Quality Standards: Mental health inpatient care

Healthcare organisations have an obligation to provide a high-quality resuscitation service, and to ensure that staff are trained and updated regularly to a level of proficiency appropriate to each person’s expected role. 

This document provides Quality Standards for cardiopulmonary resuscitation practice and training in settings that deliver mental healthcare. In this standards document, mental healthcare refers predominantly to mental health inpatient units that provide care for adults of all ages, adolescents or children. 

Each section of this document contains the Quality Standards, supporting information and supporting tools for a specific aspect of cardiopulmonary resuscitation in mental healthcare. The appendix provides a list of suggested measures to assess organisations’ adherence to the standards specified in each section. The core standards for providing cardiopulmonary resuscitation across all healthcare settings are described in ‘Introduction and overview to Quality Standards for cardiopulmonary practice and training’ 

Resuscitation Council UK recognises that the standards in this document may provide challenges for some mental health services and the organisations that are responsible for providing them. Intentionally, these standards are aspirational in certain areas. Where appropriate, each section contains links to implementation tools or examples of good practice. Each section also contains guidance on measures to assess adherence to standards. 

Terminology: 

1. The term ‘MUST’ has been used when the consensus is that the standard promotes normal practice and is obligatory. 
2. The term ‘SHOULD’ has been used when the consensus is that the standard promotes normal practice. 
3. The term ‘RECOMMENDS’ is used when the consensus is that the standard promotes best practice. 

Resuscitation Council UK recommends that each mental healthcare organisation considers the implications of these standards and makes suitable arrangements to develop the capabilities that are required. 

Organisations should consider training some staff selected from within the organisation to a higher standard than is required generally so that they can undertake the actions that are necessary and/or cascade training within their facilities. Additionally, organisations could establish a suitable service level agreement with: acute healthcare services that are sufficiently close geographically; ambulance services; or external training organisations. Mental healthcare organisations may require a combination of arrangements. 

The core standards for the provision of cardiopulmonary resuscitation across all healthcare settings are described in the Introduction and overview page.

Alongside the Quality Standards, there is a mental health: inpatient care equipment and drug list. Please refer to that by clicking here.

Many organisations that provide mental healthcare do not have a separate Resuscitation Committee within the mental health service. However, if they do not, they must have a system that incorporates the duties of resuscitation services into their governance and clinical structures. The circumstances vary across organisations and with the jurisdiction in which patients are cared for and treated in the UK. Resuscitation Council UK recognises that the structure of the NHS, and mental health services within it, is different in England, Northern Ireland, Scotland and Wales. Therefore, this document uses the term resuscitation service structure throughout. The implementation of these standards may vary slightly in each of the countries that comprise the UK. 

Standards

1. Every healthcare organisation that admits mentally ill people must have an identified Resuscitation service structure that has clearly defined terms of reference. 
2. Every organisation must have an identified board member who is responsible for resuscitation services. This was required in England by Health Services Circular 2000/028, which stated that Chief Executives must ensure that ‘a non-executive Director of the Trust is given designated responsibility on behalf of the Trust Board to ensure that a resuscitation policy is agreed, implemented, and regularly reviewed within the clinical governance framework’. 
3. The Resuscitation service structure must be part of each responsible authority’s management structure (e.g. clinical governance, clinical risk, quality improvement, education service structures). 
4. The Resuscitation service structure must include local resuscitation experts, representatives from stakeholder groups (e.g. doctors, nurses, resuscitation officers, pharmacists, management, patient/lay representative, and appropriate specialties). Examples of appropriate specialties are the ambulance service, anaesthesia, cardiology, dentistry, emergency medicine, general practice, intensive care medicine, mental health, neonatology, obstetrics, and paediatrics. The exact composition of the Resuscitation service structure should depend on local needs and arrangements. 
5. The lead person responsible for the Resuscitation service structure must have an active and credible involvement in resuscitation. This person must have the authority to drive and implement change to meet the standards in this document. 
6. The Resuscitation service structure must have administrative support. 
7. The Resuscitation service structure is responsible for implementing operational policies governing cardiopulmonary resuscitation practice and training. 
8. In the absence of other organisational arrangements, the Resuscitation service structure must also be responsible for implementing operational policies that govern prevention of cardiac arrest, including recognition of patients who are deteriorating before they arrest. 
9. Clear local arrangements should be negotiated and put in place for the Resuscitation service structure to provide advice to other local healthcare organisations that do not have the expertise that is necessary in resuscitation policies, training, clinical practice, monitoring and audit. 
10. The Resuscitation service structure must determine the level of resuscitation training required by staff members. 
11. At least twice-yearly meetings of the Resuscitation service structure are recommended. 
12. Responsibilities of the Resuscitation service structure include: 
    • ensuring implementation and adherence to national resuscitation guidelines and standards; 
    • defining the roles and composition of the resuscitation team within the organisation; 
    • ensuring that resuscitation equipment for clinical use is available and ready for use; 
    • ensuring that appropriate resuscitation drugs (including those for peri-arrest situations) are available according to local policy and ready for use; 
    • planning adequate provision of training in resuscitation; 
    • determining requirements for and choice of resuscitation training equipment; 
    • preparing and implementing all policies relating to resuscitation (this may include managing anaphylaxis); 
    • preparing and implementing policies relating to prevention of cardiac arrest and recognising patients who are deteriorating; 
    • preparing and implementing a policy on resuscitation decisions (e.g. DNACPR decisions and advanced care planning); 
    • quality improvement - action plans should be based on audits; 
    • recording and reporting incidents in relation to resuscitation in which patients’ safety may have been at risk. 
13. The healthcare organisation must ensure that there is defined financial support for the Resuscitation Service structure. 

