Jake Taylor

London Office 

Choice Support 
100 Westminster Bridge Road 
London 
SE1 7XA 

Ms Lydia Brown  
West London Coroners Office 
25 Bagleys Lane 
Fulham 
London 
SW6 2QA 

Date: 8th June 2026 

Dear Ms Brown,  

Re: Regulation 28 Report to Prevent Future Deaths – Jake Daniel Taylor who died 
on 20th January 2025.  

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 8th May 
2026 concerning the death of Jake Taylor.  

In advance of responding to the specific concerns raised in your Report, I would like to 
reiterate our condolences to Jake’s family.  

Your Report raises concerns with the following:  
No planning for this foreseeable emergency. 
Inadequate staff training (to always conduct CPR if no decision to the contrary) 
No defibrillator on site and staff misunderstanding of the function of a 
defibrillator. 
No airway training and equipment although Registered Nursing staff have this 
within their competencies. 

Choice Support acknowledges the concerns raised by the Coroner and recognises the 
critical importance of embedding learning across the organisation to minimise the risk of 
future harm. 
Following an internal investigation and a lessons learned process, we have identified a 
number of actions that have already been implemented, alongside further measures that 
we propose to take, to address the concerns identified. 

1.  Individualised emergency planning 

We acknowledge the absence of a clearly documented, individualised first aid response 
plan for Jake, particularly in relation to CPR and adaptations required due to his complex 
physical  presentation. 
to 
person-centred emergency planning.  

response,  we  have  strengthened  our  approach 

In 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Action 
All people who have a DNACPR decision is clearly displayed on 
the persons profile page on our digital planning system Nourish 
so that it is visible by any staff who support the person. 
All people currently supported at (5 people) Roy Kinnear House 
will now have a clearly documented first aid support plan. The 
steps to fulfil this are as follows:  

-  Draft  plans  to  be  developed  through  multidisciplinary 
team involvement and best interests decision-making. As 
liaise  with  medical 
the  support  provider  we  will 
professionals  who  are  best  placed  to  make  decisions 
around  the  type  of  support  and  equipment  people  will 
need in emergency interventions.  

-  Detail  the  level  of  support  and  interventions  required 

during medical emergencies 

-  Detail the type of equipment needed, which may include 

airway equipment 

-  Staff  will  have  relevant  training  on  the  first  aid  support 

plan and on the necessary equipment. 

-  Final plans to be uploaded onto each person’s profile 

In  line  with  our  First  Aid  Policy  (last  updated  May  2026)  all 
people we support across Choice Support will be supported to 
have a First Aid Support Plan that details the support they may 
need for various medical emergencies.  
This Plan will be visible on Nourish and updated as and when 
needs change, but yearly as a minimum.  

Timescales 

Completed  

For 3 people we are 
waiting  for  feedback 
on the draft plans for 
final sign off.  

For 2 people, the 
process is taking 
longer this work is 
ongoing as 
engagement from 
some family 
members has taken 
longer than 
anticipated. 

To be completed by 
30th July 2026 
31st August 2026 

2.  Inadequate  staff  training  (to  always  conduct  CPR  if  no  decision  to  the 

contrary). 
No  airway  training  and  equipment  although  Registered  Nursing  staff  have 
this within their competencies. 

Our  First  Aid  Policy  sets  out  staff  responsibilities  in  emergency  situations,  including 
immediate escalation to emergency services, delivery of basic life support and guidance 
on  the  use  of  AEDs,  and  the  requirement  for  each  person  supported  to  have  an 
individualised first aid support plan.  

Staff are required to complete:  

•  First Aid e-learning to establish core knowledge and understanding  
•  Complete practical First Aid training. Practical First Aid training then assesses staff 

competency.  

•  For some services, additional First Aid training is provided for people with complex 
or atypical body types to ensure staff can safely adapt emergency responses. In 

 
 
 
 
 
 
 
 
 
 the training, staff are introduced to possible equipment, including airway supports. 
The  use  of  such  equipment  will  then  be  based  on  the  needs  of  the  person 
supported, their health needs and in best interests discussions with the family and 
health professionals. The health professionals will guide on the most appropriate 
interventions for each individual and training requirements to support their use.  

