The evidence led to her composing a prevention of future deaths report, the details of which she outlined on Tuesday.
In it, she said both ordinary people and ambulance call handlers had difficulty recognising the symptoms of cardiac arrest and agonal breathing, a symptom experienced by Adam.
“Although there was training given, and some of those on the pitch were trained, there was still a misidentification of Adam’s agonal breathing by those on the pitch and those receiving the 999 call,” Charbit said.
She said she hoped the report would prevent similar deaths.