Standards

1. Every organisation must have at least one person, (ie the resuscitation officer (RO), resuscitation lead, resuscitation services manager, or a person who holds an equivalent role) who is responsible for co-ordinating the teaching and training of staff in resuscitation. People in any of these posts are referred to as ROs throughout this document. 
2. ROs have additional important responsibilities that include quality improvement, incident review, and maintenance of clinical equipment. 
3. Depending on the size and geographical distribution of the organisation, more than one RO may be needed to fulfil training requirements and additional responsibilities relating to resuscitation. 
4. One whole-time-equivalent RO is required to deliver training for 50% of their working time; this equates to one whole-time RO training no more than 821.5 hours per year - see below for further details. 
5. Smaller organisations must also appoint a resuscitation lead who may have other roles as part of their work commitments. 
6. Resuscitation Officers should possess a current Advanced Life Support (ALS) provider certificate (or equivalent) as a minimum standard; ideally, the ALS Instructor qualification is recommended. Where appropriate, each organisation must ensure that ROs possess certified resuscitation training in other specialist areas (e.g. paediatrics and trauma). 
7. ROs must have access to a designated training room(s) of adequate size. The room(s) should comfortably accommodate Instructors, trainees and all the training equipment required for any teaching session. 
8. ROs must have access to suitable electronic teaching aids and projection facilities. There must be adequate space for storing equipment. It is recommended that separate office space is available in which there is a desk, computer facilities and filing cabinets. 
9. ROs must have adequate access to administrative assistance. 
10. Equipment that is required for training will vary according to local needs. Adult, paediatric and neonatal manikins, airway management trainers, an ECG monitor and rhythm simulator, and at least one defibrillator dedicated for training, must be available. Equipment used for training (especially defibrillators) must be of the same models as those that are used in actual clinical practice to ensure appropriate clinical use of the equipment. All efforts must be made to ensure that adequate of equipment is available to prevent unnecessary moving and handling of equipment, especially if the geographical area covered by an organisation is substantial. 
11. There must be a defined resuscitation budget made available for ROs to maintain, upgrade and purchase new equipment for use with patients and for training. Purchasers and other funders of health care must to be made aware of this requirement when contracts, responsibilities and service agreements are negotiated and adequate provision must be made. This financial support for resuscitation services must be taken into account during budget planning by each organisation. 
12. ROs must be responsible for ensuring that there are systems in place for maintaining resuscitation equipment in good working order. Usually, this requires delegation of routine checking of equipment to other members of staff. 
13. ROs must ensure that all cardiorespiratory arrests are documented by the staff who are involved in the resuscitation attempt, and audited. The results should be sent to the local audit/governance structure. 
14. In order to maintain standards and clinical credibility, it is recommended that responding to and participating in cardiac arrest management is an integral part of the RO’s clinical responsibility. ROs who have a clinical role must have appropriate clinical supervision and support. 
15. Each RO has a responsibility to maintain their own education in resuscitation. Teaching on resuscitation courses outside the organisation is recommended in order to achieve this. In addition, regular attendance at professional meetings must be supported with a budget for study leave and expenses. 
16. ROs must not be expected to generate income to provide for their own salary. 
17. If any RO is expected to generate income for their employing organisation, that responsibility should be agreed in writing with the relevant manager. Any income must be directed to improving resuscitation services. 