Our  Practical  First  Aid  training  is  supported  by  demonstration  of  and  use  of  practical 
equipment  to  support  learning  and  confidence.  This  includes  CPR manikins  to  assess 
chest  compressions  and  rescue  breaths,  demonstration  for  recovery  position  and 
secondary survey, choking vests and bandaging equipment. Training also includes the 
use of an AED on a mannikin. Training content is reviewed and enhanced in response to 
national  and  organisational  learning  and  emerging  risks.  Practical  training  includes 
structured competency assessment, which covers primary and secondary survey, CPR, 
recovery position, choking, falls and head injury, burns, epilepsy, bleeding and shock. 

We  note  the  concern  regarding  airway  management  and  equipment.  In  this  service 
model,  clinical  equipment  such  as  oxygen  therapy  and  suctioning  is  provided  where 
clinically  indicated,  prescribed  and  documented  within  an  individual’s  care  plan.  The 
nursing  team  is  supported  to  undertake  clinical  observations,  including  monitoring  of 
blood pressure, oxygen saturation and temperature, to identify deterioration and escalate 
appropriately. Where a person requires additional medical equipment as part of a planned 
emergency response, this will be agreed through multidisciplinary team discussion and 
appropriate equipment and training will be put in place to ensure staff have the skills and 
confidence to deliver care safely and effectively. 

Action 

All  staff  at  Roy  Kinnear  House  to  be  supported  through  a  debrief 
meeting with Management and Learning and Development to focus 
on lessons learned following the Coroners’ Inquest 
Enhanced discussions will take place to include medical emergency 
scenarios involving complex support needs. 
All Registered Nurses will be supported to have a Clinical Supervision 
to carry out a skills gap analysis of their skills and training. Any gaps 
identified,  they  will  be  supported  to  attend  relevant  training  or 
refreshers.  
All staff at Roy Kinnear House will re-complete First Aid Training and 
Practical  Competency,  with  the  understanding  that  staff  should 
always conduct CPR if there is no decision to the contrary. 
Circulate  a  briefing  reminding  all  staff  at  Choice  Support  that 
CPR must be performed where no DNACPR exists, alongside 
updated CPR practice guidance in line with our First Aid Policy 

Timescales 
30st June 2026 

30th June 2026 

31st July 2026 

30th June 2026 

3.  Defibrillator availability and understanding 

 
 
 
 
 
 
 
 
 
 
 We  recognise  the  concern  regarding  the  absence  of  an  on-site  AED.  Choice  Support 
does  not  routinely  install  defibrillators  unless  determined  through  risk  assessment  and 
governance processes. We will be taking actions against this.  

First Aid training already includes training and practical competency of CPR and safe use 
of AEDs in line with national guidance. This will be reinforced for the staff at Roy Kinnear 
House.  

Action 

Choice  Support  will  purchase  an  AED  to  be  installed  at  Roy 
Kinnear  House.  We  are 
liaising  with  Quality  Assurance 
Commissioners and the ICB.  
As part of risk planning for contingencies, whilst we await an AED 
at  Roy  Kinnear  House,  we  have  mapped  out  the  3  local  AEDs 
nearest to Roy Kinnear House.  
We have also completed “drills” with the staff so they are aware 
of the location of the AEDs in the community and the time it would 
take to get the AED. 
As  an  organisation,  we  will  complete  a  risk  assessment  to 
determine  if  an  AED  is  required  at  all  of  our  registered  care 
services.  
As  an  organisation,  we  will  complete  a  risk  assessment  to 
determine if an AED is required at our supported living services. 
If one is not required, we will ensure clear visible signs to identify 
the location of the nearest AED.  

Timescales 
and 
Completed 
delivered  on  8th 
June 2026 
Completed 

31st July 2026 

31st July 2026 

4.  Clarity of support and expectations 

Roy Kinnear House is commissioned as a residential nursing service within a community 
setting.  Our  learning  has  highlighted  the  need  to  ensure  that  this  scope  is  clearly 
understood and consistently applied. We are therefore strengthening: 

•  Engagement  with  commissioners  to  ensure  a  shared  understanding  of  service 

support and to better inform the referral process for new admissions. 

•  Communication with families and representatives during assessment, admission 

and review regarding the care support provided. 

•  Discussion with families and representatives at assessment and admission to Roy 
Kinnear House on expression of wishes and life planning and how emergencies 
will be managed and where responsibility transfers to emergency services 

Action 
Introduce  a  mandatory  step  in  assessment/admission  (for 
residential  and  complex  care  support  houses)  to  confirm 
DNACPR status,  document  clearly, and  follow up  with the 
GP where unclear. 

