NHS England case study: Accessing community public access defibrillators (CPADs)

Summary

This case study is one in a set of patient safety ‘how we acted on patient safety issues you recorded’ case studies which show the direct action taken in response to patient safety events recorded by organisations, staff and the public, and how their actions support the NHS to protect patients from harm.

Content

The National Patient Safety Team identified a risk of harm from locked community public access defibrillator (CPAD) cabinets.

CPADs are stored in numerous locations to allow members of the public to provide lifesaving defibrillation in the event of an out of hospital cardiac arrest. Most CPADs are kept in locked cabinets and require a 4-digit code to unlock the cabinet and release the CPAD. The code is usually provided by the ambulance service during a 999 telephone call. 

Several reports were reviewed where members of the public, who had been guided to a CPAD, could not get the unlock code or the incorrect code was held by the ambulance control centre.

Working with NHS England cardiology colleagues, the National Patient Safety Team liaised with relevant stakeholders including the ambulance services in England, the Resuscitation Council (RCUK) and the British Heart Foundation (BHF), who maintain detailed mapping of CPADs and have researched their use. Discussions centred on the issues raised by our initial findings, such as why some cabinets are kept locked, how best to maintain data on CPAD access and use and how best to standardise an approach which would reduce delays in access. The outcome of these discussions highlighted the establishment of a National Defibrillator Network (The Circuit) and evidence from The Circuit showed that less than 1% of unlocked cabinets are vandalised, which is less than for locked cabinets.  

Whilst work on this issue is ongoing, a consensus statement has been issued by key stakeholders (NHS England, BHF, RCUK, St John Ambulance and the Association of Ambulance Chief Executives) which recommends “public access defibrillators should be placed in unlocked cabinets allowing immediate access in an emergency”.