Standards

1. All healthcare staff must undergo resuscitation training at induction and at regular intervals thereafter to maintain knowledge and skills. 
2. Training must be to a level appropriate for the staff members’ expected clinical responsibilities. 
3. This training must include use of an ‘early warning scoring’ system to identify deteriorating patients, including use of an escalation protocol to ensure early and effective treatment of patients in order to prevent cardiac arrest. The scoring and escalation system must be the same as that used in actual clinical care. Use of the National Early Warning Score (NEWS) is recommended for these purposes. Use of paediatric early warning scoring systems is recommended for practice with children. 
4. According to NICE Clinical Guideline 25 (2005) and NPSA Rapid Response Report (2008/RRR010), staff who care for patients in any mental health inpatient setting must have competences in monitoring, measurement, and interpretation of vital signs. They must have the knowledge, which is appropriate to the level of care they are providing, to recognise patients’ deteriorating health and respond effectively to acutely ill patients. 
5. Resuscitation Council UK’s Immediate Life Support (ILS) course is recommended as a minimum standard for staff who deliver or are involved in rapid tranquilisation, physical restraint and seclusion. This guidance recommends that clinical staff in each mental health inpatient facility should receive regular update training in physical health skills in addition to ILS in response to an assessment of need undertaken by each organisation. 
6. It is recommended that training enables clinical staff to possess the competencies defined in the Department of Health’s document ‘Competencies for Recognising and Responding to Acutely Ill Patients in Hospital’. 
7. According to Resuscitation Council UK guidelines, training must be in place to ensure that clinical staff can undertake cardiopulmonary resuscitation. Training and facilities must ensure that, when cardiorespiratory arrest occurs, all clinical staff can, as a minimum: 
   • recognise cardiorespiratory arrest; 
   • summon help; 
   • start CPR; 
   • attempt defibrillation, if appropriate, within 3 minutes of collapse using an automated external defibrillator or manual defibrillator. 
8. Clinical staff should have at least annual updates. 
9. In addition, units that undertake electroconvulsive therapy (ECT) must follow the latest standards for staff training and practice set by The ECT Accreditation Service (ECTAS). 
10. Training and updates that include an assessment are recommended for clinical staff. 
11. The expectation is that non-clinical staff have the resuscitation skills that would be expected from a lay person. As a minimum, non-clinical staff should be trained to: 
    • recognise cardiorespiratory arrest; 
    • summon help; 
    • start CPR using chest compressions. 
12. All staff must know how to summon help and be aware of the protocol for the settings in which they work. This could be dialling 999 or a standard telephone number within the organisation. We recommend that this should be a common national number, 2222, as recommended by the National Patient Safety Agency. 
13. A variety of methods to acquire, maintain and assess resuscitation skills and knowledge can be used for annual updates of all staff, (e.g. life support courses, simulation training, in-house training, mock-drills, ‘rolling refreshers’, e-learning, video based training/self-instruction). The appropriate methods must be determined locally. Training materials such as Lifesaver (www.life-saver.org.uk), developed by Resuscitation Council UK, or very brief videos aimed at members of the public may be appropriate for non-clinical staff. ‘Hands-on’ simulation training and assessment is recommended for clinical staff. 
14. A system must be in place for identifying resuscitation equipment for which staff require special training, such as defibrillators and emergency suction equipment. 
15. All new members of staff must have training in resuscitation as part of their induction programmes. Even those who have current training require resuscitation training on induction to ensure they are familiar with local policies and equipment. 
16. ROs or resuscitation leads must organise and co-ordinate resuscitation training for staff. However, in order to achieve training targets, ROs may need to delegate some aspects of training. 
17. Organisations must recognise and make provision for staff to have enough time to train in resuscitation skills as part of their employment. 
18. Specific training for cardiorespiratory arrests in special circumstances (e.g. for children of all ages who have collapsed, patients who are secluded or subject to restraint, and patients who have suffered blood loss) must be provided for medical, nursing and other clinical staff in the relevant specialties. 
19. All clinical staff must receive training in recognising, monitoring and managing patients whose conditions are deteriorating. 
20. All training must be recorded (e.g. in the organisation’s training database). 
21. Members of mental health resuscitation teams that have specific involvement in resuscitation, particularly team leaders, require a level of training beyond that provided by local ROs. These people should be encouraged and supported to attend nationally recognised courses, such as the Advanced Life Support (ALS) course. 