Timescales 
Completed  on  29th  
May 2026  

 
 
 
 
 
 
 
 As part of risk planning for contingencies, whilst we await an AED 
at  Roy  Kinnear  House,  we  have  mapped  out  the  3  local  AEDs 
nearest to Roy Kinnear House.  
We have also completed “drills” with the staff so they are aware 
of the location of the AEDs in the community and the time it would 
take to get the AED. 
As  an  organisation,  we  will  complete  a  risk  assessment  to 
determine  if  an  AED  is  required  at  all  of  our  registered  care 
services.  
As  an  organisation,  we  will  complete  a  risk  assessment  to 
determine if an AED is required at our supported living services. 
If one is not required, we will ensure clear visible signs to identify 
the location of the nearest AED.  

Completed 

31st July 2026 

31st July 2026 

Choice Support recognises that this case has identified areas where systems could be 
strengthened,  particularly  in  relation  to  individualised  emergency  planning,  clarity  of 
guidance and staff confidence in emergency response. 

We  have  recently  appointed  a  Chief  Quality,  Engagement  and  Impact  Officer  and  a 
Director  of  Quality,  who  are  leading  the  development  of  a  new  quality  framework  and 
overseeing the review of our Serious Incident Policy. 

Our actions focus on strengthening policy, training, planning and governance, ensuring 
staff are supported with clear, consistent guidance and that emergency responses are 
appropriately tailored to individual needs. 

Sincerely,  

Regional Operations Manager 
Choice Support

Ms Lydia Brown 
Senior Coroner for West London 
West London Coroner’s Service 
25 Bagleys Lane 
Fulham 
London  
SW6 2QA 

Dear Ms Brown, 

National Medical Director  
NHS England  
Wellington House 
133-155 Waterloo Road  
London 
SE1 8UG 

19th June 2026  

Re: Regulation 28 Report to Prevent Future Deaths – Jake Daniel Taylor who 
died on 20th January 2025.  

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 8th May 
2026 concerning the death of Jake Daniel Taylor on 20th January 2025. In advance of 
responding to the specific concerns raised in your Report, I would like to express my 
deep condolences to Jake’s family and loved ones. NHS England is keen to assure 
the family and yourself that the concerns raised about Jake’s care have been listened 
to and reflected upon.   

Your Report raised the following concerns: 

1.  An  AED  (Defibrillator)  was  not  immediately  available  in  a  healthcare  setting 

responsible for adults with high tier complex needs. 

2.  There was no individualised care plan to set out details of the appropriate First 
Aid response including necessary equipment required to be available and the 
appropriateness of conducting CPR. 

3.  Registered nursing staff were not adequately trained to carry out required basic 

life support when an emergency arose. 

Nursing Staff Training 

Research  undertaken  in  relation  to  resuscitation  has  highlighted  the  importance  of 
human factors, team interaction, communication, and leadership which all play a role 
and can influence the performance of CPR and the avoidance of any shortcomings. In 
the  absence  of  a  valid,  documented  Do  Not  Attempt  CPR  (DNACPR)  or  Advance 
Decision to Refuse Treatment (ADRT), the default clinical expectation, supported by 
joint guidance from the British Medical Association (BMA), Resuscitation Council UK, 
and Royal College of Nursing (RCN) is that CPR must be initiated without delay.  

DNACPR is a clinical recommendation rather than a legally binding instruction, and 
undocumented or informal discussions must not influence emergency response.  

In  this  case,  although  DNACPR  had  been  discussed  informally,  it  had  not  been 
formalised following transition to adult services. . 

                                                                                                                       
 
 
 
 
 
  
 
  
 
 
  
 Current  Resuscitation  Council  UK  (2025)  guidelines  reinforce  that  CPR  should  be 
initiated promptly in cardiac arrest, supported by effective systems, early defibrillation, 
and appropriate airway management.  

The NMC Code (2018, updated 2024) and Future Nurse Standards require registered 
nurses  to  act  without  delay  in  emergencies  and  maintain  competence  in  life-saving 
interventions, including airway management and recognising deterioration, consistent 
with  NICE  CG50  -  Acutely  ill  adults  in  hospital:  recognising  and  responding  to 
deterioration. 

