Jake Taylor

I am Lydia Brown, Senior Coroner, for the coroner area of West London.

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.

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. I have a duty to send a copy of your response to the Chief Coroner. In accordance with the Chief Coroner’s Publication Policy, you should send me any representations regarding publication of your response. These  representations should be made at the same time as the response is provided. I will pass any representations received to the Chief Coroner for a decision. Please note any links to webpages included in the response will not be  checked for sensitive information prior to publication, as the information is  already online . The names of those who do not respond to PFD reports are regularly  published on the Chief Coroner’s webpages Non-responses to Prevention of Future Death (PFD) reports – Courts and Tribunals Judiciary.

SUMMARY OF CORONER’S CONCERN An AED (Defibrillator) was not immediately available in a healthcare  setting responsible for adults with high tier complex needs where at  least one of the residents was at high risk of choking or aspiration. 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 Registered nursing staff were not adequately trained to carry out  required basic life support when an emergency arose.