A talented football star died aged 17 after 999 call handlers failed to recognise a tell-tale breathing pattern that’s a known sign of a cardiac arrest.
Adam Ankers collapsed as he came off the pitch after playing for Wycombe Wanderers’ under-19s team in January.Â
Someone at the scene called an ambulance, explaining that the teenager had collapsed, initially thinking he has suffered a fit, before explaining he was suffering ‘faint’ and ‘sporadic’ breathing.
This pattern is known medically as ‘agonal breathing’ — and describes when a patient is not getting enough oxygen and gasping for air. It is a known warning sign of a cardiac arrest — when the heart suddenly stops pumping blood around the body.
However, the 999 call handler failed to spot this red flag, and instead followed guidance for treating a seizure, rather than a deadly heart rhythm problem.Â
As a result, life-saving CPR was not performed until some 30 minutes later, by ambulance crew.
By this time, he had suffered major brain damage. Adam was taken to the Harefield Hospital in London where he was diagnosed with brain stem death — when a person on an artificial life support machine no longer has any functions.
A few days later, his family agreed to his life support being turned off.
Someone at the scene called an ambulance, explaining that the teenager, pictured, was suffering ‘faint’ and ‘sporadic’ breathing
An incident investigation into his death by South Central Ambulance Service (SCAS) Foundation Trust, revealed there was a potential missed opportunity to start life support earlier, Health Service Journal reported.Â
His death has highlighted a possible recurring problem in the 999 assessment and triage system, which is now being reviewed following the tragedy.
The 17-year-old was found to have an inherited heart condition, arrhythmogenic right ventricular cardiomyopathy — a condition that is thought to be responsible for roughly 600 sudden deaths a year in teenagers and young adults.
While deadly, the condition often goes unnoticed as it doesn’t always cause symptoms in early stages. However some patients experience heart palpitations and fainting.Â
Adam’s father Alastair Ankers, an anaesthetist, believes if his son had been resuscitated earlier he would have stood a better chance of recovery.Â
He told MailOnline: ‘From quite early on when Adam was still in hospital, I became aware that there were things that hadn’t gone as well on the day.
‘Crucially, there was an eight minute delay in starting resuscitation. We know that failing to start it quickly is linked to worse outcomes for brain stem injury patients.’
According to Mr Ankers, call handlers did not advise spectators who made the 999 call to use a defibrillator. Tragically, one was available nearby on the grounds of the football pitch.
The SCAS incident report says there was a potential missed opportunity to start CPR from 2.36pm onwards, which is just eight minutes before ambulance crew arrived (file image)
‘If somebody is unconscious, not responding and has abnormal breathing, you should start CPR, and that includes defibrillation,’ Mr Ankers said. ‘On that day, this didn’t happen.’
This is not the first time NHS Pathways — the guidance used by handlers to identify emergency problems — has had  problems with spotting this irregular breathing pattern, which requires immediate CPR.
HSJ reported that in 2019 there were six cases where concerns had been raised, including two where coroners had issued reports calling for changes to prevent future deaths.
Some changes were made to try to address issues with agonal breathing in 2022, but Mr Ankers case raises further questions.Â
Since the teenager’s death, SCAS has written to NHS England to ask for a national review of the system.Â
SCAS said: ‘The trust recognises that Adam’s death at such a young age is tragic and has had a profound effect on his family and friends. We offer our sincere condolences to everyone who has been affected by his death.
‘As part of our internal review, we have shared the case with the national NHS Pathways team so they can review whether any changes to the triage algorithm are required. We are awaiting their response to this. We have produced new training materials for our call centre staff regarding the importance of rechecking previous answers to system questions when new information is provided that may alter the course of the triage.’
NHSE said NHS Pathways, whose processes are overseen by a clinical committee, was reviewing the case, though it had not yet responded to SCAS’s enquiry. It added: ‘We understand the challenges in recognising agonal breathing and additional training resources on this are provided to services using NHS Pathways.
‘We work with partner organisations across the NHS to ensure that we respond appropriately to feedback and support improvements to the system where appropriate — including enhancing the agonal breathing content in 2022.’
 An inquest into Mr Ankers’ death is expected to take place later this year.