Nationally agreed Universal Principles for Advance Care Planning set out a voluntary 
process of person-centred discussion between an individual and their care providers 
about their preferences and priorities for their future care. These are likely to involve 
a number of conversations over time and with whoever the person wishes to involve. 
When advance care planning is done well, people feel they have had the opportunity 
to plan for their future care. People feel more confident that their care and treatment 
will be focused on what matters most to them in a personalised, holistic way and helps 
them to live as well as possible. This aligns with NICE Guideline NG216 (2022), which 
emphasises  person-centred,  anticipatory  care  planning  for  adults  with  learning 
disabilities,  and  findings  from  the  Learning  from  Lives  and  Deaths  (LeDeR) 
programme,  led  by  NHS  England,   which  highlights  the  need  for  proactive, 
individualised planning due to increased risk of avoidable mortality in this population 

Care Planning 

Emergency  care  for  individuals  with  high-tier,  complex  health  needs  represents  a 
safety-critical  aspect  of  service  delivery  across  health  and  social  care  systems. 
Although  deterioration  and  life-threatening  events  in  this  cohort  are  often  clinically 
predictable  due  to  underlying  conditions  (including  neurological  disorders,  epilepsy, 
aspiration risk, and physical disabilities), the onset of such emergencies is frequently 
sudden and requires an immediate, coordinated, and confident response. 

From a systems and nursing perspective, emergency preparedness for this population 
must  be  understood  as  a  structured,  proactive  intervention  rather  than  an  ad  hoc 
response.  Individual  care  plans  must  reflect  the  person’s  specific  clinical  risks, 
resuscitation  status  and  agreed  escalation  decisions.  Plans  should  be  developed 
collaboratively, documented and be readily accessible and known to all staff. 

National  learning,  including  that  from  the  LeDeR  programme,  demonstrates  that 
people with learning disabilities and complex needs are at increased risk of avoidable 
harm where care planning is insufficiently robust or not consistently applied.  

National guidance and professional standards consistently emphasise that emergency 
responses should not rely on informal knowledge or assumed understanding. Instead, 
safe practice requires standardised processes that reduce variation and support staff 
to act decisively in high-pressure situations. This includes clarity that, in the absence 

 
 of  a  documented  DNACPR  or  equivalent  directive,  cardiopulmonary  resuscitation 
should be initiated without delay. 

From a system perspective, emergency care planning must be consistently embedded 
within  commissioning  expectations  and  provider  delivery.  Plans  should  be  person-
centred,  clearly  defining  clinical  risks,  escalation  pathways,  and  resuscitation 
decisions, and must be formally documented, known to all staff caring for the patient / 
person and accessible at the point of care, and regularly reviewed to reflect changes 
in condition or circumstance. 

Variation in the quality, completeness, or review of such plans introduces avoidable 
risk. Where planning is absent, outdated, or insufficiently detailed, staff may lack the 
clarity  required  to  act  promptly  and  confidently  in  an  emergency,  increasing  the 
likelihood of delayed or suboptimal care. 

It  is  expected  that  a  person  with  complex  needs,  such  as  Jake,  would  have  an 
emergency health care plan in place or at least such information would be integrated 
within their care plan (which may include an ADRT, a Recommended Summary Plan 
for Emergency Care and Treatment ReSPECT form, or other locally agreed template). 
It would also be best practice for the person to have a  health and care passport in 
place which, if completed correctly, would suitably capture critical information about 
the  person’s  complex  health  needs  and  how  best 
these  should  be 
supported/managed.  It  is  beneficial  for  people  with  a  learning  disability  and  autistic 
people to have a health and care passport which can be regularly updated in response 
to changes in their health and wellbeing and interaction in the health and care services 
they use.  

Availability of an AED Defibrillator 

The  Care  Quality  Commission  (CQC)  are  responsible  for  the  oversight  of  AED 
defibrillators  in  health  care  settings.  Whilst  the  CQC  does  not  mandate  that  care 
homes have to have an AED onsite, they do require care homes to be able to handle 
medical  emergencies.  The  CQC  Regulation  12  (Safe  Care  and  Treatment)  further 
mandates  that  providers  assess  and  mitigate  risks,  ensuring  staff  are  appropriately 
trained and equipped. This includes consideration of emergency equipment such as 
AEDs, particularly in settings with residents at increased cardiac risk, as encouraged 
by  NHS  England  and  RCUK  guidance.  Failure  to  provide  necessary  training, 
equipment, or clear documentation represents a breach of expected standards of safe 
and effective care.  