Standards

1. The use of the 'Chain of Prevention' concept is recommended as a basis for structuring each organisation’s responses to patients who deteriorate and for the prevention of cardiorespiratory arrest. 
2. The organisation must have an education programme for ward staff and responding clinical personnel that is focused on preventing patients’ deterioration. It is recommended that staff attain the necessary competences identified in the Department of Health document ‘Competencies for Recognising and Responding to Acutely Ill Patients in Hospital’ (2009). 
3. The organisation must have a clear policy for monitoring patients’ vital signs, based on the guidance in the National Institute for Health and Clinical Excellence Clinical Guideline 50 [Acutely ill patients in hospital: recognition of and response to acute illness in adults in hospital (2007)], National Institute for Health and Clinical Excellence Clinical Guideline 25 (2007), NPSA Rapid Response Report (2008/RRR010) and the Royal College of Physicians National Early Warning Score (NEWS) (2012). 
4. An early warning scoring system must be in place to identify patients who are critically ill and, therefore, at risk of cardiorespiratory arrest. The use of the National Early Warning Score (NEWS) or a paediatric early warning score for children is recommended. 
5. The organisation must have a patient charting system that facilitates the regular measurement and recording of early warning scores. 
6. The organisation must have a clear, universally known and understood, mandated, unambiguous, graded activation protocol for escalating monitoring or summoning responses to deteriorating patient. Its use should be standardised across the organisation. 
7. The use of a standardised method for communicating information about deteriorating patients (e.g. SBAR, RSVP) between staff members is recommended. 
8. When acute clinical crises are identified, a 999 ambulance must be called if there is no designated resuscitation team, outreach service or rapid response team (e.g. Medical Emergency Team [MET]) that is immediately available. 
9. The organisation must have a clear and specific policy that requires a clinical response to 'calling criteria' or early warning systems ('track and trigger'). This must include the specific responsibilities of onsite / on call doctors and nursing staff, and include when to call for the ambulance service. NCEPOD recommends that, when patients continue to deteriorate after reviews that are not conducted by consultants, there should be escalation of patient care to senior doctors who specialise in acute physical healthcare. The reasons for non-escalation must be documented clearly in the case notes if this practice is not followed. 

Standards

1. Unless the organisation that delivers mental healthcare is situated on the same site as an acute hospital, which provides a resuscitation team that is specifically contracted to deliver an on call service for patients of the mental health unit, a 999 ambulance should be called immediately for any patient who collapses. In the interval before an ambulance arrives, staff of the mental health service should be capable of deploying the skills that are identified in point 4 below. 
2. The resuscitation service structure must determine the composition of the resuscitation team/responding staff. This is likely to vary depending on location and clinical need. All clinical facilities must have access to an outside telephone line to summon the 999 ambulance service. 
3. The RO must be informed of all cardiorespiratory arrests. 
4. The staff who respond immediately must have the following minimum skills: 
   • competent delivery of CPR; 
   • defibrillation (automated external defibrillation); 
   • basic airway interventions, including bag-mask ventilation and/or supraglottic airway; 
   • skills required for immediate post-resuscitation care. 
     
     The following skills are strongly recommended: 
      
   • intravenous cannulation (as determined by local policy and clinical need); 
   • intraosseous access (as determined by local policy and clinical need); 
   • drug administration (as determined by local policy and clinical need). 
      
