Adam Ankers
PFD Report
Response Pending
Ref: 2026-0217
Coroner's Concerns (AI summary)
Lay people, including ambulance call handlers, may have difficulty understanding the signs of agonal breathing or cardiac arrest.
View full coroner's concerns
I heard expert evidence from and other evidence which indicated To:
1. South Central Ambulance Service
2. NHSE
3. DHSC
4. Resuscitation Council UK
5. St John Ambulance POINT A: That there is difficulty in lay people (trained or not) including ambulance call handlers in understanding the signs of agonal breathing or cardiac arrest To:
1. The Football Association
2. Faculty of Sport and Exercise Medicine UK
3. The English Institute of Sport
1. South Central Ambulance Service
2. NHSE
3. DHSC
4. Resuscitation Council UK
5. St John Ambulance POINT A: That there is difficulty in lay people (trained or not) including ambulance call handlers in understanding the signs of agonal breathing or cardiac arrest To:
1. The Football Association
2. Faculty of Sport and Exercise Medicine UK
3. The English Institute of Sport
Responses
Sent To
- Association of Ambulance Chief Executives
- Department of Health and Social Care (DHSC)
- Resuscitation Council UK
- South Central Ambulance Service
- Football Association
- UK National Screening Committee
Response Status
Linked responses
1 of 13
56-Day Deadline
11 Jun 2026
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 17 May 2024 an investigation was commenced into the death of ADAM ANKERS whose date of birth was 19 October 2006. The investigation concluded at the end of the inquest on 9 March 2026. The conclusion of the inquest was Adam Ankers collapsed with a cardiac arrest whilst playing football on 31 January 2024. Agonal breathing and cardiac arrest were not identified by the 999 call handler or those on the pitch. An Automated External Defibrillator (AED) device was brought onto the pitch but not used. Basic Life Support was first delivered by paramedics and Adam suffered hypoxic brain injury. Adam was taken to hospital and died on 4 February 2024 following tests concluding brain stem death. He died due to an inherited heart condition (ARVC) which had not been identified at the time of his death. The medical cause of death was: 1a hypoxic brain injury 1b cardiac arrest 1c Arrhythmogenic right ventricular cardiomyopathy (ARVC)
Circumstances of the Death
1. On 31 January 2024, Adam Ankers was playing a Foundation grass roots football game. He had a sudden cardiac arrest due to a previously unknown inherited cardiac condition.
2. His agonal breathing at the pitch was not identified and he therefore was not given Basic Life Support and no Automated External Defibrillator (AED) was used.
3. His paternal grandmother’s cousin had been diagnosed with ARVC in 2018 in Scotland but he had failed to cascade important information contained in a letter from a genetic counsellor to Adam’s immediate family.
4. Adam’s grandmother was made aware of ARVC by her cousin in 2022 and she told Papworth Hospital when she was admitted for an ablation. Although a subsequent referral was made back to Papworth Hospital, in error no appointment was made for her despite the triaging of the referral.
5. By the time of Adam’s death, Adam, his parents, siblings and grandmother had not had any genetic testing for ARVC or the gene variant that had been identified in Glasgow in 2018.
2. His agonal breathing at the pitch was not identified and he therefore was not given Basic Life Support and no Automated External Defibrillator (AED) was used.
3. His paternal grandmother’s cousin had been diagnosed with ARVC in 2018 in Scotland but he had failed to cascade important information contained in a letter from a genetic counsellor to Adam’s immediate family.
4. Adam’s grandmother was made aware of ARVC by her cousin in 2022 and she told Papworth Hospital when she was admitted for an ablation. Although a subsequent referral was made back to Papworth Hospital, in error no appointment was made for her despite the triaging of the referral.
5. By the time of Adam’s death, Adam, his parents, siblings and grandmother had not had any genetic testing for ARVC or the gene variant that had been identified in Glasgow in 2018.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.