A teenage footballer who tragically died after collapsing during a match did not receive immediate life-saving support because staff failed to recognise critical signs of a heart attack, a coroner has concluded in a stark warning. Adam Ankers, aged 17, was participating in a game for the Wycombe Wanderers' Foundation U19 team on January 31, 2024, when he suddenly exclaimed 'my chest is tight' towards the end of the second half before losing consciousness.
Inquest Findings Reveal Critical Failures
An inquest held on Monday determined that Adam's death was 'more than minimally' contributed to by a failure to identify that he was in cardiac arrest, both by the 999 call handler and individuals present on the pitch. This critical oversight meant that no one was instructed to perform cardiopulmonary resuscitation (CPR) or utilise a defibrillator during the vital minutes before paramedics arrived at the scene.
Valerie Charbit, assistant coroner to the West London Coroner's Court, stated in her findings: 'There was a missed opportunity to deliver basic life support for Adam. Agonal breathing and cardiac arrest were not identified by the 999 call handler or those on the pitch, and first basic life support was performed by paramedics when they arrived.'
Understanding Agonal Breathing and Cardiac Arrest
Agonal breathing refers to sudden, irregular gasps that are insufficient to sustain life and require immediate CPR. Initially, it was believed that Adam, who was part of the Henley College Elite Football Development Programme, was experiencing 'a fit or seizure.' However, Ms. Charbit noted that on the 999 call, Adam could be heard breathing faintly and making 'gurgling' noises, yet his breathing was recorded as 'normal' in the triage system.
She emphasised: 'Agonal breathing was poorly recognised by the call handler and it should be recognised as a feature consistent with cardiac arrest. The answers given to the call handler did indicate that Adam was not breathing regularly. She should have recognised either agonal breathing, cardiac arrest or abnormal breathing and should have been giving basic life support instructions.'
Defibrillator Confusion and Missed Opportunities
The inquest also revealed that a defibrillator was brought to the pitch within minutes of Adam's collapse but was not used due to confusion over its safety application. Ms. Charbit explained: 'The AED (automated external defibrillator) was not used and it could have been, even if there was uncertainty as to whether Adam was breathing, because the device will say whether the patient should be shocked or not. This fact appears not to be well-known. I consider that a concerning aspect of the evidence.'
She added: 'In a country where football is so well-loved, it is, in my view, important that there is a better understanding of where and how and when an AED can be used.'
Coroner's Call for Systemic Changes
Ms. Charbit is considering issuing a prevention of future deaths report addressed to organisations including the Football Association (FA), NHS England, and the Department of Health and Social Care. Key concerns highlighted include the 'difficulty in understanding the signs of agonal breathing or cardiac arrest' and a 'need for better understanding of the use of defibrillators, particularly by a layperson and trained first-aid person.'
The coroner specifically called for the FA to make sudden cardiac arrest training mandatory for 'at least one person' on the football pitch, such as coaches and referees. She stated: 'I do consider that it is a matter of concern for grassroots football clubs affiliated with the FA that there isn't a mandatory cardiac arrest training for at least one person in the match.'
Medical Condition and Systemic Improvements
Adam died due to an inherited heart condition known as arrhythmogenic right ventricular cardiomyopathy (ARVC), which had not been identified prior to his death. He was rushed to Harefield Hospital in Uxbridge but succumbed to unsurvivable brain damage a few days later.
Since the incident, NHS England has implemented changes to its Pathways telephone triage system, where a sudden collapse during sport or exercise will now automatically be treated as requiring immediate CPR. Ms. Charbit noted: 'It must evidently be very difficult for the family to know that if Adam would have collapsed after May 2025, then his collapse would have automatically been treated as a sudden cardiac arrest.'
Family's Heartfelt Statement
Adam's parents, Alastair Ankers and Naomi Wakefield, expressed their grief in a statement following the inquest: 'We lost Adam more than two years ago and it's been a long and difficult process to get to this stage. Our family have been supported by some amazing people, for which we are truly grateful. Adam's death has had a devastating impact on his family and friends.'
They added: 'We hope that all the organisations and people touched by this inquest will learn and improve. We also thank the coroner for five proposed prevention of future death orders, and hope that no other family will have to lose a child this way.'
Broader Context and Recent Tragedies
This coroner's ruling emerges just a day after another tragic incident involving a 15-year-old Oxford player, Amelia Aplin, who died after collapsing during a girls' academy game. Oxford United confirmed the serious medical incident occurred during a match against Fulham at their training centre, with Amelia's death announced on Sunday, highlighting ongoing concerns in youth sports safety.
Ms. Charbit will be considering applications regarding her proposed prevention of future deaths report on April 14, aiming to foster crucial improvements in emergency response protocols within football and broader community settings.
