A London teenager died after “uncertain” staff at his care home failed to perform CPR on him, a coroner has found. Jake Taylor, 19, suffered a cardiac arrest at his care home, run by Choice Support, on 16 January 2025. He died four days later at Kingston Hospital.
No Beneficial Interventions from Staff
Senior coroner for West London, Lydia Brown, said there were “no beneficial interventions” from staff when Mr Taylor collapsed, as they were not sure what to do. “Due to uncertainties of staff as to how to proceed, there were no beneficial interventions until the arrival of the London Ambulance Service, some seven minutes after the 999 call was initiated, when all possible interventions were conducted,” Ms Brown said in a new Prevention of Future Deaths report. “By this time Jake had sustained an unsurvivable hypoxic brain injury. It could not be concluded if earlier interventions would have changed the outcome, but opportunities to do so were potentially lost.”
Delays in Providing First Aid
Mr Taylor had global developmental delay, cerebral palsy, and epilepsy, and was at high risk of aspiration and choking. He required 24-hour care. An inquest concluded that he died of natural causes, but the cause of his collapse could not be medically determined. The report said that when he collapsed on 16 January 2025, there were “delays in providing appropriate first aid” as necessary equipment, including a defibrillator, was not immediately available. It said that staff did not begin chest compressions until emergency responders arrived, despite being trained in first aid and having nursing qualifications.
Lack of Planning for Foreseeable Emergency
Ms Brown said there was no planning for the foreseeable emergency, and that nursing staff were not adequately trained to carry out basic life support in such a scenario. “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,” the report said. “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.”
NHS Response and Action Taken
An NHS South West London spokesperson said: “We extend our sincere sympathies to Jake’s family, and everyone affected by his death. The ICB [Integrated Care Board] took immediate action with the provider of his care, Choice Support, including seeking assurance about emergency arrangements, the availability of emergency equipment and staff training. We have also reviewed the services we commission for people with similarly complex needs and are working with providers to strengthen emergency planning, staff training and quality oversight so the learnings are acted upon.” Choice Support has been contacted for comment.
