Crash team access swipe-card did not enable access to endoscopy suite

Incorrect defibrillator pads stocked which were incompatible with machine in use

Security informed, and crash access codes updated

Resuscitation department and nurse in charge informed. Correct pads supplied and equipment ordering details changed

Medical team unaware of location of labour ward, therefore delaying arrival time

‘Cardiac arrest’ call not activated on labour ward anaesthetist's bleep, therefore delaying arrival of anaesthetist

Further education at staff induction to hospital emphasising importance of learning locations in hospital

Switchboard informed to put crash call out on labour ward bleep in future

Poorly stocked resuscitation trolley. No intubation bougie available, leading to failed intubation of mannequin

Nursing staff uncertain of terminology or use of advanced airway equipment, and therefore unable to help struggling anaesthetist

Delay in arrest team arrival due to recent building work that led to frequent moves and renaming of wards, causing confusion over location of event

Trolley used on ward was not appropriate for use as resuscitation trolley. Therefore, new larger trolley supplied by resuscitation department with space for all equipment required. Nursing staff made aware of importance of regular trolley checks

Nursing staff educated in advanced airway equipment. Nurse in charge informed of need for ongoing staff training in this area

Trust board made aware of issues, and need for increased signage and communication with staff during hospital refurbishment and structure changes

Delay in starting basic peri-arrest care due to a lack of basic equipment in critical care bedspace

Simulation was performed in a new ward area. This highlighted an issue of lack of basic stock. The ward manager was informed and stock policy amended