Regional Input 

London regional colleagues have liaised with the care provider Choice Support, who 
ran the care home Roy Kinner House where Jake was living. Choice Support advised 
that they recognised that this incident highlighted opportunities to strengthen clarity, 
consistency and anticipatory planning and have taken actions to rectify this. We are 
aware  Choice  Support  has  responded  directly  to  the  Coroner,  and  would  refer  the 
Coroner there for more details.   

 
 I  would  also  like  to  provide  further  assurances  on  the  national  NHS  England  work 
taking place around the Reports to Prevent Future Deaths. All reports received are 
discussed  by  the  Regulation  28  Working  Group,  comprising  Regional  Medical 
Directors,  and  other  clinical  and  quality  colleagues  from  across  the  regions.  This 
ensures that key learnings and insights around events, such as the sad death of Jake, 
are shared across the NHS at both a national and regional level and helps us to pay 
close attention to any emerging trends that may require further review and action.   

Thank you for bringing these important patient safety issues to my attention and please 
do not hesitate to contact me should you need any further information.  

Yours sincerely,  

National Medical Director  
NHS England

Chief Executive’s Office  
NHS Southwest London Integrated Care Board  
120 The Broadway 
 London 
 SW19 1RH 
9th June 2026 

Mrs Lydia Brown  
HM Senior Coroner  
West London 

Dear Madam 

Ref: Response to Prevention of Future Deaths Report concerning the death of Jake 
Daniel Taylor  

Thank you for your Prevention of Future Deaths (PfD) Report issued on 8 May 2026. We 
acknowledge the concerns you have raised and extend our sincere condolences to Jake’s 
family and all those affected by his death. 

As the commissioning organisation responsible for securing high-quality, safe and effective 
services for individuals with complex health needs, the ICB has carefully reviewed the 
matters identified in your report. We recognise the seriousness of the concerns raised and 
are committed to ensuring that lessons are learned and appropriate actions are taken to 
reduce the risk of similar circumstances occurring in the future. 

Following Jake’s tragic death and receipt of your report, the ICB took immediate action, 
including obtaining comprehensive assurance from the provider regarding emergency 
preparedness arrangements, the availability of emergency equipment, and staff training. A 
summary of the assurance received from the provider is set out in Section A of Appendix 1. 

The ICB also agrees with the coroner’s observation that similar circumstances could 
potentially arise in other services caring for individuals with complex and life-limiting health 
conditions. We have identified other individuals with needs similar to Jake’s for whom we 
commission services and have undertaken relevant checks whilst seeking further assurance 
from providers. We are also developing plans to share learning more widely across the 
system. A summary of the additional assurance being sought from existing providers is 
included in Section B of Appendix 1. 

As the ICB transitions into its strategic commissioning role, we will continue to consider 
longer term actions to strengthen existing processes. This will include addressing challenges 
associated with the limited market and availability of providers for complex care services, 
which remain significant issues both regionally and nationally. We will also review 
contractual arrangements and explore opportunities to standardise quality oversight 
arrangements across commissioned services. 

We trust that this response provides assurance that the concerns identified are being 
addressed through both immediate actions and longer-term system-wide improvements. We 
remain committed to working collaboratively with providers, clinicians, families and 

1 

                                                                                                                        
 
 
 
 
 
 regulatory partners to enhance the safety and quality of care provided to vulnerable 
individuals. 

Sincerely  

Interim Chief  Nursing Officer 
Southwest London ICB 

Appendix 1:  Summary Actions taken by ICB following learning  

Section A: Assurance provided to ICB by Choice Support  
Organisational learning and actions taken 
▪  Reviewed and updated First Aid Policy in line with national guidance, Resuscitation Council 

UK updates. 

▪  Clarified emergency response expectations within a residential nursing care setting, 
including timely escalation to emergency services and delivery of basic life support. 

▪  Strengthened training, competency assessment and guidance for staff, including additional 

▪ 

focus on complex body types. 
Implemented structured, individualised first aid and emergency response planning through 
multidisciplinary team and best interests’ processes (This is still underway at Roy Kinnear 
House as the progress varies for each individual supported at the house. 

▪  Reviewed equipment provision at Roy Kinnear House, confirming that monitoring 

equipment supports observation, escalation and decision making, with clinical equipment 
such as oxygen and suctioning available only where prescribed and documented in care 
plans. 

