The subtle sign your heart is about to stop: that 999 call handlers missed in tragic football star, 17

A talented football star died at the age of 17 after 999 call handlers failed to recognize a distinct breathing pattern that is a known sign of cardiac arrest.

Adam Ankers collapsed as he came off the pitch after playing for Wycombe Wanderers’ under-19 team in January.

Someone at the scene called an ambulance and explained that the teenager had collapsed, initially thinking he had had a seizure. before explaining that he was experiencing ‘faint’ and ‘sporadic’ breathing.

This pattern is medically known as ‘agonal breathing’ and describes when a patient is not getting enough oxygen and is gasping for air. It is a well-known warning sign of cardiac arrest: the heart suddenly stops pumping blood through the body.

However, the 999 call handler failed to notice this warning and instead followed guidelines for treating a seizure, rather than a fatal heart rhythm problem.

As a result, life-saving CPR was not performed by paramedics until approximately 30 minutes later.

By then he had suffered extensive brain damage. Adam was taken to Harefield Hospital in London, where he was diagnosed with brain stem death – when a person on an artificial life support machine loses functions.

A few days later, his family agreed to have his life support turned off.

Someone at the scene called an ambulance and explained that the teenager in the photo was experiencing ‘faint’ and ‘sporadic’ breathing

An incident investigation into his death by the South Central Ambulance Service (SCAS) Foundation Trust found there was a potential missed opportunity to start life support earlier. This is reported by Health Service Journal.

His death has highlighted a possible recurring problem in the 999 assessment and triage system, which is now under review following the tragedy.

The 17-year-old was found to have an inherited heart condition called arrhythmogenic right ventricular cardiomyopathy – a condition thought to be responsible for around 600 sudden deaths a year in teenagers and young adults.

Although fatal, the condition often goes unnoticed because it does not always cause symptoms in its early stages. However, some patients experience palpitations and fainting.

Adam’s father Alastair Ankers, an anesthetist, believes that if his son had been resuscitated earlier he would have had a better chance of recovery.

He told MailOnline: ‘Very early on, while Adam was still in hospital, I became aware that things had not gone well that day.

‘Crucially, there was an eight-minute delay in starting CPR. We know that not starting them promptly is associated with worse outcomes for patients with brainstem injuries.”

According to Mr Ankers, the call handlers did not advise the onlookers who called 911 to use a defibrillator. Tragically, there was one available nearby in the football field grounds.

The SCAS incident report says there was a potential missed opportunity to begin CPR from 2.36pm, which is just eight minutes before paramedics arrived (file image)

“If someone is unconscious, unresponsive and has abnormal breathing, you should start CPR, including defibrillation,” Mr Ankers said. “On that day, this didn’t happen.”

This isn’t the first time that NHS Pathways – the guidance used by emergency responders to identify emergency problems – has had trouble spotting this irregular breathing pattern, which requires immediate resuscitation.

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 have been made to address issues with agonal breathing in 2022, but Mr Ankers’ case raises further questions.

Since the teenager’s death, SCAS has written to NHS England to ask for a national review of the system.

SCAS said: “The trust recognizes that Adam’s death at such a young age is tragic and has had a profound effect on his family and friends. We extend our sincere condolences to everyone affected by his death.

‘As part of our internal review, we have shared the matter with the national NHS Pathways team so that they can assess whether any changes to the triage algorithm are required. We await their response to this. We have created new training materials for our call center agents on the importance of re-checking previous answers to system questions when new information is provided that could change the flow of triage.”

NHSE said that NHS Pathways, whose processes are overseen by a clinical committee, was reviewing the matter, although it had not yet responded to SCAS’s inquiry. It added: ‘We understand the challenges in recognizing agonal breathing and additional training resources on this are being provided to services using NHS Pathways.

‘We are working with partner organizations across the NHS to ensure we respond appropriately to feedback and support improvements to the system where necessary – including improving agonal breathing capacity by 2022.’

An inquest into Mr Ankers’ death is expected to take place later this year.