Dear Mr. Stewart,

Re. Kathleen Gregory: Prevention of Future Deaths Report (Ref. 2025-0408)

I am writing in response to your recent Prevention of Future Deaths Report, regarding the above-named patient. I would like to start by extending my condolences again to the patient’s family.

This case, I would agree, shows a reversible cause at the stage at which the patient was choking and had a pulse (was conscious). As per United Kingdom (UK) resuscitation guidance, one would attempt five back-blows followed by five abdominal thrusts (if the initial intervention was ineffective), in order to try and dislodge the obstruction. At the point at which the patient became pulseless/unresponsive (which as noted in the report was the case when the paramedic was notified of the incident) the patient by definition had gone into cardiac arrest and as per UK resuscitation guidelines one would then commence CPR at this point (ALS/backslaps).

In terms of our RESPECT form conversations with patients, these would involve a discussion around what you (the patient) would like us to do in the event that your heart were to stop beating and you were to go into cardiac arrest. In the case of this particular patient, I feel that the window of reversibility had been lost at the point that they became unresponsive/pulseless since as per UK resuscitation guidelines the opportunity for interventions to dislodge the obstruction had passed. Consequently, CPR was then indicated, something which the patient had expressed on their RESPECT form that they didn't want to occur.

Unfortunately, as may sometimes be the case, there isn't always a black and white answer, and in my opinion, this is such a situation. Although the RESPECT form is not a legally binding document, it is nonetheless a declaration of the patient’s wishes, wishes which are important and pertinent. I would also wish to observe that a patient with multiple comorbidities, who goes into cardiac arrest, may have a very small chance of recovery even where CPR has been administered.

In summary, my opinion in regards to this particular scenario, would be that at the point at which the patient was choking and pulsed, they were reversible. However, from the point at which the patient became pulseless and was in cardiac arrest, any reversibility had gone and the RESPECT form would therefore become relevant.

I agree that there is a degree of interpretation with regards to a RESPECT form in such a situation, and that therefore perhaps the wording or structure of the form needs to change. Naturally, this would be an issue for the national issuing body, but if it was felt to be relevant perhaps it is something that could be pursued with them directly.

St Marys Road | Beccles | Suffolk | NR34 9NX - We are Research Active I recognise fully, and respect the premise, that where there are opportunities for any organisation to make changes, and implement learning that will improve patient care, these should be adopted and implemented in full. Accordingly, I would propose the following:

1. A significant event analysis of this case looking specifically at the completion and wording on the RESPECT form. Also, the overall level of detail and content with which the form had been completed. The findings of this analysis will be discussed at the monthly Multi- Disciplinary meeting within our practice and then disseminated to the full practice team. This is scheduled to take place on Thursday 4th September 2025.

2. A practice-level review of the training given to clinicians on the completion of RESPECT forms, and an exploration of options with regards to further training needs for our team in terms of RESPECT form completion and options for the delivery of this. This review to be completed, and relevant training arranged within the next four weeks.

3. Further training for our clinical staff on the management of choking situations, has been arranged for Thursday 16th October 2025.

4. In the event that this case should have given rise to any sense that fundamental changes need to be made to the framework of RESPECT forms themselves (or the national guidance that supports their use and interpretation), I would urge you to take this up with the relevant national body.

May I take this opportunity to thank you for furnishing us with your considered findings from this case. As a provider of medical services, we wish to assure all those concerned that we take these findings extremely seriously, and have sought to reflect upon their implications for our practice and the delivery of care to any patients in future.

Please do not hesitate to contact me if I can be of any further assistance in this matter.