A local teenager died after uncertain care home staff failed to perform CPR on him.

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Lydia Brown, senior coroner for West London, said there were "no beneficial interventions" from staff when Mr Taylor collapsed at the care home, as they were not sure what to do.

In a new Prevention of Future Deaths report, Ms Brown said: "Due to uncertainties of staff as to how to proceed, there were no beneficial interventions until the arrival of the London Ambulance Service, some seven minutes after the 999 call was initiated, when all possible interventions were conducted.

"By this time Jake had sustained an unsurvivable hypoxic brain injury. It could not be concluded if earlier interventions would have changed the outcome, but opportunities to do so were potentially lost."

Mr Taylor required 24-hour care, had global developmental delay, cerebral palsy and epilepsy and was at high risk of aspiration and choking.

An inquest concluded Mr Taylor died of natural causes, but the cause of his collapse could not be medically determined.

The report said that when he collapsed on January 16, 2025, there were "delays in providing appropriate first aid" as necessary equipment – including a defibrillator – was not immediately available.

It said staff did not begin chest compressions until emergency responders arrived, despite being trained in first aid and having nursing qualifications.

Ms Brown said there was no planning for this foreseeable emergency, and that nursing staff were not adequately trained to carry out basic life support in such a scenario.

The report said: "In this case the staff were not able to respond and their evidence to the court demonstrated that they felt unprepared and uncertain about what to do.

"This is a situation that could be replicated throughout the services that care for individuals such as Jake.

"Those commissioning the services should consider if the individual emergency care planning is comprehensive and complete and reviewed where appropriate."

An NHS South West London spokesperson said: "We extend our sincere sympathies to Jake's family, and everyone affected by his death.

"The ICB [Integrated Care Board] took immediate action with the provider of his care, Choice Support, including seeking assurance about emergency arrangements, the availability of emergency equipment and staff training.

"We have also reviewed the services we commission for people with similarly complex needs and are working with providers to strengthen emergency planning, staff training and quality oversight so the learnings are acted upon."

Choice Support has been contacted for comment.

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