A teenage footballer who collapsed during a match died after a 999 call handler and those present failed to recognise the signs of a cardiac arrest, a coroner has found. Adam Ankers, 17, was playing for Wycombe Wanderers’ Foundation Under-19 team on 31 January 2024 when he complained of a tight chest and fell unconscious. He was taken to Harefield Hospital but died on 4 February from unsurvivable brain damage.
An inquest on Monday concluded that the failure to identify cardiac arrest “more than minimally” contributed to his death. Assistant coroner Valerie Charbit said there was a “missed opportunity to deliver basic life support” as no one was advised to perform CPR or use a defibrillator before paramedics arrived. Adam could be heard breathing faintly and making gurgling noises on the 999 call, but the call handler recorded his breathing as “normal”.
The coroner noted that agonal breathing, an indicator of cardiac arrest, was poorly recognised. A defibrillator was brought to the pitch within minutes but was not used due to confusion over its safety. Ms Charbit said the device would have indicated whether a shock was needed, adding that knowledge about defibrillators among the public and trained first-aiders is lacking.
Ms Charbit is considering issuing a prevention of future deaths report to the Football Association, NHS England, and the Department of Health and Social Care. She highlighted the need for mandatory cardiac arrest training for at least one person on the pitch, particularly coaches and referees. Since Adam’s death, NHS England has updated its telephone triage system so that sudden collapse during sport is automatically treated as requiring immediate CPR.
