening Committee and relevant specialist organisations in cardiology and genomics. We hope this response is helpful. Should you require any further clarification, we would be pleased to assist. Yours sincerely, President Resuscitation Council UK 5 Resuscitation Council UK (2025) Public access defibrillators: A guide for communities. 1st Floor 60-62 Margaret Street, London. W1W 8TF Registered Charity Number 1168914
See every Prevention of Future Deaths report matching Valerie Charbit, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.