▪  Plans to install an AED at Roy Kinnear House, following consideration on training and 

maintenance. Risk assess residential care services across Choice Support, in considering 
a need for an AED at locations. 

▪  Strengthen early communication with commissioners, families and representatives so 

expectations about emergency response and limits of provision are explicitly understood 
from assessment onwards 

Section B: Additional assurance/ actions by ICB  
ICB has undertaken the following (completed on ongoing) 

▪ 

Identified other residents with such complex needs who we are commissioning services for, 
and we have undertaken relevant checks and obtaining assurance with plans to share 
learning wider across the system  

▪  Created the following additional assurance checklist to be shared with identified providers 

as a priority (this is still ongoing)  

a.  Emergency Planning for Foreseeable Medical Emergencies 

2 

                                                                                                                        
 
 
 
 
 
 
 All commissioned providers supporting individuals with identified high-risk health 
conditions to undertake a review of their emergency preparedness arrangements. This 
will include: 

•  Development and implementation of individualised emergency response plans 
for service users with recognised high-tier clinical needs and life-threatening 
risk profiles. 

•  Ensuring that emergency plans clearly describe foreseeable clinical 

emergencies, early warning signs, escalation pathways, emergency treatment 
requirements and resuscitation status. 

•  Confirmation that emergency care plans are developed in partnership with 

• 

relevant clinicians, families and advocates where appropriate. 
Introduction of a review process to ensure plans remain current and are 
reviewed following significant clinical events, changes in condition or at least 
annually. 

b.  Resuscitation Training and Understanding of CPR Requirements 

All commissioned providers will be required to: 

•  Review and strengthen mandatory life support training programmes. 
•  Ensure all relevant staff receive training on legal and professional 

responsibilities relating to resuscitation decisions, including the requirement to 
commence CPR unless a valid and documented advance decision or DNACPR 
recommendation is in place. 
Implement regular competency assessments and practical scenario-based 
training. 

• 

•  Maintain auditable records of staff compliance with training requirements. 

c.  Availability and Use of Defibrillators 
All commissioned providers will be required to: 

•  Undertake a risk assessment of all services supporting individuals with 
complex health needs to determine the need for automated external 
defibrillators (AEDs). 

•  Ensure that services identified as requiring AED provision have appropriate 

equipment available and maintained. 

•  Provide practical training to staff regarding the function, operation and 

limitations of AEDs. 

•  Establish routine checks and governance arrangements to ensure equipment 

remains available and operational. 

d.  Airway Management Training and Equipment 

All commissioned providers to: 

•  Review emergency equipment provision against the assessed needs of service 

users. 

•  Ensure registered nurses maintain competencies appropriate to the clinical 

needs of the individuals they support. 

•  Review training requirements relating to airway management and emergency 

response for both registered and unregistered staff. 

•  Ensure appropriate emergency airway equipment is available where clinically 

indicated and that staff are trained in its use. 

3 

                                                                                                                        
 
 
 
 Progress of compliance on the above areas to be shared with ICB CHC case manager 
and quality team. 

▪  As the ICB transitions into its new role of strategic commissioning we will continue to 

explore more long-term actions to strengthen existing   processes to include managing the 
limited market and choice of provider for complex care (which is a challenge regionally and 
nationally), contractual arrangements and standardising quality oversight. 

Appendix 2: Matters of Concerns (section 10 from PfD document)  

The MATTERS OF CONCERN are as follows:  

•  No planning for this foreseeable emergency. Inadequate staff training (to always conduct 

CPR if no decision to the contrary)  

•  No defibrillator on site and staff misunderstanding of the function of a defibrillator.  
•  No airway training and equipment although Registered Nursing staff have this within their 

competencies. 

I consider that individual emergency planning for those service users with recognised high tier 
needs and life-threatening risk profiles is essential to ensure best possible outcomes and care 
tailored to their needs.  

Medical emergencies in this cohort of patients are predictable but are likely to happen 
suddenly and unexpectedly. In this case the staff were not able to respond and their evidence 
to the court demonstrated that they felt unprepared and uncertain about what to do. This is a 
situation that could be replicated throughout the services that care for individuals such as 
Jake.  

Those commissioning the services should consider if the individual emergency care planning 
is comprehensive and complete and reviewed where appropriate. 

4