5. NCEPOD recommends that each hospital ensures that there is an agreed plan for airway management during cardiac arrest. This may involve bag-mask ventilation for patients during and after cardiac arrests of short duration or greater use of supraglottic airway devices as an alternative. This means that mental healthcare units must have staff available who are able to use these devices in the interval before an ambulance arrives. 
6. Patients requiring ongoing acute medical care and resuscitation require transfer to an acute hospital. This means that: 
   • there should be a protocol in place for arranging transfers between identified units and hospitals; 
   • the protocol is tested periodically as a rehearsal and adjusted as is necessary; 
   • formal agreements between mental health units and suitable acute hospitals are negotiated and funded; 
   • there are formal agreements in place with the ambulance service to make the transfers that are required. The ambulance service must be party to the protocols between the mental health units and acute hospitals and engaged in the rehearsal. 
7. The team or designated responding staff (they can be from the mental health inpatient unit or acute hospital as determined locally) must be summoned in response to every cardiorespiratory arrest or when patients collapse. 
8. Activation of the team or designated responding staff must also be part of the local escalation plan for patients whose conditions deteriorate. 
9. The team or designated responding staff must be summoned to all cardiorespiratory arrests by the use of a common telephone number. The National Patient Safety Agency has recommended that this number should be 2222. 
10. The organisation must ensure that the resuscitation team or designated responding staff are activated within 30 seconds of the call for help. A daily test call is recommended as a minimum. Responses to test calls must be monitored and any failure must be followed up and remedied immediately. 
11. Relatives may or may not wish to be present during attempted resuscitation of patients who have a cardiorespiratory arrest. The organisation should have a policy on providing support for relatives during resuscitation attempts. The resuscitation team or designated responding staff are responsible for ensuring compliance with that policy. 
12. The resuscitation team or designated responding staff should arrange patients’ transfers after their resuscitation. 
13. If there is a mental health resuscitation team, its members may change daily or more frequently, according to shifts and patterns of duty. Members may not know each other or the skill mix of the team members. A Resuscitation Team meeting is recommended at the beginning of members’ periods on duty. 
14. Team debriefings of resuscitation team members are recommended. The exact mechanism (e.g. end of each event, end of each shift, weekly) must be determined locally. 
15. Ideally, the role of team leader in a resuscitation team should be undertaken by a person who is a current Advanced Life Support (ALS) provider or has equivalent training. Immediate Life Support (ILS) providers (or those with equivalent training) can also lead the team while waiting for more skilled help to arrive. This may be from a hospital-based resuscitation team or from the ambulance service. In the case of units for children and young adolescents, the team leader must have equivalent Paediatric Life Support provider status. The role of team leader must be allocated on the basis of clinical knowledge, skills and experience.       
16. The team leader is responsible for: 
    • directing and co-ordinating each resuscitation attempt; 
    • ensuring that current guidelines are followed; 
    • ensuring the safety of those present; 
    • ending the resuscitation attempt when indicated (if applicable to the individual’s clinical role and training); 
    • documenting each attempt to resuscitate (including ensuring that audit and incident report are completed in a timely way and submitted); 
    • communication with relatives; 
    • handover of care to other clinical teams; 
    • diagnosis and documentation of death if appropriate. 
      
      Some of these responsibilities may require delegation to other team members (e.g. death certification by a registered doctor with a licence to practise).     
       
17. The organisation must ensure that a complete and detailed record of the cardiorespiratory arrest is retained within the patient’s clinical records. Collection of data at the time of the cardiorespiratory arrest is recommended for audit. 
18. Units that undertake electroconvulsive therapy (ECT) must follow the latest standards for staff training set by The ECT Accreditation Service (ECTAS). 

Standards

1. Unless the mental health inpatient facility is situated on the same site as an acute hospital, a 999 ambulance should be called immediately to each child who collapses or deteriorates (see section on the resuscitation of children in the Quality Standards for acute care). 
2. Organisations have a duty to ensure that staff who work with children are trained accordingly. Ideally, the team leader or designated responding staff should have expertise in resuscitating children. 
3. The designated responding staff must have knowledge about the equipment and doses of drugs (the availability of which should be determined by local policy) that children require. They must understand the differences in causes of, and treatment required by cardiorespiratory arrest in children as compared with adults. 
4. The designated responding staff must be familiar with their expected roles and should receive training in paediatric resuscitation. 
5. When resuscitating children, particular consideration must be given to allowing the presence of relatives or caretakers during the resuscitation attempt. An experienced member of staff who can explain what is going on should be delegated to stay with them and liaise with the team on their behalf. 
6. The use of paediatric resuscitation charts and drug dosing aides is essential. In circumstances in which a child’s weight is not known, a method of calculating drug dosages from length or age is useful. 
7. Most paediatric cardiac arrests are secondary events. Therefore, specific paediatric early warning scoring systems with a ‘Track and Trigger’ should be used to maximise prevention of cardiac arrest. 
8. Where appropriate, a separate CPR decision form and/or Emergency Healthcare Plan (EHP) is recommended for children.

Standards

Organisations must have policies and procedures in place for resuscitation in special circumstances (e.g. blood loss due to trauma, suffocation, application of a ligature to the neck and hanging, self-harm, seclusion, rapid tranquillisation, etc.). 

After successful resuscitation, patients must be transferred to acute hospitals for more specialised care. Transfers must be carried out by the 999 ambulance service, a retrieval team, or by local arrangements where the mental health unit is on a site that is shared with an acute hospital. All transfers should follow the appropriate national guidance. 

The organisation should have a system in place to ensure handover of care and safe transfer. 

Mental health organisations must transfer to acute inpatient units for further post-resuscitation care all patients who have been resuscitated after a cardiorespiratory arrest. They must use the 999 ambulance service unless there are other local transfer arrangements where the mental health unit is on a site that is shared with an acute hospital. Post-cardiac-arrest care must be based upon the current guidelines. 

Standards

Click here for the equipment and drug list for mental health inpatient care settings.

Standards 

1. Healthcare professionals must be familiar with and follow published guidance, including in particular ‘Decisions relating to Cardiopulmonary Resuscitation’, a joint statement by the British Medical Association, Resuscitation Council UK, and the Royal College of Nursing, and the General Medical Council’s current guidance on ‘Treatment and care towards the end of life: good practice in decision making’. 
2. Healthcare professionals must be familiar with and must comply with the law as it applies to decisions about CPR. There are some differences in the law among countries of the United Kingdom. Healthcare provider organisations must ensure that their staff receive appropriate information and training regarding these laws. 
3. Healthcare professionals involved in making decisions about CPR must have appropriate training and competency in so doing, and similarly those who undertake the sensitive discussions with patients and those close to patients must have appropriate training and competency in so doing. Healthcare provider organisations must ensure that they have sufficient staff trained and competent in performing these functions, and that staff have adequate time and facilities to perform them properly. 
4. Resuscitation Council UK has defined standards for recording decisions about CPR. It is recommended that decisions about CPR are recorded on a form that is easily recognised and has a standard content and format, to allow healthcare professionals to recognise it and assess its content and validity immediately. 
5. Healthcare organisations must have policies about CPR decisions and documents that are recognised by the other organisations so that decisions about CPR continue across organisational and geographic boundaries when patients are transferred from one setting to another. In particular, this should include the ambulance service, so that these decisions are respected during transfer. 
6. Healthcare organisations must ensure that healthcare staff have access to appropriate stationery or electronic media for recording, accessing and reviewing decisions about CPR. 
7. Healthcare organisations must ensure that patients and those close to patients have ample opportunities to discuss resuscitation and decisions about CPR should they wish to, but that such discussions are not forced upon those who do not want them. Written information about resuscitation decisions, or information in other media (e.g. DVD or ‘podcast’) should be made readily available for patients and those close to them but should not be used as an attempted substitute for sensitive, face-to-face discussion with a suitably trained and competent healthcare professional. 

Standards

1. NCEPOD recommends that every CPR attempt is reported through the healthcare organisation’s patient safety incident reporting systems. This information must be reported to the organisation’s Board on a regular basis. 
2. All CPR attempts must be reviewed. When appropriate, a root cause analysis must be undertaken and the action plan implemented. A suggested guide for reviewing cardiac arrests is available in the supporting tools below. 
3. Taking part in the National Cardiac Arrest Audit (NCAA) is recommended. NCAA is included in the Department of Health’s Quality Accounts as a recognised national audit (This is only appropriate if a mental healthcare organisation has access to a resuscitation team summoned by the use of 2222). 
4. Audit of DNACPR policies is mandatory (Health Services Circular 2000/028). 
5. Organisations must review local audit data regularly against published standards. Where audit identifies deficiencies or unexpected poor performance, a review at an appropriate level must be undertaken. The resuscitation service structure must receive appropriate support to achieve this. 

Standards

• Research must be conducted in accordance with the NHS Research Governance Framework. Research involving human participants, their organs, tissue or data require NHS Research and Development approval. Such research may also require approval from a Research Ethics Committee. If in doubt, advice should be sought from the local Research and Development Office in the first instance or NHS Research Ethics Advice Service. 
• Research involving patients who lack capacity must also comply with relevant legislation (e.g. UK Medicines for Human Use [Clinical Trials] Regulations 2004; Mental Capacity Act 2005 [England and Wales]); Adults with Incapacity [Scotland] Act 2000). 
• The organisation’s resuscitation service structure can be a valuable source of advice for staff who are contemplating undertaking clinical research in resuscitation. 

Suggested measures to assess adherence to standards

The numbers listed in the first column correspond to the standards referred to in the corresponding chapter of this document.